Male spondyloarthritis patients and those with longer disease duration have less severe disc degeneration: propensity score-matched comparison.

Objective: Using whole spine sagittal T2 MRI, we aimed to compare the severity and prevalence of disc degeneration (DD) in axial SpA patients vs the general population and to determine any association between spinal inflammation, structural changes, mobility and DD among SpA patients. Methods: Two prospectively collected cohorts of SpA patients (n = 411) and the general population (n = 2007) were recruited. Eventually, 967 participants from the populational cohort and 304 participants from the SpA cohort were analysed. Two hundred and nineteen matched pairs were generated by propensity score matching. Imaging parameters, including Pfirrmann grading, disc herniation, high-intensity zone, Schmorl's node, Modic change and anterior marrow change were studied and compared from C2/3 to L5/S1. DD was defined as Pfirrmann grade 4 or 5. Demographic factors, including age, sex and BMI, were collected. Multivariable linear regression was used to determine the association between spinal inflammation [Spondyloarthritis Research Consortium of Canada (SPARCC) spine MRI index], structural changes [modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS)] and mobility (BASMI) with lumbar Pfirrmann score. Results: SpA patients had lower prevalence of DD (P < 0.001). The disease stage-stratified regression model showed that SPARCC spinal MRI index was associated with higher lumbar Pfirrmann scores in early disease (ß = 0.196, P = 0.044), whereas mSASSS was associated with lower lumbar Pfirrmann scores in later disease (ß = -0.138, P = 0.038). Males had higher mSASSS (P < 0.001) and lower odds of whole spine DD (odds ratio = 0.622, P = 0.028). Conclusion: SpA patients had lower DD severity than the general population. Males had higher mSASSSs, and increased mSASSS at later disease was associated with less severe DD.

Propensity-matched Comparison Between Chronic Nonspecific Low Back Pain and Axial Spondyloarthritis: Impact on patient-perceived Quality of Life.

STUDY DESIGN: Prospective study. OBJECTIVE: To compare the burden between chronic nonspecific low back pain (LBP) and axial spondyloarthropathy (SpA). SUMMARY OF BACKGROUND DATA: Chronic nonspecific LBP and SpA are two debilitating yet different chronic musculoskeletal disorders. To compare their burden, propensity score matching is used to control for potential confounders and match the study subjects. MATERIALS AND METHODS: Two prospectively collected cohorts of LBP (n=269) and SpA (n=218) patients were studied. Outcomes included current LBP, 36-item Short Form Questionnaire, Oswestry Disability Index, EuroQol 5-dimension 5-level Questionnaire, and EuroQol Visual Analog Scale. With the inherent differences between the two types of patients, propensity score matching was performed for comparing the two groups. Baseline covariates of age, sex, education level, occupation, smoking, and drinking history were selected for the estimation of propensity scores for each subject with the logistic regression model. Significant independent variables for the outcome of current back pain were included in the multivariate logistic regressions. RESULTS: A total of 127 matched pairs were identified, with 254 patients. In the matched cohort, more patients with chronic LBP had current back pain (95.3%) as compared with SpA (71.7%). Patients with SpA were younger ( P <0.001), with more males ( P <0.001), and better educated ( P =0.001). There was less current back pain and higher nonsteroidal anti-inflammatory drug use ( P <0.001). Most SpA patients had lower Oswestry Disability Index than LBP patients and with low disease activity. Patients with LBP had worse outcome scores as compared with SpA patients given the same Visual Analog Scale. LBP patients had 8.6 times the odds (95% CI: 3.341-20.671; P <0.001) of experiencing current back pain compared with SpA patients. CONCLUSIONS: The disease activity of SpA patients is well controlled. However, patients with chronic LBP have worse pain severity, disability, and health-related quality of life. This has implications on resource utilization and the necessity of advancing LBP understanding and management. LEVEL OF EVIDENCE: Type I prognostic study.

MRI lesions in SpA: a comparison with noninflammatory back pain using propensity score adjustment method.

Background: Magnetic resonance imaging (MRI) is important in the management of axial spondyloarthritis (SpA). However, many MRI lesions are not exclusive to axial SpA. Further characterization of these lesions may lead to better clinical decisions. Objective: The objective of this study was to compare the frequency of individual spinal MRI lesions between axial SpA and noninflammatory back pain. The factors associated with individual lesions in participants with axial SpA were also determined. Design: This was a cross-sectional observational study. Methods: MRI lesions in 447 participants with axial SpA and 122 participants with noninflammatory back pain were compared using the propensity score adjustment method. Individual lesions included discovertebral lesions (DVL), Modic type 1 lesions, DVL without Modic type 1 lesions, facet joint lesions, costovertebral joint lesions, corner inflammatory lesions (CIL), and fatty corner lesions (FCL). The factors associated with the lesions were determined using regression analyses. Results: Among participants with axial SpA, 81.9% were HLA-B27-positive, 55.0% had radiographic axial SpA, and 60.5% had radiographic features of spinal damage (mSASSS >2). Almost half (48.6% in axial SpA versus 31.1% in noninflammatory back pain) had inflammatory lesions on spinal MRI. In propensity score matching with noninflammatory back pain, axial SpA had an increased occurrence of DVL without Modic type 1 lesion (OR = 3.43, p = 0.01), costovertebral lesion (OR = 11.89, p = 0.02), number of CIL (B = 1.19, p < 0.001), and number of FCL (B = 3.33, p < 0.001). Similar associations were found in the regression models in the radiographic axial SpA subgroup: DVL without Modic type 1 lesion (OR = 2.46, p = 0.001), costovertebral lesion (OR = 3.86, p < 0.001), number of CIL (B = 1.13, p < 0.001), and FCL (B = 2.29, p < 0.01). Conclusion: MRI lesions including DVL without Modic type 1, costovertebral joint lesions, CIL, and FCL were more specific in axial SpA.

Clinical, radiological, and magnetic resonance imaging characteristics of axial spondyloarthritis with late onset.

We aimed to investigate the clinical, diagnostic, and imaging features of patients with late onset axial spondyloarthritis (SpA) with initial symptom manifestation aged over 45 years. Participants with axial SpA were consecutively recruited. Clinical, demographic, blood, and imaging parameters were compared between the groups with early (≤45 years) and late onset (>45 years) at a cross-sectional level. Logistic regressions were used to determine the independent associations with axial SpA with late onset. A total of 455 participants were recruited. Among them, 70 (15.4%) had late onset disease. Multivariate analyses showed that axial SpA with late onset was associated with higher C-reactive protein based ankylosing spondylitis disease activity index (ASDAS-CRP) (B = 0.10; P = .04), higher intensity of spinal inflammation as measured by maximum apparent diffusion coefficient (spinal ADC max) (B = 0.27; P = .03) and mean ADC (spinal ADC mean) (B = 0.30; P = .004), lower modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) (B = -0.12; P = .02), more tender joint count (B = 0.12; P = .02), and fewer inflammatory back pain (IBP) (OR = 0.26; P < .001). Axial SpA with late onset had higher clinical disease activity, higher intensity of spinal MRI inflammation, less radiographic damage, and more tender joint count. There was also less inflammatory back pain, which could make the diagnosis more difficult.

Both ASDAS and ADC are associated with spinal mobility in active axial spondyloarthritis: A comparison between early and later disease.

OBJECTIVE: Using diffusion-weighted imaging (DWI)-derived apparent diffusion coefficient (ADC), we aimed to determine the relationship between intensity of spinal inflammation and mobility in patients with axial spondyloarthritis (SpA) in early and later stages of active disease. The Ankylosing Spondylitis Disease Activity Score (ASDAS) was also used for a more comprehensive evaluation. METHODS: Participants with axial SpA and back pain were recruited from 10 rheumatology centers. Clinical, biochemical and radiological parameters were collected. Short tau inversion recovery (STIR) sequence magnetic resonance imaging (MRI) and DWI of the spine and sacroiliac (SI) joints were performed. ADC maps were generated. Participants were examined for Bath Ankylosing Spondylitis Metrology Index (BASMI). Linear regression models were used to determine associations between BASMI and various clinical, radiological, and MRI parameters in participants with active inflammation on spinal ADC maps. RESULTS: One-hundred and twenty-seven participants were included in the analyses. Multivariate linear regression showed that mean ADC spine (ß = .16; P = .03), ASDAS-C-reactive protein (CRP) (ß = .29, P < .001), and ASDAS-erythrocyte sedimentation rate (ESR) (ß = .25, P < .01) were associated with BASMI. In participants with duration of back pain ≤3 years, mean spine ADC (ß = .37; P = .03), ASDAS-CRP (ß = .44; P = .01), and ASDAS-ESR (ß = .42; P = .01) were associated with BASMI after adjustment for confounding factors. In participants with duration of back pain >3 years, only ASDAS-CRP (ß = .25; P < .01) and ASDAS-ESR (ß = .20; P = .20) were associated with BASMI. CONCLUSION: Intensity of inflammation and clinical disease activity were independently associated with impairment of spinal mobility. The associations were stronger in early (≤3 years) than later disease.

Responsiveness of the EuroQoL 5-Dimension (EQ-5D) questionnaire in patients with spondyloarthritis.

BACKGROUND: Spondyloarthritis (SpA) has a significant impact on patients' quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for cost-utility analysis of health care interventions and calculation of quality-adjusted life-years. It has been validated in patients with SpA. However, its responsiveness property is unclear. Hence, the aim of study is to test the responsiveness properties of the EQ-5D health measure for Chinese patients with SpA. METHODS: Prospective and consecutive recruitment of 151 Chinese patients with SpA was conducted with follow-up assessments 6 months later. Demographic data including smoking and drinking habits, education level, income and occupation was collected. Disease-associated data including disease duration, presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS), mental health (HADS) and the EQ-5D scores were recorded. Responsiveness was tested against the global rating of change scale (GRC) and changes in disease activity using BASDAI and ASDAS-CRP. RESULTS: A total of 113 (74.8%) patients completed the follow-up assessments. Most patients (61.6%) had low disease activity level with BASDAI <4 and 39.7% of patients had inactive disease by ASDAS-CRP. EQ-5D scores was well discriminated along with BASDAI and BASFI scores. EQ-5D scores also correlated well with HADS. The GRC was not able to discriminate adequately. No significant ceiling or floor effect was observed. CONCLUSIONS: EQ-5D demonstrates satisfactory responsiveness property for assessment of changes in SpA disease activity. LEVEL OF EVIDENCE: II.

Diagnostic utility of whole spine and thoracic spine MRI corner inflammatory lesions in axial spondyloarthritis.

BACKGROUND: The presence of ⩾3 corner inflammatory lesions has been proposed as the definition of a positive spinal magnetic resonance imaging (MRI) for axial spondyloarthritis (axSpA), but subsequent studies showed inconclusive findings. Our objective was to evaluate whether locations of corner inflammatory lesions (CILs) would affect the diagnostic utility of MRI in axSpA. METHOD: Two groups were consecutively recruited from eight rheumatology centers in Hong Kong. The 'axSpA' group included 369 participants with a known diagnosis of axSpA. The 'non-specific back pain' (NSBP) control group consisted of 117 participants. Clinical, biochemical, and radiological parameters were collected and all patients underwent MRI of the spine and sacroiliac joints. CILs were assessed based on their locations (cervical, thoracic or lumbar) to determine the optimal cutoff for diagnosis. RESULTS: The cutoff of ⩾5 whole spine CILs (W-CILs) and ⩾3 thoracic spine CILs (T-CILs) had comparable specificity to MRI sacroiliitis. Of 85/369 axSpA patients without sacroiliitis on conventional radiograph or MRI, 7 had ⩾5 W-CILs and 11 had ⩾3 T-CILs. Incorporating the proposed cutoffs into Assessment of SpondyloArthritis international Society axSpA criteria, ⩾5 W-CILs and ⩾3 T-CILs had similar performance when added to the imaging criteria for sacroiliitis (sensitivity 0.79 versus 0.80, specificity 0.92 versus 0.91). CONCLUSION: Spinal MRI provided little incremental diagnostic value in unselected axSpA patients. However, in patients without sacroiliitis on MRI or radiographs, 8-13% might be diagnosed by spinal MRI. Thoracic and whole spine MRI had similar diagnostic performance using the proposed cutoff of ⩾5 W-CILs and ⩾3 T-CILs.

MRI inflammation of facet and costovertebral joints is associated with restricted spinal mobility and worsened functional status.

OBJECTIVE: To investigate the association of spinal inflammation on MRI in patients with various clinical, functional and radiological outcomes in patients with axial spondyloarthritis (SpA). METHODS: Three hundred and ninety-seven participants with axial SpA and back pain were recruited from 10 rheumatology centres. Clinical, biochemical and radiological parameters were collected and participants underwent MRI of the spine. MRI features including inflammatory lesions of facet joints and costovertebral joints, corner inflammatory lesions, and spondylitis were assessed. BASFI, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Global Index, BASMI and modified Stoke Ankylosing Spondylitis Spinal Score were measured. Multivariate linear regression models were used to determine the associations between MRI parameters and various clinical, functional and radiological outcomes. RESULTS: BASMI and BASFI correlated well with inflammatory features in spinal MRI. Multivariate analysis showed that lumbar facet joint inflammation was independently associated with BASMI (regression coefficient (ß) = 0.12, P < 0.001), lumbar spinal flexion (ß = 0.13, P = 0.00), lateral spinal flexion (ß = 0.09, P = 0.04), tragus-to-wall distance (ß = 0.16, P < 0.001) and BASFI (ß = 0.14, P = 0.01). Costovertebral joint inflammation was also associated with BASMI (ß = 0.08, P = 0.05). CONCLUSION: Inflammatory lesions of facet and costovertebral joints in MRI are associated with restriction in spinal mobility and functional impairment. These important yet commonly overlooked lesions should be reviewed in clinical practice in patients with SpA.

Intensity of spinal inflammation is associated with radiological structural damage in patients with active axial spondyloarthritis.

OBJECTIVE: The aim was to investigate the relationship between the intensity of spinal inflammation using the apparent diffusion coefficient (ADC) and radiographic progression in axial SpA. METHODS: This is a cross-sectional study of participants with axial SpA and back pain. Clinical, biochemical and radiological parameters were collected. The ankylosing spondylitis disease activity score (ASDAS)-CRP was determined. Radiographic progression was represented by the modified Stoke ankylosing spondylitis spine score (mSASSS). MRI with short tau inversion recovery (STIR) and diffusion-weighted imaging sequences were performed simultaneously. Inflammatory lesions on STIR were used for the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI indexes and as references in outlining regions of interest in ADC maps to produce mean (ADCmean) and maximal (ADCmax) ADC values. Univariate and multivariate linear regression analyses were used to determine independent associations between ADC and radiographic progression. RESULTS: The 84 participants with identifiable lesions on spinal ADC maps recruited were characterized by a mean (s.d.) age of 45.01 (13.68) years, long disease duration [13.40 (11.01) years] and moderate clinical disease activity [ASDAS-CRP 2.07 (0.83)]. Multivariate regression analysis using ADCmean as the independent variable showed that age (regression coefficient [B] = 0.34; P = 0.01), male sex (B = 0.25; P = 0.04) and ADCmean (B = 0.30; P = 0.01) were positively associated with mSASSS. Multivariate regression analysis using ADCmax as the independent variable showed a tendency for ADCmax to be associated with mSASSS (B = 0.21; P = 0.07). CONCLUSION: The intensity of spinal inflammation as determined by ADC is associated with radiographic progression in participants with active axial SpA.

Clinical Associations of Uveitis in Axial Spondyloarthritis Group and Ankylosing Spondylitis Group: Do They Represent the Same Disease?

OBJECTIVE: The aim of this study was to determine the prevalence and associated factors for uveitis in ethnic Chinese patients with axial spondyloarthritis (SpA) and ankylosing spondylitis (AS). METHODS: This was a cross-sectional study. Patients fulfilling the Assessment of SpondyloArthritis international Society axial SpA criteria were recruited consecutively from 3 rheumatology centers in Hong Kong from March 2014 to July 2017. Clinical and biochemical parameters were collected. History of uveitis was inquired from both history and medical records. All patients received lumbosacral spine x-rays and whole-spine and sacroiliac joint magnetic resonance imaging. Patients were defined as axial SpA if they fulfilled the Assessment of SpondyloArthritis international Society criteria and AS if they fulfilled the modified New York criteria. Clinical and radiological findings were compared between patients with and without uveitis in the 2 groups. Factors associated with uveitis were identified with univariate analyses and multivariate logistic regression analyses. RESULTS: Among 252 patients, 67 patients (26.6%) had a history of uveitis. The male-to-female ratio was 55.4 to 44.6. Disease duration was 12.3 ± 11.7 years. In the axial SpA group, multivariate regression showed that older age (odds ratio [OR], 1.05; p = 0.01), human leukocyte antigen B27 positivity (OR, 11.79; p = 0.01), and history of inflammatory bowel disease (OR, 9.74; p = 0.04) were positively associated with uveitis. In the AS group, multivariate regression showed that back pain duration (OR, 1.05; p = 0.01) and male sex (OR, 3.46; p = 0.03) were associated with uveitis. CONCLUSIONS: Axial SpA represents a spectrum of diseases. Its clinical associations with uveitis should be distinguished from those of traditional AS.

ASDAS is associated with both the extent and intensity of DW-MRI spinal inflammation in active axial spondyloarthritis.

Objective: To investigate the relationship between Ankylosing Spondylitis Disease Activity Score (ASDAS) and intensity of spinal inflammation measured by apparent diffusion coefficient (ADC) in MRI in participants with active axial spondyloarthritis (SpA). Methods: Participants with axial SpA and back pain were recruited. Clinical, demographic, biochemical and imaging data were collected. ASDAS was calculated based on C reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Inflammatory lesions were identified in short tau inversion recovery images and the corresponding ADC maps to determine the maximum apparent diffusion coefficient (ADCmax), normalised maximum ADC, mean apparent diffusion coefficient (ADCmean) and normalised mean ADC by two independent readers. Spondyloarthritis Research Consortium of Canada (SPARCC) spine and sacroiliac (SI) joint MRI indexes were determined. Univariate and multivariate linear regression models were used to determine the associations between of ASDAS with ADC values, SPARCC spine and SI MRI scores. Results: Eighty-two participants had identifiable ADC lesions. Multivariate analyses using ADCmax and SPARCC spine MRI as independent variables showed associations with ASDAS-CRP (ADCmax: B=0.27, p=0.02; SPARCC: B=0.32, p=0.01) and ASDAS-ESR (ADCmax: B=0.24, p=0.03; SPARCC: B=0.36, p<0.01); using ADCmean and SPARCC spine MRI as independent variables also showed an association with ASDAS-ESR (ADCmean: B=0.22, p=0.05; SPARCC: B=0.36, p<0.01) and a tendency to associate with ASDAS-CRP (ADCmean: B=0.21, p=0.07; SPARCC: B=0.34, p<0.01). Conclusion: ASDAS is associated with both the extent and the intensity of spinal inflammation in patients with detectable inflammatory lesions. Our results showed that ASDAS is an objective disease assessment tool. Trial registration number: HKUCTR-2087.

Psychometric validation of the EuroQoL 5-dimension (EQ-5D) questionnaire in patients with spondyloarthritis.

BACKGROUND: Spondyloarthritis (SpA) has a significant impact on patients' quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for the cost-utility analysis of health care interventions and calculation of quality-adjusted life years. However, the applicability of the EQ-5D health measure in Chinese patients with SpA is currently unknown. Hence, the aim of the study is to test the psychometric properties and to validate the use of the EQ-5D health measure for utility analyses in Chinese patients with SpA. METHODS: Prospective and consecutive recruitment of 220 Chinese patients with SpA was conducted. Demographic data including smoking and drinking habits, education level, income, and occupation was collected. Disease-associated data including disease duration, the presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS, ODI), mental health (HADS depression and anxiety), and the EQ-5D scores were recorded. SF-36 scores were used to verify the findings. Baseline correlations were performed along with test-retest reliability, validity, and internal consistency tests. Specifically, the relationship between EQ-5D and disease activity and functional scores was studied. RESULTS: EQ-5D scores achieved acceptable internal consistency and reliability. A ceiling effect was observed for all domains of the EQ-5D except for pain/discomfort. No floor effect was observed. Significant negative correlations were observed between ODI, HADS, BASFI, BASMI, BASDAI, and ASDAS-CRP and with EQ-5D. A higher disease activity was well-differentiated by EQ-5D, as with the disability and mental health scores. CONCLUSIONS: The EQ-5D demonstrates satisfactory psychometric properties for assessment of SpA patients. It has high utility for demonstrating changes in disease activity and disability.

Diffusion-weighted imaging versus short tau inversion recovery sequence: Usefulness in detection of active sacroiliitis and early diagnosis of axial spondyloarthritis.

OBJECTIVE: To compare the utility of Diffusion weighted imaging (DWI) with short tau inversion recovery (STIR) sequence in the diagnosis of early axial spondyloarthritis (SpA). METHODS: Three hundred and five patients with chronic back pain were recruited consecutively from 3 rheumatology centers. Clinical, radiological and blood parameters were recorded. Patients with back pain duration no more than 3 years were classified as having early disease. STIR sequence and DWI of the sacroiliac joints were obtained and assessed using the Spondyloarthritis Research Consortium of Canada (SPARCC) method. The Assessment in Spondyloarthritis international Society definition was used to define positive STIR and DWI. Results were compared to expert diagnosed axial SpA. RESULTS: When compared to STIR sequence, DWI had similar sensitivity (STIR 0.29, DWI 0.30) and specificity (STIR 0.97, DWI 0.92) in diagnosing sacroiliitis. However, STIR sequence had better reliability (STIR 0.78, DWI 0.61). In early disease group, DWI was not better than STIR sequence in detecting active sacroiliitis (sensitivity DWI vs STIR: 0.34 vs 0.36; specificity DWI vs STIR: 0.93 vs 0.93; positive predictive value DWI vs STIR: 0.92 vs 0.92; negative predictive value DWI vs STIR: 0.36 vs 0.37). Using the Assessment in SpondyloArthritis international Society (ASAS) classification criteria, 67/98 patients with early disease (sensitivity 0.91 specificity 0.90) and 221/305 overall (sensitivity 0.90; specificity 0.92) were classified as axial SpA. Among the expert diagnosed axial SpA patients who did not meet the ASAS criteria, only 2 had positive DWI. CONCLUSION: DWI and STIR have similar sensitivity in diagnosing axSpA in early disease. However, the use of DWI is limited by poorer reliability when compared with STIR.

The Discriminative Values of the Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Disease Activity Score, C-Reactive Protein, and Erythrocyte Sedimentation Rate in Spondyloarthritis-Related Axial Arthritis.

OBJECTIVES: The aims of this study were to determine the effectiveness of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein (ASDAS-CRP), Ankylosing Spondylitis Disease Activity Score-Erythrocyte Sedimentation Rate (ASDAS-ESR), and inflammatory markers in screening for axial-joint inflammation as detected by magnetic resonance imaging (MRI) and to find out factors that could affect scoring of the indices. METHODS: One hundred fifty-three Chinese spondyloarthritis patients were recruited. Clinical data and BASDAI were collected, and Bath Ankylosing Spondylitis Metrology Index was measured. Serum ESR and CRP were checked, and ASDAS-ESR and ASDAS-CRP were calculated. Radiographs of cervical and lumbar spine were performed for modified Stoke Ankylosing Spondylitis Spinal Score. All patients underwent MRI of the spine and sacroiliac joints. Axial-joint inflammation was evaluated by Spondyloarthritis Research Consortium of Canada MRI indices. Multivariate linear regressions were used to determine potential factors that could affect disease activity indices. Receiver operating characteristic curve was used to determine the effectiveness in screening for axial-joint inflammation. RESULTS: BASDAI was associated with current back pain (B = 0.89, P = 0.01), ASDAS-CRP with current back pain (B = 0.74, P = 0.04), and current dactylitis (B = 0.70, P = 0.03) ASDAS-ESR with current back pain (B = 0.95, P = 0.01), and current dactylitis (B = 0.99, 0.002). The ROC curve revealed that CRP was the only variable that successfully discriminated spondyloarthritis patients with and without axial-joint inflammation by MRI, although it had poor accuracy (area under the curve, 0.63; 95% confident interval, 0.53-0.72; P = 0.01). CONCLUSIONS: Based on our results, MRI could be used to supplement traditional disease assessment tools for more accurate disease evaluation.

Comparing diffusion weighted imaging with clinical and blood parameters, and with short tau inversion recovery sequence in detecting spinal and sacroiliac joint inflammation in axial spondyloarthritis.

OBJECTIVES: To investigate the usefulness of diffusion weighted imaging (DWI) by comparing with clinical features, blood parameters and traditional short tau inversion recovery (STIR) sequence in detecting spinal and sacroiliac (SI) joint inflammation in axial spondyloarthritis (axSpA) patients. METHODS: One hundred and ten axSpA patients were recruited. Clinical, radiological and blood parameters were recorded. DWI and STIR MRI were performed simultaneously and results were scored according to the Spondyloarthritis Research Consortium of Canada (SPARCC) for comparison. Apparent diffusion coef cient (ADC) values were also calculated. RESULTS: DWI did not correlate with clinical parameters or blood parameters. It also had lowered sensitivity. When compared with STIR sequence, it correlated well with STIR sequence at the SI joint level (CC 0.76, p<0.001), but weakly at the spinal level (CC 0.23, p=0.02). At the SI joint level, the presence of inflammation on both STIR sequence and DWI was associated with an increase in maximum (B=0.24, p=0.02 in STIR; B=0.37, p<0.001 in DWI) and mean ADC values (B=0.17, p=0.003 in STIR; B=0.15, p=0.01 in DWI). Maximum (B=0.19, p=0.04) and mean spinal ADC values (B=0.18, p=0.01) were also positively associated with DWI detected spinal inflammation. Presence of Modic lesions showed positive correlation with STIR sequence (B=7.12, p=0.01) but not spinal ADC values. CONCLUSIONS: Despite DWI correlates with STIR sequence, it has lower sensitivity. However, ADC values appear to be independent of Modic lesions and may supplement STIR sequence to differentiate degeneration.

A Lethal Sequelae of Spinal Infection Complicating Surgery and Radiotherapy for Head and Neck Cancer.

Patients who have undergone neck dissection and radiotherapy are at risk of cervical spine infections. Furthermore, previous radiotherapy and cervical spine infections can lead to fistula formation to the subarachnoid space and intracranial infection. This report discusses the serious consequences of a missed cervical spine infection including cerebrospinal fluid fistula formation and persistent central nervous system infection, and serves as a reminder to clinicians of the possible association between cervical spine infections and prior head and neck surgery and radiotherapy. In all such cases, the posterior pharyngeal wall should be inspected during follow-up. Despite the appearance of an intracranial infection, the cervical spine should be investigated, especially if the response to appropriate antibiotics is suboptimal.

Left ventricular myocardial dysfunction and premature atherosclerosis in patients with axial spondyloarthritis.

OBJECTIVE: To evaluate left ventricular (LV) function and carotid intima-media thickness (IMT) in patients with axial SpA in relationship to underlying disease severity. METHODS: We recruited 104 patients with axial SpA and 50 controls. Detailed transthoracic echocardiography was performed and analysed with two-dimensional speckle tracking strain analysis for systolic function and tissue Doppler-derived E/E' for diastolic function assessment. Carotid IMT was measured by ultrasonography to evaluate subclinical atherosclerosis. Radiological severity of patients with axial SpA was assessed by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). RESULTS: Despite a similar LV ejection fraction [62.7% (s.d. 3.9) vs 62.8% (s.d. 3.8), P = 0.83], patients with axial SpA had impaired LV myocardial longitudinal strain (LS), circumferential strain (CS) and radial strain (RS) compared with controls [-18.1% (s.d. 2.4) vs -20.1% (s.d. 2.5), -17.2% (s.d. 2.2) vs -20.3% (s.d. 2.9) and 37.1% (s.d. 8.6) vs 43.2% (s.d. 10.9), respectively; all P < 0.01]. In addition, patients with axial SpA had a greater E/E' [7.9 (s.d. 2.5) vs 7.0 (s.d. 1.7), P < 0.01] and carotid IMT [0.78 mm (s.d. 0.19) vs 0.69 mm (s.d. 0.10), P < 0.01] than controls. After adjusting for potential confounding factors, axial SpA remained independently associated with LV myocardial strains, E/E' and carotid IMT. Importantly, multivariate linear regression analysis demonstrated that mSASSS was independently associated with LV longitudinal strain, E/E' and carotid IMT. CONCLUSION: Our study demonstrated that patients with axial SpA had impaired LV systolic and diastolic function and increased carotid IMT. Importantly, mSASSS was independently associated with LV longitudinal strain, E/E' and carotid IMT after adjusting for confounding factors. Speckle tracking echocardiography may be a useful tool for early detection of impaired LV function in patients with SpA and carotid IMT examination can provide valuable assessment of subclinical atherosclerosis in patients with SpA.

B-cell-targeted therapies in systemic lupus erythematosus.

Autoreactive B cells are one of the key immune cells that have been implicated in the pathogenesis of systemic lupus erythematosus (SLE). In addition to the production of harmful auto-antibodies (auto-Abs), B cells prime autoreactive T cells as antigen-presenting cells and secrete a wide range of pro-inflammatory cytokines that have both autocrine and paracrine effects. Agents that modulate B cells may therefore be of potential therapeutic value. Current strategies include targeting B-cell surface antigens, cytokines that promote B-cell growth and functions, and B- and T-cell interactions. In this article, we review the role of B cells in SLE in animal and human studies, and we examine previous reports that support B-cell modulation as a promising strategy for the treatment of this condition. In addition, we present an update on the clinical trials that have evaluated the therapeutic efficacy and safety of agents that antagonize CD20, CD22 and B-lymphocyte stimulator (BLyS) in human SLE. While the results of many of these studies remain inconclusive, belimumab, a human monoclonal antibody against BLyS, has shown promise and has recently been approved by the US Food and Drug Administration as an indicated therapy for patients with mild to moderate SLE. Undoubtedly, advances in B-cell immunology will continue to lead us to a better understanding of SLE pathogenesis and the development of novel specific therapies that target B cells.