Diagnostic delay in psoriatic arthritis: insights from a nationwide multicenter study.

This study aimed to investigate the duration of diagnostic delay in patients with psoriatic arthritis (PsA) and identify potential contributing factors using a comprehensive, population-based approach. Data were obtained from the Turkish League Against Rheumatism (TLAR)-Network, involving patients who met the CASPAR criteria. Diagnostic delay was defined as time interval from symptom onset to PsA diagnosis, categorized as ≤ 2 years and > 2 years. Temporal trends were assessed by grouping patients based on the year of diagnosis. Various factors including demographics, clinical characteristics, disease activity, quality of life, physical function, disability, fatigue, and well-being were examined. Logistic regression models were used to identify factors associated with diagnostic delay. Among 1,134 PsA patients, mean diagnostic delay was 35.1 months (median: 12). Approximately 39.15% were diagnosed within 3 months, and 67.02% were diagnosed within 24 months. Patients experiencing longer delays had higher scores in Psoriatic Arthritis Quality of Life Questionnaire (PsAQoL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), patient's global assessment (PtGA) and physician's global assessment (PhGA). Diagnostic delay has decreased over time, with median delay falling from 60 to 24 months throughout pre-2010 and 2015-2019 terms. Several factors were identified as significant contributors to delayed diagnosis, including lower levels of education (OR = 2.63), arthritis symptoms preceding skin manifestations (OR = 1.72), low back pain at first visit (OR = 1.60), symptom onset age (OR = 0.96), and psoriasis subtype (OR = 0.25). Timely diagnosis of PsA is crucial for effective management and improved outcomes. Despite recent improvements, about one-third of PsA patients still experience delays exceeding 2 years. By identifying influential factors such as education level, arthritis symptoms preceding skin manifestations, initial visit symptoms, age of symptom onset, and psoriasis subtype, healthcare practitioners may create specific techniques to help in early detection and intervention.

Beyond expectations: disease duration and psychological burden in psoriatic arthritis.

This study aims to investigate the relationship between disease duration and psychological burden in PsA and to identify the risk factors associated with psychological distress. Patients with PsA who met CASPAR classification criteria enrolled by Turkish League Against Rheumatism (TLAR)-Network. Patients were categorized into three groups based on disease duration: early stage (< 5 years), middle stage (≥ 5, < 10 years), and late stage (≥ 10 years). All patients underwent clinical and laboratory assessment using standardized protocol and case report forms. The associations between psychological variables and clinical parameters were assessed by a multivariate analysis. Of the 1113 patients with PsA (63.9% female), 564 (%50.7) had high risk for depression and 263 (%23.6) for anxiety. The risk of psychological burden was similar across all PsA groups, and patients with a higher risk of depression and anxiety also experienced greater disease activity, poorer quality of life, and physical disability. Multivariate logistic regression revealed that female gender (OR = 1.52), PsAQoL (OR = 1.13), HAQ (OR = 1.99), FiRST score (OR = 1.14), unemployment/retired (OR = 1.48) and PASI head score (OR = 1.41) were factors that influenced the risk of depression, whereas the current or past enthesitis (OR = 1.45), PsAQoL (OR = 1.19), and FiRST score (OR = 1.26) were factors that influenced the risk of anxiety. PsA patients can experience a comparable level of psychological burden throughout the course of their disease. Several socio-demographic and disease-related factors may contribute to mental disorders in PsA. In the present era of personalized treatment for PsA, evaluating psychiatric distress can guide tailored interventions that improve overall well-being and reduce disease burden.

Degenerative changes of lumbar spine and their clinical implications in patients with axial spondyloarthritis.

The objective of this study was to assess degenerative changes (DCs) on magnetic resonance imaging (MRI) of lumbar spine in axial spondyloarthritis (axSpA) and non-specific mechanical low back pain (mLBP). Patients were consecutively recruited and all underwent MRI of the lumbar spine in this cross-sectional study. Disk degeneration (DD, Pfirrmann classification), endplate changes (Modic, types 1, 2, and 3), annular fissure, disk bulging, and protrusion or extrusion at each lumbar spinal level were assessed using anonymized images. Patients with axSpA were assessed for disease activity, functioning, and quality of life. Univariate and subsequent multivariate logistic regression analyses with adjustments of various covariates were used to assess association between MRI findings and clinical variables. One hundred twenty-three patients had non-radiographic (nr-axSpA) and 144 had radiographic axSpA/ankylosing spondylitis (AS). Degenerative changes were more prevalent in patients with mLBP (n = 105) than axSpA. Disk degeneration was the most prevalent MRI finding, followed by annular fissure, disk herniation (protrusion or extrusion), and Modic changes (MCs) in axSpA. Disk herniation was more prevalent in patients with nr-axSpA compared to AS. Modic changes (OR = 6.455), lumbar disk herniation (OR = 2.278), annular fissure (OR = 2.842), conventional synthetic or biologic disease-modifying antirheumatic drugs (csDMARDs) non-users (OR = 2.225), and advanced age (OR = 31.556) were factors associated with an increased risk of DD in axSpA. Coexisting DD increased the burden of disease in axSpA. A considerable proportion of patients with axSpA had DD at the lumbar spine. These degenerative changes might explain some of the complaints and should not been overlooked in patients with axSpA. Key Points • Lumbar herniated nucleus pulposus (LHNP) is more frequent in nr-axSpA while MC is more frequent in AS. • DD may cause an increase in BASFI and BASMI scores in axSpA. • Spinal DCs might be an alternative explanation for low back complaints and should not been overlooked in patients with axSpA.

The impact of nail psoriasis on disease activity, quality of life, and clinical variables in patients with psoriatic arthritis: A cross-sectional multicenter study.

AIM: Nail involvement is common in psoriatic arthritis. This study assesses clinical characteristics, nail psoriasis prevalence, and impact of nail psoriasis on disease activity in patients with psoriatic arthritis (PsA). METHOD: This cross-sectional multicenter study was conducted by the Turkish League Against Rheumatism using PsA patients recruited from 25 centers. Demographic and clinical characteristics of PsA patients, such as disease activity measures, quality of life, and nail involvement findings were assessed during routine follow-up examinations. Patients were divided into two groups according to the presence or absence of nail psoriasis and compared using the χ2 test or Fisher exact test for categorical variables and the t-test or Mann-Whitney U test for continuous variables. RESULTS: In 1122 individuals with PsA, 645 (57.5%) displayed nail psoriasis. The most frequent features of fingernails were ridges (38%), followed by pitting (21%) and onycholysis (19%). More females were present in both groups (with and without nail psoriasis; 64% vs 67%, P < 0.282). Patients with nail psoriasis were older, indicated more pain and fatigue, experienced greater swelling, tender joint counts, and skin disease severity, and had a higher disease activity score compared with those without nail psoriasis (all P < 0.05). CONCLUSION: We demonstrate an increased prevalence of nail psoriasis observed in patients with psoriatic arthritis. Patients with nail involvement experience increased disease activity, lower quality of life, and diminished mental and physical status compared with those without nail involvement.

Inconsistencies of the Disease Activity Assessment Tools for Psoriatic Arthritis: Challenges to Rheumatologists.

OBJECTIVE: Currently, concerning the evaluation of psoriatic arthritis (PsA), there is no agreement on a standardized composite index for disease activity that includes all relevant domains. The present study sought to assess the rates of remission (REM)/low disease activity (LDA) and disease states [minimal disease activity (MDA), very low disease activity (VLDA)] as defined by diverse activity scales (DAPSA, DAS28-ESR) in an attempt to display discrepancies across these assessment tools for peripheral PsA. METHODS: The study involved 758 patients (496 females, 262 males; mean age 47,1 years) with peripheral PsA who were registered to the Turkish League Against Rheumatism (TLAR) Network. The patients were assessed using the DAS28-ESR, DAPSA, MDA, and VLDA. The overall yield of each scale was assessed in identifying REM and LDA. The presence or absence of swollen joints was separately analysed. RESULTS: The median disease duration was 4 years (range 0-44 years). According to DAPSA and DAS28-ESR, REM was achieved in 6.9% and 19.5% of the patients, respectively. The rates of MDA and VLDA were 16% and 2.9%, respectively. Despite the absence of swollen joints, a significant portion of patients were not considered to be in REM (296 (39.1%) patients with DAS28-ESR, 364 (48%) with DAPSA, and 394 (52%) with VLDA). CONCLUSION: Patients with peripheral PsA may be assigned to diverse disease activity levels when assessed with the DAS28-ESR, DAPSA, MDA and VLDA, which would inevitably have clinical implications. In patients with PsA a holistic approach seems to be necessary which includes other domains apart from joint involvement, such as skin involvement, enthesitis, spinal involvement, and patient-reported outcomes.

Impact of obesity on quality of life, psychological status, and disease activity in psoriatic arthritis: a multi­center study.

This article aims to evaluate the possible effect of obesity on quality of life, psychological status, and other clinical variables in Psoriatic arthritis (PsA). PsA patients have been recruited by the Turkish League Against Rheumatism-Network from various centers in Turkey in this cross-sectional study. Patients with a body mass index (BMI) ≥ of 30 kg/m2 were considered obese. Differences among patients with regard to obesity status were assessed with health-related quality of life measures (PsA Quality of Life Questionnaire [PsAQoL]), psychological status (Hospital Anxiety and Depression Scale [HADS]), and disease activity parameters (the Disease Activity index for PSoriatic Arthritis [DAPSA], Disease Activity Score 28-C-reactive protein [DAS28-CRP], Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Psoriasis Area and Severity Index [PASI]), physical functions (Ankylosing Spondylitis Functional Index [BASFI], Health Assessment Questionnaire [HAQ], and Health Assessment Questionnaire for the spondyloarthropathies [HAQ-S]). Pain was assessed using visual analog scale of pain (VAS-P), and fatigue was evaluated using visual analog scale of fatigue (VAS-F) and Functional Assessment of Chronic Illness Therapy (FACIT). A total of 1033 patients with PsA, 650 (62.9%) non-obese and 383 (37.1%) obese were included in the study. The PsAQoL, HADS-Anxiety, HADS-Depression, DAPSA, DAS28-CRP, BASDAI, BASFI, HAQ and HAQ-S scores of the obese group were higher than the non-obese group (p < 0.05). VAS-P and PASI scores were similar between group of patients with and without obesity. Obese patients had higher median scores of VAS-F and FACIT than non-obese patients (p < 0.05). Linear regression analysis showed that BMI affects the quality of life, depression, and disease activity. Consequently, obesity has significant associations with higher disease activity, lower QoL, risk of anxiety, depression, and fatigue. Therefore, obesity should also be taken into account in the management of PsA patients.

Gender differences in the discriminative value of inflammatory low back pain criteria.

BACKGROUND/PURPOSE: Inflammatory low back pain (IBP) is the leading symptom in axial spondyloarthritis (axSpA) and its assessment is crucial for the diagnosis. Our aim was to assess gender specific differences in the discriminative ability of the items and criteria sets in a specific patient population consisting patients with axSpA and other causes of chronic low back pain (LBP). METHODS: Patients with chronic LBP with an onset less than 45 years were included and screened for the Assessment of Spondyloarthritis International Society (ASAS) axSpA criteria. Items of IBP, according to Calin, Berlin and ASAS expert criteria were evaluated in patients with axSpA and non-SpA LBP by a blinded researcher. Discriminative ability of the single items and sets were assessed in terms of sensitivity, specificity and area under the curve (AUC) analysis in male and female patients and compared between genders. RESULTS: Single IBP items performed similarly well in men and women, as well as criteria sets. Despite similar discriminative performance of IBP items and criteria sets in both genders, women tend to have slightly better performance. Our results revealed similar sensitivity but slightly lower specificity for most of the single items and criteria sets compared to previous reports. CONCLUSION: Gender may have an influence on the discriminative performance of some of the IBP items and criteria sets as well. Calin criteria seem to perform slightly better in both genders than Berlin and ASAS criteria sets. KEY WORDS: Inflammatory, back pain, gender, axial spondyloarthritis.

Clinical characteristics, disease activity, functional status, and quality of life results of patients with psoriatic arthritis using biological and conventional synthetic disease-modifying antirheumatic drugs.

OBJECTIVES: This study aims to compare the clinical characteristics, disease activity, and quality of life (QoL) of patients with psoriatic arthritis (PsA) who use biological and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) in a nationwide cohort throughout Turkey. PATIENTS AND METHODS: A total of 961 patients (346 males, 615 females; mean age 46.9±12.2 years; range, 18 to 81 years) with PsA according to the classification criteria for PsA were included in the study. The patients' demographic and clinical characteristics, physical examination results, Disease Activity Score 28, Disease Activity Index for Psoriatic Arthritis and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Psoriasis Area and Severity Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, Hospital Anxiety and Depression Scale, Health Assessment Questionnaire, Psoriatic Arthritis Quality of Life (PsAQoL), and short form-36 scores were all recorded. RESULTS: Of the patients, 23% underwent biological DMARD (bDMARD) monotherapy, 42% underwent conventional synthetic DMARD (csDMARD) monotherapy, 10% underwent a csDMARD combination therapy, and 10% underwent a combination bDMARD and csDMARD treatment. The visual analog scale (VAS pain), patient global assessment, physician global assessment, and BASDAI scores were found to be lower among patients using combination treatment of csDMARD and bDMARD, while the swollen joint count was found to be lower among patients using bDMARD. The PsAQoL score was found to be the lowest among patients not using any medication and the highest among those using bDMARD. CONCLUSION: In our study, patients with PsA were successfully treated with both csDMARD and bDMARD monotherapy. When the biological treatments used for PsA were compared with csDMARD, it was found that biological treatments had a positive effect on both disease activity and the QoL. Combinations of csDMARDs and bDMARDs were preferred in cases in which the disease activity was still high or increased. Because of the highest efficacy of the combined treatment, we highly suggest increasing the number of patients on combined treatment.

Gender-related differences in disease activity and clinical features in patients with peripheral psoriatic arthritis: A multi-center study.

OBJECTIVE: This study sought to compare disease activity, clinical features, and patient-reported outcomes concerning anxiety, depression, fatigue, function, quality of life, and fibromyalgia between female and male patients with peripheral PsA in a Turkish population. METHODS: This multi-center Turkish League Against Rheumatism (TLAR) Network study included 1038 patients (678 females, 360 males) diagnosed with peripheral PsA according to the CASPAR criteria. The demographic and clinic parameters of the patients were recorded. Disease activity was evaluated using the scores of DAS28 and cDAPSA. Remission, minimal disease activity (MDA), and very low disease activity (VLDA) were determined. Health Assessment Questionnaire (HAQ), Short-Form-36 (SF-36), Hospital Anxiety and Depression Scale (HAD), fatigue VAS (0-10), and Fibromyalgia Rapid ScreeningTool (FiRST) were used. Disease activity and patient-reported outcomes were compared in male and female patients, and the predictors of MDA for both genders were analyzed. RESULTS: The patients' mean age was 47.6years (SD: 12) for females and 46.3years (SD: 12.3) for males. In terms of DAS28 and cDAPSA, female patients had significantly higher disease activity scores, while male patients had significantly higher remission rates (P<0.05). There was a significant difference in the rate of MDA in favor of males (P<0.05), but not in VLDA. The incidences of dactylitis, enthesitis, tenosynovitis, and inflammatory bowel disease were similar in male and female patients, except for spondylitis, which was higher in males (P<0.05). Overall, although there was no significant between-group difference in age and disease duration, female patients had significantly higher BMI and late-onset disease (P<0.05). Female patients had higher HAD, HAQ, and FiRST and lower SF-36 scores than males (P<0.05). In both male and female patients, the disease activity score of cDAPSA was significantly correlated with the scores of FiRST, HAD, VAS-F, and HAQ (P<0.05). In regression analysis, tender joint count, swollen joint count, PASI, pain VAS, and enthesitis were the MDA predictors in both genders. CONCLUSION: In patients with peripheral PsA, males are more likely to develop spondylitis while other extraarticular manifestations are similar. Female patients appear to have lower rates of remission and MDA and higher levels of disease activity. Female patients experience a more severe course of PsA, with higher levels of pain and fatigue, lower quality of life, and increased functional limitations. The predictors of MDA, i.e., tender joint count, swollen joint count, PASI, pain VAS, and enthesitis are similar between the two genders.

The effect of gender on disease activity and clinical characteristics in patients with axial psoriatic arthritis.

OBJECTIVES: In this study, we aimed to evaluate the effect of gender on clinical findings, disease activity, functional status and quality of life in patients with axial involvement in Turkey. METHODS: Patients with PsA who met the CASPAR classification criteria were enrolled consequently in this cohort. Turkish League Against Rheumatism (TLAR)-Network was formed with the participation of 25 centres. The demographic variables, fatigue, diagnostic delay, the beginning of peripheral arthritis, enthesitis, dactylitis and spine involvement, inflammatory low back pain, BASFI, HAQ, HAQ-s, visual analogue scale-pain (VAS-pain), anxiety, depression and disease activity parameters (ESR, DAS28, BASDAI) were recorded. Axial involvement was assessed according to clinical and radiological data according to modified New York (MNYC) or Assessment of SpondyloArthritis international Society (ASAS) criteria. RESULTS: A total of 1018 patients with PsA were included in this study. Of the 373 patients with axial involvement, 150 were male (40.2%) and 223 (59.8%) were female. Spondylitis was detected in 14,7% of men and 21,9% of women in all patients. Pain score (VAS) (p < .002), fatigue (p < .001), ESR (p < .001), DAS28 (p < .001), BASDAI score (p < .001), PsAQoL (p < .001), HAQ score (p < ,01), HAQ-S score (p < .001), anxiety (p < .001), depression (p < .024), FACIT (p < .001) and FiRST (p < .001) scores were statistically significantly worse in women than males with axial PsA. However, quality of life was better (p < .001) and PASI score (p < .005) were statistically worse in male patients than in female patients with axial involvement. CONCLUSION: This study has shown that the burden of disease in axial PsA has significant difference between genders. Disease activity, physical disability, functional limitation, depression and anxiety scores were higher in female patients, while quality of life were better and PASI score were higher in male patients. Therefore, we suggest that new strategies should be developed for more effective treatment of axial PsA in female patients.

The impact of fatigue on patients with psoriatic arthritis: a multi-center study of the TLAR-network.

Fatigue is a substantial problem in patients with psoriatic arthritis (PsA) that needs to be considered in the core set of domains. This study aimed to evaluate fatigue and its relationship with disease parameters, functional disability, anxiety, depression, quality of life, and correlation with disease activity as determined by various scales. A total of 1028 patients (677 females, 351 males) with PsA who met the CASPAR criteria were included [Turkish League Against Rheumatism (TLAR) Network multicenter study]. The demographic features and clinical conditions of the patients were recorded. Correlations between fatigue score and clinical parameters were evaluated using the Disease Activity Score 28 (DAS28), Disease Activity in Psoriatic Arthritis (DAPSA), Clinical DAPSA (cDAPSA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Fibromyalgia Rapid Screening Tool (FiRST), minimal disease activity (MDA), and very low disease activity (VLDA). Fatigue was assessed with the Functional Assessment of Chronic Illness Therapy (FACIT-F) and a 10-point VAS (VAS-F). The mean age of the patients was 47 (SD: 12.2) years, and the mean disease duration was 6.4 (SD: 7.3) years. The mean VAS-F score was 5.1 (SD: 2.7), with fatigue being absent or mild, moderate, and severe in 12.8%, 24.6%, and 62.5% of the patients, respectively. Fatigue scores were significantly better in patients with DAS28 remission, DAPSA remission, cDAPSA remission, MDA, and VLDA (p < 0.001). Fatigue scores significantly increased with increasing disease activity levels on the DAS28, DAPSA, and cDAPSA (p < 0.001). VAS-F scores showed correlations with the scores of the BASDAI, BASFI, PsAQoL, HAD-A, FiRST, pain VAS, and PtGA. FiRST scores showed fibromyalgia in 255 (24.8%) patients. FACIT-F and VAS-F scores were significantly higher in patients with fibromyalgia (p < 0.001). In regression analysis, VLDA, BASDAI score, FiRST score, high education level, HAD-Anxiety, and BMI showed independent associations with fatigue. Our findings showed that fatigue was a common symptom in PsA and disease activity was the most substantial predictor, with fatigue being less in patients in remission, MDA, and VLDA. Other correlates of fatigue were female gender, educational level, anxiety, quality of life, function, pain, and fibromyalgia.

Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi-center study.

Psoriatic arthritis (PsA) is an inflammatory arthritis with distinct phenotypic subtypes. Enthesitis is assigned as a hallmark of the disease, given its significant relations to disease activity and quality of life. Our objective is to evaluate the prevalence of enthesitis and its association with some clinical parameters, particularly quality of life, using data from a national registry. Patients with PsA meeting ClASsification criteria for Psoriatic Arthritis (CASPAR) were enrolled by means of a multi-centre Turkish League Against Rheumatism (TLAR) Network Project. The following information was recorded in web-based case report forms: demographic, clinical and radiographic data; physical examination findings, including tender and swollen joint counts (TJC and SJC); nail and skin involvement; Disease Activity Score-28 for Rheumatoid Arthritis with Erythrocyte Sedimentation Rate (DAS 28-ESR); Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); Maastricht Ankylosing Spondylitis Enthesitis Score (MASES); Psoriasis Area Severity Index (PASI); Bath Ankylosing Spondylitis Radiology Index for the spine (BASRI-s); Health Assessment Questionnaire (HAQ); Bath Ankylosing Spondylitis Functional Index (BASFI); Health Assessment Questionnaire for the spondyloarthropathies (HAQ-s); Psoriatic arthritis quality of Life scale (PsAQoL); Short Form 36 (SF-36); Hospital Anxiety Depression Scale (HADS); Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); and Fibromyalgia Rapid Screening Tool (FiRST) scores. The patients were divided into two groups, namely with and without enthesitis, based on the triple Likert-type physician-reported statement of 'active enthesitis', 'history of enthesitis' or 'none' in the case report forms. Patients with active enthesitis were compared to others in terms of these clinical parameters. A total of 1130 patients were enrolled in this observational study. Of these patients, 251 (22.2%) had active enthesitis according to the clinical assessment. TJC, HAQ-s, BASDAI, FiRST and PsAQoL were significantly higher whereas the SF-36 scores were lower in patients with enthesitis (p < 0.05). Chronic back pain, dactylitis, and tenosynovitis were more frequent in the enthesopathy group (59.4%/39%, 13.1%/6.5% and 24.7%/3.4%, respectively). Significant positive correlations between the MASES score and the TJC, HAQ, DAS 28-ESR, BASDAI, FiRST and PsAQoL scores, and a negative correlation with the SF-36 score were found. When linear regression analysis was performed, the SF-36 MCS and PCS scores decreased by - 9.740 and - 11.795 units, and the FiRST scores increased by 1.223 units in patients with enthesitis. Enthesitis is an important involvement of PsA with significant relations to quality of life determined with PsAQoL and SF-36 scores. Our study found higher frequency of dactylitis and chronic back pain, and worse quality of life determined with SF-36 and PsAQoL scores in patients with enthesitis.

Residual symptoms and disease burden among patients with psoriatic arthritis: is a new disease activity index required?

The aim of this study was to investigate residual symptoms or disease burden among patients with psoriatic arthritis (PsA) in remission or low disease activity (LDA) according to different outcome measures. A total of 126 patients with PsA were included and the following variables were assessed: Tender joint count (TJC), swollen joint count (SJC), patient's global assessment, physician's global assessment, pain, extra-articular manifestations, Psoriasis Area and Severity Index, Health Assessment Questionnaire, fatigue, Short Form-36, psoriatic quality of life, Hospital Anxiety and Depression Scale and C-reactive protein (CRP). Disease activity was measured using three different outcome measures including minimal disease activity (MDA), disease activity score for 28 joints (DAS28-CRP) and disease activity in psoriatic arthritis (DAPSA). The number (%) of patients who achieved remission or LDA was 9(14.1), 34(27.0) and 67(53.2) according to MDA, DAPSA and DAS28-CRP criteria, respectively, under usual care. SJC > 1 was seen in 3(8.8%) and 13(19.4%) of patients in remission or LDA as defined by the DAPSA and DAS28-CRP respectively. TJC > 1 was found at least 32.4% of patients with PsA in remission or LDA by any definition. 22.2-49.3% of patients with PsA in remission or LDA still suffered from clinically important fatigue. No patients in MDA had a substantial functional impairment while 2.9-19.4% of patients fulfilling remission or LDA according to the DAPSA and DAS28-CRP experienced functional disability. At least 22.2% of patients with PsA in remission or LDA by any description had higher risk for depression, and at least 11.1% for anxiety. Despite patients with PsA in remission or LDA by various definition, they may continue to experience pain, tender or swollen joints, fatigue, physiologic distress as well as functional impairment suggesting that there is a significant unmet need with regard to definition of remission or LDA in PsA.

Management of Psoriatic Arthritis: Turkish League Against Rheumatism (TLAR) Expert Opinions.

OBJECTIVES: This study aims to establish the first national treatment recommendations by the Turkish League Against Rheumatism (TLAR) for psoriatic arthritis (PsA) based on the current evidence. PATIENTS AND METHODS: A systematic literature review was performed regarding the management of PsA. The TLAR expert committee consisted of 13 rheumatologists and 12 physical medicine and rehabilitation specialists experienced in the treatment and care of patients with PsA from 22 centers. The TLAR recommendations were built on those of European League Against Rheumatism (EULAR) 2015. Levels of evidence and agreement were determined. RESULTS: Recommendations included five overarching principles and 13 recommendations covering therapies for PsA, particularly focusing on musculoskeletal involvement. Level of agreement was greater than eight for each item. CONCLUSION: This is the first paper that summarizes the recommendations of TLAR as regards the treatment of PsA. We believe that this paper provides Turkish physicians dealing with PsA patients a practical guide in their routine clinical practice.

Effect of Turbinate Intervention on Nasal Functions in Septorhinoplasty Surgery.

OBJECTIVE: This study was performed to evaluate the effect of inferior turbinate reduction on nasal function. MATERIALS AND METHODS: A total of 32 patients who underwent septorhinoplasty (SRP) operation were included in the study and assigned into 2 groups as group I who received inferior turbinate reduction during SRP operation consisted of 17 patients and the group II who consisted of 15 patients without inferior turbinate reduction. For 2 groups before and after surgery, visual analogue score and findings of the acoustic rhinometry were recorded both before and after decongestion of the nasal mucosa. RESULTS: Postoperative mean visual analogue scale (VAS) scores revealed a statistically significant reduction compared with preoperative values on right and left side of the nasal cavity, both before and after topical decongestion in group I (P < 0.005). Also in group II, the differences of VAS scores for both sides before and after topical decongestion were statistically significant (P < 0.05). Postoperatively, the increase of the volume measurements at the level of pyriform sinüs (VOL2) value on the right side of the nasal cavity before and after decongestion and volume measurements at the level of the nasal valve (VOL1) values on both sides after topical decongestion were found to be statistically significant in group I. When the VAS scores and acoustic rhinometry measurements of group I and group II patients were compared the difference, for before and after topical decongestion, postoperative mean MCA1 (minimal cross-sectional area at the level of the nasal valve) values for left side and right side of nasal cavity were higher in group I than group II and these differences were statistically significant (P < 0.005). CONCLUSIONS: As a result, in the SRP operations, turbinoplasty should be implemented by taking into account the function as well as aesthetic concern. Similar results were obtained in other studies that were carried on.

Extra-articular manifestations and burden of disease in patients with radiographic and non-radiographic axial spondyloarthritis.

OBJECTIVE: Although the prevalence of peripheral and extra-articular disease in ankylosing spondylitis (AS) has been assessed in many studies, data on non-radiographic axial spondyloarthritis (nr-axSpA) is scanty. The aim of this study was first, to compare radiographic-axSpA/AS (r-axSpA/AS) and nr-axSpA concerning peripheral arthritis and extra-articular manifestations (EAMs), and second, to assess potential differences between patient subgroups with or without EAMs regarding disease burden. METHODS: Data was extracted from our single center axSpA database. Patients having at least one of the EAMs (uveitis and/or inflammatory bowel disease (IBD) and/or psoriasis) were compared to those who did not have EAMs. Patients' clinical data including disease activity, functional and psychological status, physical limitations, quality of life (QoL) and magnetic resonance imaging of sacroiliac joints (SIJ MR) were evaluated. RESULTS: Patients with nr-axSpA (n=193) were younger, had female predominance, better functional and physical status, higher frequency of bone edema in SIJ MR and peripheral arthritis but similar QoL, prevalence of HLA B27 and EAMs compared to r-axSpA/AS (n=352). The prevalence of current or ever uveitis (14.5 vs 15.3%, p=0.791), psoriasis (6.2 vs 5.4%, p=0.689) or IBD (4.1 vs 3.4%, p=0.663) in nr-axSpA and r-axSpA/AS were similar. In both subgroup of patients, EAMs positive and negative patients had similar functional status and QoL, as well as disease activity and laboratory parameters. CONCLUSION: Patients with nr-axSpA and r-axSpA/AS have similar prevalence of EAMs and clinical burden of disease. Having EAMs does not have a major influence on clinical parameters and patient reported outcome measures in nr-axSpA and r-axSpA/AS.

Gender specific differences in patients with psoriatic arthritis.

OBJECTIVES: To assess gender related differences in a cohort of patients with psoriatic arthritis (PsA). METHODS: Consecutively recruited patients were included and underwent clinical, radiological and laboratory evaluation by using standardized protocol and case report forms. RESULTS: Women (n = 115) with PsA had higher symptom duration and body mass index (BMI), tender and swollen joint counts, disease activity score-28 joints (DAS28), Erythrocyte sedimentation rate (ESR) and poorer physical activity and fatigue than men (n = 72) with PsA. Psoriasis area and severity index (PASI) were higher in male patients. However quality of life (SF36 physical and mental component scores), articular pattern, extra-articular features (including uveitis, iritis) and family history for psoriasis, spondyloarthritis (SpA) (PsA and ankylosing spondylitis [AS]) were quite similar between men and women. CONCLUSIONS: Some of the clinical and laboratory variables tend to be different between men and women with PsA. The extent of quality of life and articular pattern seem to be similar in both genders. Men with PsA are more likely to have higher PASI scores and longer duration to develop arthritis after the onset of psoriasis, while women are more likely to have higher disease activity and report more fatigue and physical activity limitations.

Is there any gender-specific difference in the cut-off values of ankylosing spondylitis disease activity score in patients with axial spondyloarthritis?

AIM: To assess the validity of Assessment in Spondyloarthritis International Society (ASAS) endorsed Ankylosing Spondylitis Disease Activity Score (ASDAS) C-reactive protein (-CRP) and ASDAS erythrocyte sedimentation rate (-ESR) in axial spondyloarthritis (axSpA) and to estimate the cut-off values for male and female patients with axSpA. METHODS: Patients with axSpA were assessed for disease activity, functions, mobility and AS Quality of Life (ASQoL) and pain. The discriminant ability of ASDAS versions was assessed using standardized mean differences. Optimal cut-off values of ASDAS versions were calculated. RESULTS: Patients with axSpA were included (196 AS, 164 non-radiographic axSpA). ASDAS versions and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) had good correlations with patient's global (PtG) and physician's global (PhG) assessment in both groups; however, men had relatively higher coefficients. Women had significantly higher pain, ASQoL, ASDAS-ESR, BASDAI item scores, PtG, PhG and ESR. Discriminant abilities of ASDAS-CRP, ASDAS-ESR and BASDAI were similar in men and women regarding low and high disease activity. ASDAS cut-offs are quite similar in both genders and in accordance with predefined values. The cut-offs for ASDAS-ESR were relatively lower than ASDAS-CRP and women tend to have higher cut-offs than men. CONCLUSION: The construct validity of ASDAS-CRP to discriminate low and high disease activity and cut-off values are similar in male and female patients with axSpA; however, cut-offs for ASDAS-ESR need to be defined.

An Unusual Coexistence of Progressive Pseudorheumatoid Dysplasia and Relapsing Polychondritis.

Progressive pseudorheumatoid dysplasia is a rare hereditary skeletal disease characterized by bone and cartilage dysplasia, progressive arthropathy without sign of systemic or synovial inflammation. Relapsing polychondritis (RP) is a rare autoimmune disease associated with inflammation in cartilaginous and other proteoglycan rich structures. An associated autoimmune and/or hematologic disorder is seen in over 30% of patients with RP. To our knowledge, coexistence of progressive pseudorheumatoid dysplasia and RP has not been previously reported. In this article, we describe an unusual case of coexisting progressive pseudorheumatoid dysplasia with RP. Physicians should be aware of this possible association.

Effects of Exercise on Low Density Lipoprotein Receptor Related Protein 5 Gene Expression in Patients With Postmenopausal Osteoporosis.

OBJECTIVES: This study aims to investigate the effects of aerobic exercise on low density lipoprotein receptor related protein 5 (LRP5) gene messenger ribonucleic acid expression and evaluate the relationship between the clinical parameters and gene expression in patients with postmenopausal osteoporosis (OP). PATIENTS AND METHODS: Seven patients with postmenopausal OP (mean age 60.0±5.3 years; range 51 to 66 years) were included in the study. An exercise protocol/program consisting of treadmill exercising for 30 minutes three days a week for six weeks was performed at a moderate intensity. LRP5 gene expression levels were evaluated before the onset of the exercise program and then four hours after the end of the first session and 12th (fourth week) and 18th (sixth week) sessions of exercise. RESULTS: Our results demonstrated variable changes in the LRP5 gene expression after the aerobic exercise sessions. Excluding one patient, the LRP5 gene expression levels showed a slight tendency to increase. In spite of this tendency, gene expression differences during the exercise sessions were not significant. CONCLUSION: Our results suggest that interindividual variations of LRP5 gene expression exist after moderate intensity aerobic exercises in patients with postmenopausal OP. Despite of this variability, LRP5 gene expression levels increased slightly, except in peripheral blood in one patient. Future studies with larger sample sizes and different sampling time/tissues are required to shed more light on the impact of exercise at molecular level in OP.