Presentation of enthesitis-related arthritis and juvenile-onset spondyloarthritis: a cross-sectional study in a pediatric and adult clinic.

BACKGROUND: Juvenile idiopathic arthritis (JIA) comprises a whole spectrum of chronic arthritis starting before 16 years of age. The study aims to explore the clinical and demographic descriptors, treatment, and disease progression of enthesitis-related arthritis (ERA) in comparison with juvenile-onset spondyloarthritis (SpA). METHODS: Cross-sectional analysis of consecutive patients in two dedicated clinics, with a single visit and retrospective case-notes review. Arthritis, enthesitis and sacroiliitis were evaluated by scoring disease activity and damage. Continuous variables were reported by median, interquartile range; categorical variables were reported by the frequency comparison of the two groups. RESULTS: Thirty-three cases were included, being 23 (69.7%) with ERA. The median age at diagnosis was 12.5 y (SpA) vs. 9 y (ERA) (p < 0.01); the time from symptom onset to diagnosis was 5.5 y (SpA) vs. 1.5 y (ERA) (p < 0.03). In both groups, the predominant presentation was a single joint or < 5 lower limb joints and asymmetric involvement, with a high frequency of enthesitis. There was a higher frequency of mid-tarsal and ankle synovitis in the ERA group and hip involvement in those with SpA. The comparison of the frequency of spine symptoms at presentation, 30% SpA vs. 21.7% ERA (p = 0.7), was not significant, and radiographic progression to spinal involvement occurred in 43.5% of ERA patients. The median time for spinal progression and age at onset was 2.2 and 12 y for ERA, and 4 and 16.5 y for SpA, respectively. Activity and damage scores were not significantly different between the groups. Treatment comparison resulted in 91.3% of ERA and 100% SpA being treated, predominantly with NSAIDs in both groups, followed by DMARDs and biologics, with a higher frequency of biologics in SpA. CONCLUSION: The main differences were the late diagnoses of SpA, and the hip and spine involvement, with higher frequency of biologic treatment in juvenile-onset SpA compared to ERA.

Prevalence of axial spondyloarthritis in Colombia: data from the National Health Registry 2017-2021.

INTRODUCTION: Registries allow ascertaining the epidemiology of chronic diseases such as axial spondyloarthritis (axSpA). The Colombian Ministry of Health has implemented a National Health Registry (SISPRO) that collects data from each medical contact in the system, which provides close to universal coverage (around 98%). OBJECTIVE: To establish the 5-year prevalence of axSpA in Colombia, and to describe its demographics, using data from January 1st, 2017, to December 31st, 2021. METHODS: We performed an observational, cross-sectional study using the International Statistical Classification of Diseases and Related Health Problems as search terms related to ax-SpA, based on SISPRO data. We estimated the prevalence using three approaches: (1) ankylosing spondylitis (AS) diagnoses; (2) diagnoses compatible with axSpA; and (3) diagnoses compatible with axSpA, including sacroiliitis. We calculated prevalence per 100,000 inhabitants. RESULTS: Based on our three approaches, patients with a primary diagnosis compatible with ax-SpA ranged between 12,684 and 117,648, with an estimated 5-year adjusted prevalence between 26.3 and 244 cases per 100,000 inhabitants (0.03-0.2%). The male-to-female ratio ranged between 1.2:1 and 0.4:1, which was markedly skewed towards a higher prevalence in women when we included the code for sacroiliitis. We found the highest frequency of cases in the 50-54 years group. A differential prevalence was observed between different regions in our country, particularly in regions known to have European ancestors. CONCLUSION: This is the first study that describes demographic characteristics of ax-SpA in Colombia and offers valuable information for stakeholders. Key Points • Using the official country-level health database, the prevalence of axSpA in Colombia ranges between 26.3 and 244 cases per 100,000 inhabitants (0.03% - 0.2%) • The prevalence of axSpA peaked among the 50-54 years patient group, suggesting an increased survival • Nations with a substantial admixture, such as Colombia, may present a differential prevalence of axSpA among regions within the country • Including the ICD-10 code for sacroiliitis (M46.1) in epidemiological studies probably overestimates the frequency of axSpA.

Pan American League of Associations for Rheumatology recommendations for the management of axial spondyloarthritis.

Axial spondyloarthritis (axSpA) comprises a spectrum of chronic inflammatory manifestations affecting the axial skeleton and represents a challenge for diagnosis and treatment. Our objective was to generate a set of evidence-based recommendations for the management of axSpA for physicians, health professionals, rheumatologists and policy decision makers in Pan American League of Associations for Rheumatology (PANLAR) countries. Grading of Recommendations, Assessment, Development and Evaluation-ADOLOPMENT methodology was used to adapt existing recommendations after performing an independent systematic search and synthesis of the literature to update the evidence. A working group consisting of rheumatologists, epidemiologists and patient representatives from countries within the Americas prioritized 13 topics relevant to the context of these countries for the management of axSpA. This Evidence-Based Guideline article reports 13 recommendations addressing therapeutic targets, the use of NSAIDs and glucocorticoids, treatment with DMARDs (including conventional synthetic, biologic and targeted synthetic DMARDs), therapeutic failure, optimization of the use of biologic DMARDs, the use of drugs for extra-musculoskeletal manifestations of axSpA, non-pharmacological interventions and the follow-up of patients with axSpA.

Implementation of screening criteria for inflammatory bowel disease in patients with spondyloarthritis and its association with disease and endoscopic activity.

There is little literature on the implementation of screening criteria for inflammatory bowel disease (IBD) in patients with spondyloarthritis (SpA). This study aimed to apply IBD screening criteria in a group of patients with SpA without IBD diagnosis and correlate them to endoscopic findings and disease activity. A total of 82 patients with SpA were included. The IBD screening test and ileocolonoscopy with digital chromoendoscopy with magnification and histological analysis were performed. The data were analysed with Chi-square test/Fisher's exact test and multiple correspondence analysis. The major screening criteria found in 48.7% of the patients were associated with a history of infection (p = 0.037). Rectal bleeding was associated with the diagnosis of ankylosing spondylitis, acute inflammation, enthesitis and tissue architecture alteration in the ileum (p < 0.050). Diarrhoea was associated with a higher disease activity score (p = 0.02). Minor screening criteria were associated with painful inflammatory joint (p = 0.05), high disease activity score (p = 0.001) and high calprotectin levels (p = 0.050). Abdominal pain (36.9%) was associated with axial/peripheral compromise (p = 0.017), inflammatory back pain (p = 0.01), enthesitis (p = 0.021), higher disease activity score (p = 0.023) and acute ileum inflammation (p = 0.046). Diarrhoea of 4 weeks and abdominal pain were the most prevalent major and minor screening criteria, respectively, being related to early manifestations of inflammatory bowel compromise and higher disease activity score. This screening test grants a chance of opportune referral of SpA patients from rheumatology to gastroenterology.

Direct Medical Costs and Healthcare Resource Utilization of Treating Patients With Two Clinical Subtypes of Axial Spondyloarthritis in Colombia.

OBJECTIVES: This study aimed to calculate the healthcare resource utilization and direct medical costs in patients with 2 subtypes of axial spondyloarthritis (axSpA) in a rheumatic care center in Colombia. METHODS: This is a retrospective cost-of-illness study. Patients with at least 1 medical consultation associated with an axSpA diagnosis between October 2018 and October 2019 were identified. Patients were classified as having radiographic (r-axSpA) or nonradiographic axSpA (nr-axSpA). Direct medical costs were calculated in Colombian pesos and expressed in American dollars using an exchange rate of 3263 Colombian pesos = 1 US dollar ($). Predictors of total direct costs were identified using a generalized linear model with gamma distribution and log-link. RESULTS: A total of 162 patients with a mean age of 49.6 years (± 13.7) were included in the study. Among these, 147 (90.7%) were considered as having r-axSpA and 15 (9.3%) nr-axSpA, with mean costs of $6600 (± 6203) and $843 (± 1135), respectively (P < .001). The total direct mean cost was calculated at $6067 (± 6144) per patient. Medication costs were the main driver of total costs (97.6%, $5921), with biologic disease-modifying antirheumatic drugs accounting for nearly 92.0% ($5582) of these costs. Rheumatologist (100%) and physiatrist (64.2%) visits were the most frequently used medical service. CONCLUSIONS: The economic burden associated with axSpA in the Colombian setting is substantial. There is a significant difference in direct medical costs between the r-axSpA and the nr-axSpA. Health policies aimed at the comprehensive management of nr-axSpA would have an important role in the reduction of the associated direct medical costs.

Fecal calprotectin as a biomarker of microscopic bowel inflammation in patients with spondyloarthritis.

AIM: Microscopic bowel inflammation is present in up to 60% of all patients with spondyloarthritis (SpA) and appears to be associated with more severe joint disease and a higher risk of developing inflammatory bowel disease (IBD). This study aimed to determine the utility of fecal calprotectin (fCAL) in evaluating endoscopic and histological bowel inflammation in SpA patients. METHODS: Ileocolonoscopies with biopsies and fCAL measurements were performed in 65 patients with SpA. RESULTS: In 47 (72.3%) patients, the fCAL levels were higher than 50 µg/g, whereas in 20 (30.7%), these levels were greater than 250 µg/g. A total of 38 (58.5%) patients presented with microscopic bowel inflammation, and 13 (20%) presented with signs of endoscopic inflammation. fCAL levels were significantly higher in patients with microscopic bowel inflammation than in those without inflammatory findings (P < .001); additionally, these levels were slightly higher in patients with endoscopic signs of bowel inflammation (P = .053). A fCAL cutoff value of 96 µg/g predicted histological bowel inflammation with 73% sensitivity and 67% specificity. No statistically significant difference was observed in the fCAL levels between patients who had been treated or not treated with nonsteroidal anti-inflammatory drugs (NSAIDs). CONCLUSION: Our findings confirm a high prevalence of microscopic bowel inflammation in SpA patients, regardless of the use of NSAIDs. The evaluation of fCAL levels proved to be useful in the identification of microscopic inflammation and could help in the more judicious indication of ileocolonoscopy. These results support the use of fCAL for the evaluation of microscopic bowel inflammation in SpA patients.

Factors Associated With Diagnostic Delay of Axial Spondyloarthritis in Colombian Patients.

BACKGROUND/OBJECTIVE: The diagnostic delay of axial spondyloarthritis (axSpA) is globally reported to be between 3 and 11 years. Early diagnosis and treatment have long-term benefits for patients and the health care system. Several international studies have evaluated some factors associated with diagnostic delay, but there are no known studies in the Colombian population. This study assesses the factors associated with diagnostic delay of axSpA in a rheumatology center in Bogota, Colombia. METHODS: This monocentric analytical cross-sectional study was done in a specialized rheumatology center. Patients who fulfilled the 2009 Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axSpA were included. Information was obtained from medical records and a phone call. Bivariate and multivariate analyses were done to assess the associated factors with diagnostic delay. RESULTS: One hundred one patients were included, 54 were women (53.5%). The median diagnostic delay was 2 years (interquartile range, 1-7). The bivariate analysis showed that a younger age at diagnosis (p = 0.042) and previous diagnosis of lumbar degenerative disease (p = 0.029) were associated with a longer diagnostic delay. The logistical regression showed that previous lumbar degenerative disc disease (odds ratio, 2.8; 95% confidence interval, 1.09-7.53) and fibromyalgia (odds ratio, 4.0; 95% confidence interval, 1.2-13.1) diagnosis were both associated with a longer diagnostic delay. CONCLUSIONS: Factors associated with a longer diagnostic delay were previous diagnosis of lumbar degenerative disc disease and fibromyalgia. Additional studies are needed so that the reasons for diagnostic delay are understood and early diagnosis and management of axSpA are enabled.

2021 clinical practice guidelines for the diagnosis, treatment, and follow-up of patients with peripheral spondyloarthritis. Colombian Association of Rheumatology.

BACKGROUND: Peripheral spondyloarthritis is a chronic inflammatory disease in which clinical presentation is related to the presence of arthritis, enthesitis and/or dactylitis. This term is used interchangeably with some of its subtypes such as psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthritis. OBJECTIVE: To develop and formulate a set of specific recommendations based on the best available evidence for the diagnosis, treatment and monitoring of adult patients with peripheral spondyloarthritis. METHODS: A working group was established, clinical questions were formulated, outcomes were graded, and a systematic search for evidence was conducted. The guideline panel was multidisciplinary (including patient representatives) and balanced. Following the formal expert consensus method, the GRADE methodology "Grading of Recommendations Assessment, Development and Evaluation" was used to assess the quality of the evidence and generate the recommendations. The Clinical Practice Guideline includes ten recommendations; related to monitoring of disease activity (n = 1) and treatment (n = 9). RESULTS: In patients with peripheral spondyloarthritis, the use of methotrexate or sulfasalazine as the first line of treatment is suggested, and local injections of glucocorticoids is recommended conditionally. In patients with failure to cDMARDs, an anti TNFα or an anti IL17A is recommended. In case of failure to bDMARDs, it is suggested to use another bDMARD or JAK inhibitor. In patients with peripheral spondyloarthritis associated to inflammatory bowel disease, it is recommended to start treatment with cDMARDs; in the absence of response, the use of an anti TNFα over an anti-IL-17 or an anti-IL-12-23 is recommended as a second line of treatment. In patients with psoriatic arthritis, the combined use of methotrexate with bDMARD is conditionally recommended for optimization of dosing. To assess disease activity in Psoriatic Arthritis, the use of DAPSA or MDA is suggested for patient monitoring. CONCLUSIONS: This set of recommendations provides an updated guide on the diagnosis and treatment of peripheral spondyloarthritis.

The Role of HLA-B27 in Argentinian Axial Spondyloarthritis Patients.

BACKGROUND: The prevalence of human leukocyte antigen B27 (HLA-B27) is variable around the world. Our objectives were to estimate the frequency of HLA-B27 in an Argentinian cohort of axial spondyloarthritis (axSpA), to evaluate the differences between HLA-B27-positive and HLA-B27-negative patients, and to analyze its performance as a diagnostic biomarker. METHODS: Observational study including patients older than 18 years, with axSpA diagnosis assessed in a fast track program (Reuma-Check SpA). All patients underwent the following: blood tests, HLA-B27, sacroiliac images, and enthesitis ultrasound. Sociodemographic data and SpA symptoms were also collected. The clinical assessor was blinded to complementary studies. For the sensitivity and specificity analysis, patients with chronic low back pain without axSpA who performed the same circuit in the same period were used as control, paired 1:1 (sex and age). RESULTS: One hundred fifty patients were included, 75 axSpA and 75 controls. The frequency of HLA-B27 was 43% (95% confidence interval [CI], 30-53). The differences between HLA-B27-positive and HLA-B27-negative patients were observed in age of low back pain onset (36 vs 46 years), BASFI (Bath Ankylosing Spondylitis Functional Index) (4 vs 5), and extra-articular SpA features such as uveitis and inflammatory bowel disease (29% vs 50%). When this frequency was compared (low back pain control group), the difference was 43% versus 9% (odds ratio, 7.7; 95% CI, 2.8-24), and HLA-B27 had a sensitivity of 43%, specificity of 91%, positive predictive value of 85%, negative predictive value of 58%, and likelihood ratio of 4.9 (95% CI, 3-8). CONCLUSIONS: The frequency of HLA-B27 in axSpA was 43%; positive patients had an earlier age of onset (36), a higher BASFI, and more SpA features. For the diagnosis of SpA, HLA-B27 had a good specificity but low sensitivity.

Clinical and laboratory features of patients with undifferentiated spondyloarthritis and ankylosing spondylitis / Características clínicas y de laboratorio de pacientes con espondiloartritis indiferenciada y espondilitis anquilosante

ABSTRACT BACKGROUND: The terms Spondyloarthritis and spondyloarthropathy (Spa) are used to define a group of diseases with related clinical characteristics and genetics. AIM: To report the clinical and demographic characteristics of ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (USpA) and to evaluate the frequency of cyclic citrullinated peptide antibody (anti-CCP) positivity. MATERIAL AND METHODS: Two hundred patients with USpA or AS, 100 control patients with a diagnosis of rheumatoid arthritis (RA) and 100 healthy volunteers were included. For each patient, their detailed medical histories, physical examination, whole blood counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-CCP, routine biochemical tests, and HLA-B27 test results were evaluated. ASDAS and BASDAI scores and morning stiffness were used to evaluate the disease activity. RESULTS: The presenting symptom of 73 (73%) patients in the AS group and 58 (58%) patients in the USpA group was pain in axial joints. A family history of Spa was positive in 32 patients from both groups (32%). A positive HLA-B27 was found in 55% of the AS group and 25% of the USpA group (p < 0.01 for the difference between groups). The frequency of positive HLA-B27 was significantly higher in individuals with a family history of SpA (p = 0.022). A positive Anti-CCP was found in 56% of the RA group, a significantly higher frequency compared with other groups (p < 0.001). The frequency of positive Anti-CCP in patients in AS (9%) and USpA (6%) was significantly higher than in healthy controls (p < 0.001). CONCLUSIONS: The frequency of anti-CCP positivity was higher in SpA patients than in healthy controls.

INTRODUCCIÓN: Los términos espondiloartritis y espondiloatropatia (Spa) se usan para definir un grupo de enfermedades con características y genética relacionadas. OBJETIVO: Informar las características clínicas y demográficas de la espondilitis anquilosante (EA) y espondiloartritis indiferenciada (USpA) - y para evaluar la frecuencia de positividad del anticuerpo péptido citrulinado cíclico (anti-CCP). MATERIAL Y MÉTODOS: En este estudio observacional se incluyeron doscientos pacientes con USpA y EA, 100 pacientes control con diagnóstico de artritis reumatoide (AR) y 100 voluntarios sanos. Se evaluó la historia clínica, exámen físico, recuentos sanguíneos completos, velocidad de sedimentación globular (ESR), proteína C reactiva (PCR), anti-CCP, pruebas bioquímicas de rutina y resultados de la prueba HLA-B27. Para evaluar la actividad de la enfermedad se utilizaron las puntuaciones ASDAS y BASDAI y la rigidez matutina. RESULTADOS: El síntoma inicial de 73 (73%) pacientes en el grupo de EA y 58 (58%) pacientes en el grupo de USpA fue dolor en las articulaciones axiales. Treinta y dos pacientes de cada grupo (32%) tenían antecedentes familiares de SPA. HLA-B27 fue positivo en el 55% del grupo AS y el 25% del grupo USpA con una diferencia significativa entre los dos grupos (p < 0.001). La frecuencia de positividad HLA-B27 fue mayor en individuos con historia familiar de SpA (p = 0,02). Se encontraron anti-CCP positivos en el 56% del grupo con AR, una frecuencia significativamente mayor en comparación con otros grupos (p < 0,01). La frecuencia de anti-CCP positivo fue mayor los pacientes con AS (9%) y USpA (6%) que en el grupo sano (p < 0,001). CONCLUSIONES: La frecuencia de positividad anti-CCP fue mayor en los grupos de SpA en comparación con los grupos control sanos.

Engagement process for patients with spondyloarthritis: PANLAR early SpA clinics project - centers of excellence.

Spondyloarthritis (SpA) is one of the most complex rheumatological diseases to diagnose and treat because, in the early stages of the disease, the inflammatory low back pain is often difficult to identify, and patients are diagnosed when they already have advanced structural processes. There is an urgent need to establish healthcare models that allow optimization of the management of these patients. The objective of this work is to propose a care model that is adaptable to the factual realities of Latin America. A systematic search of the literature terms (MeSH) was performed to search associated terms. Taking the model of the REAL-PANLAR project as an example and incorporating some related literature, a model of centers of excellence for SpA in Latin America is proposed that can be reasonably established and implemented. This model proposes 3 types of centers of excellence for SpA according to the level of complexity of each institution, and its criteria are defined based on indicators of structure, processes, and results. This is the first effort in Latin America to try to standardize the care of patients with spondyloarthritis. Key Points • The unmet needs in Latin America in the care of SpondyloArthritis (SpA), demand solutions that facilitate the rapid and assertive access of patients to specialized centers such as Center of Excellence in SpA. • This project facilitates the standardization of high-quality care for patients with SpA, starting from its diagnosis and up to clinical follow-up. • Due to standardization of care, better clinical and safety outcomes are achieved for patients, as well as patient-reported outcomes. • By standardized models of care, will be achieved a reduction in the progress of this pathology and optimization in the use of high-complexity services and high-cost therapies, improving cost-efficiency for public health systems in each country.

"Reuma-Check": Performance of a Comprehensive Fast-Track Program for the Diagnosis of Axial Spondyloarthritis in South America.

OBJECTIVES: The aim of this study was to evaluate the performance of a comprehensive diagnosis program called "Reuma-check" for the diagnosis of axial spondyloarthritis (SpA) in patients with low back pain (LBP). METHODS: This is a cross-sectional study. Patients with LBP aged 18 years or older were preselected, and those with at least 1 SpA feature completed the circuit. They were referred after 2 strategies: education for orthopedists and a campaign on social networks. All patients underwent a clinical evaluation, laboratory testing, and imaging (including human leukocyte antigen B27 evaluation and magnetic resonance imaging). The diagnosis of axial SpA was established by an expert rheumatologist opinion. Time from onset of symptoms to "Reuma-check," time from patient referral to admission of the checkup, and time from "Reuma-check" to diagnosis were evaluated. RESULTS: A total of 175 of 246 patients were included, most of them came from the social media campaign (55%). Seventy-five (43%) of 175 patients were diagnosed as axial SpA. The median time from referral (or self-referral) to access to the program was 1.3 months. The median time from symptoms onset to access to the program was 31.7 months, and the median time from the performance of "Reuma-check" to final diagnosis was 2 weeks. Features associated with a diagnosis of axial SpA were as follows: inflammatory LBP (odds ratio [OR], 6.64; 95% confidence interval [CI], 1.6-28), clinical enthesopathy (OR, 4.56; 95% CI, 1.1-18.4), positive human leukocyte antigen B27 (OR, 23.02; 95% CI, 3.5-58), and positive magnetic resonance imaging (OR, 14.34; 95% CI, 3.5-58). CONCLUSIONS: "Reuma-check" allowed a high frequency of axial SpA diagnosis and improved access to rapid diagnosis, shortening the time from referral to diagnosis with a shorter acquisition time for the ancillary studies. Patients with a final diagnosis of axial SpA presented distinctive features.

Clinical and laboratory features of patients with undifferentiated spondyloarthritis and ankylosing spondylitis.

BACKGROUND: The terms Spondyloarthritis and spondyloarthropathy (Spa) are used to define a group of diseases with related clinical characteristics and genetics. AIM: To report the clinical and demographic characteristics of ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (USpA) and to evaluate the frequency of cyclic citrullinated peptide antibody (anti-CCP) positivity. MATERIAL AND METHODS: Two hundred patients with USpA or AS, 100 control patients with a diagnosis of rheumatoid arthritis (RA) and 100 healthy volunteers were included. For each patient, their detailed medical histories, physical examination, whole blood counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-CCP, routine biochemical tests, and HLA-B27 test results were evaluated. ASDAS and BASDAI scores and morning stiffness were used to evaluate the disease activity. RESULTS: The presenting symptom of 73 (73%) patients in the AS group and 58 (58%) patients in the USpA group was pain in axial joints. A family history of Spa was positive in 32 patients from both groups (32%). A positive HLA-B27 was found in 55% of the AS group and 25% of the USpA group (p < 0.01 for the difference between groups). The frequency of positive HLA-B27 was significantly higher in individuals with a family history of SpA (p = 0.022). A positive Anti-CCP was found in 56% of the RA group, a significantly higher frequency compared with other groups (p < 0.001). The frequency of positive Anti-CCP in patients in AS (9%) and USpA (6%) was significantly higher than in healthy controls (p < 0.001). CONCLUSIONS: The frequency of anti-CCP positivity was higher in SpA patients than in healthy controls.

Assessing rheumatologists' attitudes and utilization of classification criteria for ankylosing spondylitis and axial spondyloarthritis: a global effort.

OBJECTIVES: This study aims to assess rheumatologists' perceptions, utilization patterns, and attitudes towards the modified New York (mNY) criteria for ankylosing spondylitis (AS) and Assessment of SpondyloArthritis International Society (ASAS) criteria for axial spondyloarthritis (axSpA). METHODS: Members of the national rheumatology societies in five countries (United States of America (USA), Canada, India, Turkey, and Brazil) were invited to participate in a survey containing questions regarding rheumatologists' familiarity, and use of AS and axSpA classification criteria in daily practice, perceived specificity of spondyloarthritis features in making the diagnosis, patterns of imaging tests performed in daily practice, and their opinion about the need for modification of current classification criteria. The responses were analyzed by gender, age, years in practice, as well as by country of practice. Descriptive statistics, t test, and chi-square test were used for comparison of groups. RESULTS: Approximately 6% rheumatologists (478 out of 8021 professional association members) from five countries completed the survey. The country-specific response rates were Brazil 4%, USA 4.3%, India 11%, Canada 14%, and Turkey 29%, though the overall contributions from individual countries were USA 47%, India 14.9%, Brazil 13.8%, Turkey 12.8%, and Canada 8.8%. The mean age of respondents was 50 years (± 11.8), 31% were females and 90% spent majority (> 75%) of their time in clinical practice. The mNY and ASAS criteria were regularly used in clinical practice by 44 and 66% of responders, respectively. Those reporting "always" using ASAS criteria were more likely to be women (p = 0.006), and within 5 years of completing rheumatology training. Vast majority (74%) regarded Inflammatory Back Pain (IBP) as a specific feature for axSpA. Majority (50 and 60%, respectively) regarded uveitis and dactylitis as "very specific" features helping them make the diagnosis of axSpA, whereas heel enthesitis, peripheral inflammatory arthritis, and response to NSAIDs were considered "somewhat specific" by 50% of the responders. Less than half (47%) of the responders used the mNY grading for X-ray of SI joints. In the case of normal X-ray of SI joint, the use of MRI was more frequent than CT scan (83.6 vs. 10.9%) in assessing for sacroiliitis. If sacroiliitis was not seen on X-rays, the likelihood of ordering MRI was significantly higher among rheumatologists completing training within < 15 years versus > 25 years prior (90 vs. 75%, p = 0.007). Overall, 70% thought that ASAS criteria were adequately specific for clinical trials. However, 42% respondents still felt a need to modify ASAS classification criteria for axSpA. Also, 46% respondents felt that mNY criteria should be modified. CONCLUSIONS: In the absence of diagnostic criteria, majority of rheumatologists are using the classification criteria for diagnosis of axSpA. Though axSpA classification criteria are perceived to be specific for clinical trials, 40% rheumatologists feel the need to modify these criteria. Key Points • This study informs how rheumatologists in five countries spread over four different continents diagnose axSpA in clinical practice. • Since majority rheumatologists among survey respondents across the countries use ASAS criteria for diagnosis of axSpA, more specific criteria may be required to avoid overdiagnosis. • MRI is commonly used to rule out sacroiliitis in case of normal X-ray of sacroiliac joints.

Espondiloartrosis cervical e hipertrofia del ligamento amarillo / Cervical Spondyloarthrosis and Hypertrophy of the Yellow Ligament

RESUMEN Introducción: La espondiloartrosis cervical es una enfermedad articular crónica degenerativa, es la afección articular más frecuentemente observada en la población madura y una de las principales causas de discapacidad en todo el mundo, por lo que es importante el diagnóstico y tratamiento en las fases tempranas. Objetivo: Informar un caso clínico representativo de espondiloartrosis cervical e hipertrofia del ligamento amarillo. Presentación del caso: Paciente femenina de 49 años que seis años atrás sufrió una caída, y se golpeó el occipucio contra la pared, lo que le provocó pérdida transitoria del conocimiento y dolor en la región cervical; tres años después comenzó con limitación a los movimientos laterales del cuello, malestar y dolor sordo, referido a la nuca y al cuello. Conclusiones: El diagnóstico de espondiloartrosis cervical e hipertrofia del ligamento amarillo representa un desafío clínico, por lo poco común de la enfermedad a esta edad. El caso presentado es una paciente con alteraciones estructuradas en el esqueleto axial y gran repercusión anatómica y funcional debido a un relativo diagnóstico tardío, con evolución insatisfactoria. Por tanto, conviene conocer la enfermedad para realizar una detección precoz y ofrecer mejor atención terapéutica(AU)

ABSTRACT Introduction: Cervical spondyloarthrosis is a chronic degenerative joint disease, it is the most frequent joint condition in the mature population and one of the main causes of disability throughout the world, so diagnosis and treatment in the early stages are important. Objective: To report a representative clinical case of cervical spondyloarthrosis and hypertrophy of the yellow ligament. Case presentation: A 49-year-old female patient suffered a fall six years ago, hitting her occiput against the wall, causing her temporary loss of consciousness and pain in the cervical region. Three years later, she began with limitation of lateral neck movements, discomfort and dull pain, referred to the nape and neck. Conclusion: The diagnosis of cervical spondyloarthrosis and hypertrophy of the yellow ligament represents a clinical challenge, due to the rare nature of the disease at this age. The case reported is a patient with structured alterations in the axial skeleton and great anatomical and functional repercussions due to a relatively late diagnosis, with unsatisfactory evolution. Therefore, it is convenient to know the disease in order to early detect it and to offer better therapeutic care(AU)

Recognition of spondyloarthritis lesions on magnetic resonance imaging: Results of an educational intervention.

BACKGROUND: Magnetic resonance imaging (MRI) is a fundamental diagnostic tool in axial spondyloarthritis (SpA), allowing us an earlier diagnosis of the disease compared to radiography. OBJECTIVE: To compare the performance of a recognition test on SpA MRI lesions and theoretical knowledge, before and after carrying out an educational intervention (hands-on workshop). We also evaluated whether the successes in the tests were associated with the individual characteristics of the participants. METHODS: A test was carried out involving 10 questions (seven for image recognition and three for theoretical knowledge) before and after the attendance to an MRI workshop in SpA performed in different cities in Argentina. The number of correct answers was assessed before and after the workshop; good performance was defined as the achievement of 6 correct answers on average between the pre- and post-test. Participants' characteristics were collected. RESULTS: A total of 106 participants were evaluated. Average of correct answers before and after the workshop were 5.3 and 6.8, respectively (P = .0001); 65% of participants achieved good performance. Performance is not associated with the characteristics of trained physicians. CONCLUSION: MRI training workshops in SpA allow rheumatologists to improve recognition of acute inflammatory and structural lesions. The long-term effects of such training need further evaluation.

Association of ERAP2 polymorphisms in Colombian HLA-B27+ or HLA-B15+ patients with SpA and its relationship with clinical presentation: axial or peripheral predominance.

OBJECTIVE: To determine the association between endoplasmic reticulum aminopeptidase (ERAP)1 and ERAP2 single-nucleotide polymorphisms (SNPs) and human leukocyte antigens (HLA)-B27+ or HLA-B15+ patients with spondyloarthritis (SpA). METHODS: 104 patients with SpA according to Assessment of Spondyloarthritis International Society criteria were included in the study. HLA typing was performed by PCR. The polymorphisms were determined by real-time PCR on genomic DNA using customised probes for SNPs rs27044, rs17482078, rs10050860 and rs30187 in ERAP1, and rs2910686, rs2248374 and rs2549782 in ERAP2. RESULTS: 70 of the104 patients with SpA were HLA-B27+ and 34 were HLA-B15+. The distribution of ERAP1 and ERAP2 SNPs between the HLA-B15+ and HLA-B27+ patients with SpA did not reveal differences. Likewise, no differences in the frequencies of ERAP1 SNP haplotypes and alleles HLA-B15 or HLA-B27 were found. Interestingly, however, the frequencies of three particular haplotypes formed by ERAP2 SNPs rs2549782/rs2248374/rs2910686 varied between HLA-B15+ and HLA-B27+ patients: the ERAP2 SNPs haplotype TGT was more common in HLA-B15+ patients with SpA (OR 2.943, 95% CI 1.264 to 6.585; P=0.009), whereas the ERAP2 SNP haplotypes TGC and CAT were more associated with HLA-B27+ patients with SpA: (OR 4.483, 95% CI 1.524 to 13.187; p=0.003) and (OR 9.014, 95% CI 1.181 to 68.807; p=0.009), respectively. CONCLUSION: An association was found between HLA-B15+ patients with SpA and haplotype TGT of ERAP2 SNPs. On the other hand, HLA-B27+ patients with SpA were associated with ERAP2 haplotypes TGC and CAT. These associations could be related to the clinical presentation of the disease, specifically with a peripheral or axial predominance, respectively.