Worse scores but similar patterns of disease activity: interpreting outcomes in women with axial spondyloarthropathy.

OBJECTIVE: The aim of this study was to evaluate the impact of sex on disease activity in axial spondylitis (axSpA). METHOD: Data were extracted from the Ankylosing Spondylitis Registry of Ireland (ASRI). In this cross-sectional study, patients were analysed on the basis of sex, with a series of comparison analyses performed. RESULTS: Overall, 886 participants were enrolled in the ASRI [232 (26.2%) women, 644 (72.6%) men]. Females recorded significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (4.57 vs 3.83, p < 0.01) and Ankylosing Spondylitis Quality of Life questionnaire (ASQoL) (7.51 vs 6.12, p < 0.01) scores than males. There was a stronger correlation in the Bath Ankylosing Spondylitis Functional and Metrology Indices (BASFI and BASMI) in females (rs = 0.619, p < 0.01) than in males (rs = 0.572, p < 0.01). Analysis of factors in BASDAI revealed that the higher total scores in females compared to males were due not to any single component, but to worse scores in all six components of the BASDAI combined. Ranking of components by severity between sexes revealed identical ranking in four of the six components of the BASDAI. CONCLUSIONS: Women with axSpA reported significantly worse disease activity, quality of life, and functional ability than men. However, the BASDAI capturedsimilar patterns of disease activity. Limitation of spinal mobility in women with axSpA corresponded to greater impairment in functional ability. Further evaluation of disease monitoring tools is required to ensure that disease activity is accurately captured in men and women with axSpA.

The toll of unemployment in axial spondyloarthropathy: high prevalence and negative impact on outcomes captured in a national registry.

OBJECTIVE: Axial spondyloarthropathy (axSpA) is an inflammatory arthritis of the axial skeleton. Persistent disease activity can result in significant disability and affect the ability to maintain employment. This study aimed to determine the prevalence of unemployment in axSpA and the impact on patient outcomes. METHOD: Data from the Ankylosing Spondylitis Registry of Ireland (ASRI) were cleaned, and information on employment, demographics, and disease characteristics was extracted. Patients were analysed on the basis of employment and categorized as employed or unemployed. RESULTS: Of the 759 participants included in the analysis, 23.5% (178) were unemployed, higher than national averages of 6.2-13.1% during the study period. Unemployed participants reported significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; 5.1 vs 3.6), Metrology Index (BASMI; 4.8 vs 3.4), Functional Index (BASFI; 5.2 vs 3.0), Health Assessment Questionnaire (HAQ; 0.82 vs 0.40), and Ankylosing Spondylitis Quality of Life (ASQoL; 9.4 vs 5.4) scores compared to employed (all p < 0.01). Male gender (odds ratio, 95% confidence interval: 2.65, 1.46-4.83), worse BASMI (1.16, 1.02-1.33), and worse HAQ scores (2.18, 1.13-4.19) were significantly associated with unemployment. CONCLUSION: The prevalence of unemployment in axSpA patients is higher than in the general population, and is associated with worse quality of life, poorer levels of function, and higher levels of disease activity. Predictors of unemployment in axSpA were male gender, worse spinal mobility, and poorer level of function. Recognition of patients at risk of unemployment will improve opportunities for intervention and maintain participation in the workforce.

Oral manifestations of lupus.

INTRODUCTION: Mucosal involvement is commonly seen in patients with lupus; however, oral examination is often forgotten. Squamous cell carcinoma arising within oral lupoid plaques has been described, emphasizing the importance of identifying and treating oral lupus. METHODS: We undertook a retrospective single-centre study looking at oral findings in patients attending our multidisciplinary lupus clinic between January 2015 and April 2016. RESULTS: A total of 42 patients were included. The majority of patients were female (88%) and had a diagnosis of discoid lupus erythematosus (62%). Half of the patients had positive oral findings, 26% had no oral examination documented, and 24% had documented normal oral examinations. CONCLUSION: Our findings suggest that oral pathology is common in this cohort of patients. Regular oral examination is warranted to identify oral lupus and provide treatment. Associated diseases such as Sjogren's syndrome may also be identified. Patients should be encouraged to see their general dental practitioners on a regular basis for mucosal review. Any persistent ulcer that fails to respond to treatment or hard lump needs urgent histopathological evaluation to exclude malignant transformation to squamous cell carcinoma.

Generation of Ramped Current Profiles in Relativistic Electron Beams Using Wakefields in Dielectric Structures.

Temporal pulse tailoring of charged-particle beams is essential to optimize efficiency in collinear wakefield acceleration schemes. In this Letter, we demonstrate a novel phase space manipulation method that employs a beam wakefield interaction in a dielectric structure, followed by bunch compression in a permanent magnet chicane, to longitudinally tailor the pulse shape of an electron beam. This compact, passive, approach was used to generate a nearly linearly ramped current profile in a relativistic electron beam experiment carried out at the Brookhaven National Laboratory Accelerator Test Facility. Here, we report on these experimental results including beam and wakefield diagnostics and pulse profile reconstruction techniques.

Demonstration of Single-Shot Picosecond Time-Resolved MeV Electron Imaging Using a Compact Permanent Magnet Quadrupole Based Lens.

We present the results of an experiment where a short focal length (∼1.3 cm), permanent magnet electron lens is used to image micron-size features (of a metal sample) with a single shot from an ultrahigh brightness picosecond-long 4 MeV electron beam emitted by a radio-frequency photoinjector. Magnification ratios in excess of 30× were obtained using a triplet of compact, small gap (3.5 mm), Halbach-style permanent magnet quadrupoles with nearly 600 T/m field gradients. These results pave the way towards single-shot time-resolved electron microscopy and open new opportunities in the applications of high brightness electron beams.

Long-term outcome of anti-tumor necrosis factor alpha blockade in the treatment of juvenile spondyloarthritis.

OBJECTIVES: A significant proportion of patients with juvenile spondyloarthritis (JSpA) are refractory to treatment with established medications. The objective of this study was to assess long-term efficacy of treatment with anti-TNF agents in patients with JSpA. METHODS: An observational study of 16 patients with JSpA from 3 centres treated with infliximab (n=10) and etanercept (n=6) was performed, with a median follow-up period of 7.2 years. Prospective data was collected according to a standardized protocol. Outcomes examined were TEC, TAJC, markers of inflammation (ESR, CRP), functional assessments (C-HAQ, BASDAI, BASFI), and ongoing requirement for anti-TNF treatment. RESULTS: 13/16 patients (83%) had achieved clinical remission 6 months into the treatment. Improvement was sustained over time, with a median TAJC and TEC of 0 at any time point after 6 weeks. 6/16 patients (38%) showed a flare of arthritis after a median of 3.5 years. Two patients with hip disease prior to treatment required an arthroplasty 3 and 8 years post anti-TNF initiation. Patients showed progression of sacroiliitis with median modified New York score of 1 (range 0-3) at time of diagnosis and 3 (range 0-4) at last follow-up (p=0.002). Median BASDAI at last follow up was 1.6, median BASFI 3.1. Two patients developed transient reactions (one generalised, one local); no patient developed other adverse effects during the study. CONCLUSIONS: Anti-TNF treatment in JSpA refractory to standard treatment results in good long-term disease control except for pre-existing hip disease. However, radiographic evidence suggests inferior efficacy for control of sacroiliac joint disease.

The prevalence of patellar tendinopathy in elite academy rugby: a clinical and imaging study.

OBJECTIVES: Patellar tendinopathy (PT) is a challenging condition with variable outcomes. It is not commonly reported in rugby. This study was undertaken to evaluate the prevalence of PT in elite academy rugby. DESIGN: Cross-sectional study. METHODS: Members of the rugby academies in Ireland were evaluated using blinded, standardised clinical examination, self reported questionnaires and ultrasound. Anthropometrics were examined, body mass and fat% were measured by bio-impedance. The Cincinnati Sports Activity Scale, established activity levels. The VISA-P scale evaluated symptoms. Ultrasound examination established tendon thickness, echogenicity and homogeneity including focal areas of tendinopathy in both transverse and longitudinal planes. Studies were reviewed and graded by two musculoskeletal radiologists. Statistical analysis was performed using PASW 18 and CIA software. Significance was set at p<.05. RESULTS: Thirty individuals (36.1%) had US abnormalities identified with 38 abnormal tendons. The abnormalities seen were microcalculi (44.7%; N=17), thickened tendons ± large areas of cystic degenerative change (26.3%) and macrocalculi or large hypoechoic areas (28.9%; N=11). Eleven individuals (13.3%) fulfilled the clinical diagnosis of PT based on clinical examination. Combining both US and clinical the prevalence of PT in this cohort was 9.6% (N=8). There was a statistically significant difference between the prevalence of patellar tendinopathy based upon US findings (p=.027) and the combination of both clinical examination and US (p=.044) in different training academies. CONCLUSIONS: This work shows that PT is a relatively common injury in elite academy rugby players and that training practices may contribute to its development.

Generation of coherent broadband photon pulses with a cascaded longitudinal space-charge amplifier.

The longitudinal space-charge amplifier has been recently proposed by Schneidmiller and Yurkov as an alternative to the free-electron laser instability for the generation of intense broadband radiation pulses [Phys. Rev. ST Accel. Beams 13, 110701 (2010)]. In this Letter, we report on the experimental demonstration of a cascaded longitudinal space-charge amplifier at optical wavelengths. Although seeded by electron beam shot noise, the strong compression of the electron beam along the three amplification stages leads to emission of coherent undulator radiation pulses exhibiting a single spectral spike and a single transverse mode. The on-axis gain is estimated to exceed 4 orders of magnitude with respect to spontaneous emission.

Single-shot coherent diffraction imaging of microbunched relativistic electron beams for free-electron laser applications.

With the advent of coherent x rays provided by the x-ray free-electron laser (FEL), strong interest has been kindled in sophisticated diffraction imaging techniques. In this Letter, we exploit such techniques for the diagnosis of the density distribution of the intense electron beams typically utilized in an x-ray FEL itself. We have implemented this method by analyzing the far-field coherent transition radiation emitted by an inverse-FEL microbunched electron beam. This analysis utilizes an oversampling phase retrieval method on the transition radiation angular spectrum to reconstruct the transverse spatial distribution of the electron beam. This application of diffraction imaging represents a significant advance in electron beam physics, having critical applications to the diagnosis of high-brightness beams, as well as the collective microbunching instabilities afflicting these systems.

Benefits of pre-referral preparation for rheumatology clinics.

Appropriate allocation of rheumatology clinic appointments depends on the information contained in referral letters. Such letters were analysed for the presence of pertinent information and a scoring system was devised to assess the quality of enclosed data. In a smaller cohort, relevant basic tests were carried out prior to the appointment. 122 referral letters were received over a 1 month period. Symptom duration was documented in (39) 32%, while (64) 52.5% listed medications. Only (23) 17.2% indicated the urgency of the problem. Approximately (31) 25% of referrers performed relevant routine investigations. Mean score out of 10 was 5.1 (range 1.5-9). Of the 40 (33%) patients with pre-appointment investigations, the clinic attendance rate and subsequent discharge rate were significantly higher than those without these tests. This study shows that comprehensive referral letters and basic investigations significantly help to prioritize appointments and facilitate earlier diagnosis and treatment for patients with rheumatic disease.

Inflammatory and degenerative sacroiliac joint disease in a primary back pain cohort.

OBJECTIVE: The prevalence of sacroiliac (SI) joint abnormalities in a primary low back pain population remains unresolved. The aims of our study were to define the prevalence of SI joint disease in this cohort, and to identify clinical features that might accurately predict radiographic changes in the SI joint and spine. METHODS: Lumbar spine and anteroposterior pelvis radiographs taken over a 3-year period for the evaluation of back pain at a major chiropractic college were scored for the presence of inflammatory or degenerative features. Data were subsequently extracted by means of a predetermined template from the clinical notes. The outcomes were correlated using Spearman's correlation coefficients. RESULTS: We identified 315 patients (173 men, 142 women), ages 18-60 years. Of these, 100 patients (31.7%) demonstrated SI joint abnormalities: 75 (23.8%) degenerative, 25 (7.9%) inflammatory. Sex was strongly associated with type of SI joint pathology; degenerative disease was predominantly found in women (68%), whereas inflammatory disease was predominantly found in men (63%). In women there was no correlation between degenerative SI joint abnormalities and degenerative changes in the lumbar spine. Of the clinical descriptors evaluated, none were associated with the radiographic findings with the exception of buttock pain, which was associated with inflammatory sacroiliitis. Neither being overweight nor pregnancy history was associated with degenerative changes in the SI joint. CONCLUSION: In a primary back pain cohort, degenerative SI joint disease may be an under-recognized clinical entity. It is strongly influenced by sex but is unrelated to degenerative changes in the lumbar spine. Currently proposed clinical discriminators performed poorly in correlating with radiographic changes in the SI joint.

From gene expression to serum proteins: biomarker discovery in ankylosing spondylitis.

OBJECTIVES: Studying post-infliximab gene expression changes could provide insights into the pathogenesis of ankylosing spondylitis (AS). METHODS: Gene expression changes were screened by microarray on peripheral blood RNA of 16 AS patients at baseline and 2 weeks post-infliximab, and selected results were confirmed by quantitative real-time (qRT)-PCR. Corresponding serum-soluble LIGHT (sLIGHT) was estimated by ELISA and the fold change in sLIGHT was correlated to the fold change in erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and the Bath AS disease activity index. RESULTS: Post-infliximab, 69% of the patients (11/16) achieved an ASAS20 response. Six candidate genes were differentially expressed by microarray; four of which were validated by qRT-PCR. sLIGHT showed the most significant difference. There was good correlation of baseline sLIGHT with CRP (R = 0.60; p = 0.01) and ESR (R = 0.51; p = 0.04). The fold change in sLIGHT correlated with change in both CRP (R = 0.71, p = 0.002) and ESR (R = 0.77, p<0.001). CONCLUSION: LIGHT is significantly downregulated by infliximab. sLIGHT correlated well with changes in inflammatory markers.

Comparison of clinical and radiographic severity of juvenile-onset versus adult-onset ankylosing spondylitis.

OBJECTIVES: An important unresolved issue in the pathogenesis and clinical course of ankylosing spondylitis (AS) is whether juvenile-onset AS (JoAS) is a clinical entity in its own right or just an earlier onset variant of adult-onset AS (AoAS). A study was undertaken to address this issue. METHODS: All patients with AS were extracted from the database of a large spondylitis clinic. Those with symptom onset at < or =16 years were compared with those with symptom onset at > or =17 years. Odds ratios (OR) were calculated and adjusted for disease duration and current age. RESULTS: 267 patients with AS were identified; 84 met the criteria for JoAS and 183 met the criteria for AoAS. There were no differences in gender ratio (male: JoAS 81%, AoAS 79%) or in HLA-B27 status (positive: JoAS 75%, AoAS 81%). The axial/peripheral pattern of disease at presentation differed; an exclusively peripheral pattern was seen in 26% with JoAS but in only 4.6% of those with AoAS (p<0.001). There were no differences in disease activity between the two groups. When adjusted for disease duration, axial features were more prominent in AoAS than JoAS as represented by neck pain (OR 2.93 (95% CI 1.54 to 5.55)), neck stiffness (OR 3.39 (95% CI 1.80 to 6.39)), back pain (OR 2.96 (95% CI 1.43 to 6.11)) or back stiffness (OR 3.30 (95% CI 1.50 to 7.28)). AoAS was associated with worse functional and quality of life measures and higher fatigue scores when adjusted for disease duration. CONCLUSIONS: JoAS follows a distinctive clinical course from AoAS. These clinical features are dictated by factors other than male gender and HLA-B27 and warrant further investigation.

Efficacy of pulmonary rehabilitation in an Irish population.

This study evaluated the results after 8 and 52 weeks of a comprehensive pulmonary rehabilitation programme for patients with chronic obstructive pulmonary disease (COPD) in Ireland. 170 patients with clinical and physiological evidence of COPD (mean FEV1 43.1 +/- 17.0%pred.) were recruited into an 8 week programme. At the time of final evaluation 15 patients had died, 25 patients had not been compliant with required attendances and 1 patient had transferred to another programme. To date assessments of 106 of the remaining 129 patients were made after eight weeks and of 78 patients after 1 year. Assessment consisted of pulmonary function testing; exercise tolerance as measured by a progressive maximal walking test (shuttle walk test) and an endurance test (treadmill test); quality of life (QoL) as measured by the Chronic Respiratory Disease Questionnaire (CRDQ), the St. George's Hospital Questionnaire (SGHQ) and the Breathing Problems Questionnaire (BPQ); and perceived dyspnoea on the Borg scale. Significant improvements in exercise tolerance, (shuttle p<.001, treadmill p<.001), QoL, (BPQ p<.001, CRDQ p<.001, SGHQ p<.001) and dyspnoea (p<.001) were demonstrated after 8 weeks. These improvements were maintained at 1 year. These results suggest that pulmonary rehabilitation can increase exercise tolerance and improve QoL in patients with COPD.