Treatment overview of axial spondyloarthritis in 2023.

The treatment of patients with axial spondyloarthritis (axSpA) is characterized by non-pharmacological and pharmacological treatment options. It may depend on the type and extent of musculoskeletal and extramusculoskeletal manifestations. Recent data on non-pharmacological treatment options, such as physical activity, physiotherapy, and modification of lifestyle factors, are summarized in this review. Moreover, we have provided an overview on non-steroidal anti-inflammatory drugs and the ever-expanding number of biological and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs, respectively). In addition to data on efficacy and safety, the review also encompasses data on switching/cycling, tapering, and treatment selection for specific patient subgroups to optimize treatment outcomes.

[Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]. / Häufigkeit und Schweregrad von Sarkopenie bei Patient*innen mit entzündlichen und nichtentzündlichen muskuloskeletalen Erkrankungen : Ergebnisse einer monozentrischen Studie in einem tertiären Zentrum.

INTRODUCTION: Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria. OBJECTIVE: To investigate the prevalence and severity of SP in patients with RMD. METHODS: A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X­ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics. RESULTS: Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP. DISCUSSION: This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.

[How many patients with inflammatory rheumatic diseases have the technical prerequisites for video consultations and are also willing to use this to carry out visits by medical specialist visits?] / Wie viele Patienten mit entzündlich rheumatischen Erkrankungen haben die technischen Voraussetzungen für Videosprechstunden und sind bereit, fachärztliche Visiten so durchzuführen?

BACKGROUND: The currently disseminating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and limited capacities in outpatient rheumatological care, pose questions about possible alternatives to clinical visits, also in view of the digital revolution. It is unclear whether and to what extent patients with inflammatory rheumatic diseases are willing and in a position to deal with the new media, such as video consultation. METHODS: In the middle of the pandemic in May 2020 outpatients were surveyed using a standardized questionnaire in order to document their possibilities and willingness to participate in a video consultation. The treating physicians were asked whether carrying out a video consultation was considered to be a possible and meaningful option. RESULTS: Overall, 232 patients with inflammatory rheumatic diseases were surveyed (64.7% female, average age 54.0 ± 15.2 years), seropositive (n = 58) and seronegative (n = 51) rheumatoid arthritis (RA), spondyloarthritis (SpA, n = 77) including axial SpA (axSpA) and psoriatic arthropathy (PsA) as well as collagenosis and vasculitis (CoV, n = 46). The mean duration of disease was 5.5 ± 8.2 years, whereby in 75 patients (32.3%) it was the first diagnosis. The mean disease activity (0-10, subjective patient self-estimation) was 4.7 ± 2.5. Overall, 176 patients were basically aware of the possibility to carry out video consultations (75.9%) and 166 considered that they were technically capable to participate (71.6%) but only 131 were principally willing to participate (56.5%). Logistic regression analyses showed that the willingness to participate in video consultations decreased with increasing age (ß = 0.28, p = 0.01). According to the medical estimation video consultations were thought to be principally possible for 161 patients for technical reasons (69.4%) and for 127 for medical reasons (54.7%); however, a video consultation within the framework of treatment was only considered to be meaningful by the physician for 76 patients (32.8%). CONCLUSION: Not all patients can or want to participate in video consultations and the willingness declines with increasing age. The estimation of the meaningfulness of video consultations by physicians was also limited to approximately one third of the patients surveyed. This must be taken into consideration for the future planning of video consultations.

[Effect of multimodal rheumatologic complex treatment in patients with axial spondylarthritis : A systematic evaluation with standardized outcome parameters, such as the ASAS Health Index]. / Wirkung der multimodalen rheumatologischen Komplexbehandlung bei Patienten mit axialer Spondyloarthritis : Eine systematische Erhebung mit standardisierten Outcomeparametern wie dem ASAS-Gesundheitsindex.

BACKGROUND: Multimodal rheumatologic complex treatment (MRCT) is based on an acute inpatient treatment concept for patients with clinically relevant functional impairments and exacerbation of pain, which are caused by rheumatic and musculoskeletal diseases. Patients with axial spondylarthritis (axSpA) including ankylosing spondylarthritis (AS) often suffer from such health problems. Regular movement exercises and physical therapy measures are an important pillar of treatment management. The ASAS Health Index (ASAS-HI) can be used to document the global functional ability and health of axSpA patients. The selectivity of the ASAS HI for nonpharmacological treatment changes has so far not yet been proven. OBJECTIVE: Evaluation of the MRCT and ASAS HI for nonpharmacological treatment measures of patients with axSpA carried out in the Ruhr Area Rheumatism Center. The primary endpoint was an improvement of the ASDAS≥ 1.1. It was assumed that > 25% of the patients would achieve this threshold. METHODS: Consecutively included patients with active axSpA and relevant functional impairments received inpatient treatment for 14 days during MRCT. On days 1 (V1) and 14 (V2) all patients completed questionnaires on pain (NRS), disease activity (BASDAI, ASDAS) and function (BASFI, ASAS HI). The clinical examination was carried out using BASMI and measurement of C­reactive protein (CRP) at both times. RESULTS: The 66 prospectively included patients had an average age of 47.2 years (SD 14.2 years), a duration of symptoms of ca. 20 years, 65.3% were male, 75% were positive for HLA B27 and CRP was elevated in 41.3%. The disease activity at V1 was elevated: BASDAI 5.6 (1.8), ASDAS 3.1 (0.9), whereas functional ability and mobility were reduced: BASFI 3.5 (1.8), BASMI 5.6 (2.1), ASAS-HI 8.4 (3.4). During the course the global patient verdict improved (NRS 0-10) from 6.9 (1.7) at V1 to 4.8 (1.8) at V2 and the pain from 6.9 (1.9) to 4.7 (2.0) (all p < 0.001). The disease activity also decreased at V2: BASDAI 4.1 (1.9), ASDAS 2.4 (1.0), function and mobility were also improved: BASFI 4.3 (2.4), BASMI 2.7 (1.6), ASAS HI 6.5 (3.8) (all p < 0.001). CONCLUSION: In this study the effectiveness of a 2­week MRCT according to OPS 8-983.1 with respect to important patient-centered outcomes (PCO) could be proven and the results of previous studies could be confirmed. In this context ASAS-HI was also sensitive to change.

Magnetic resonance imaging characteristics in patients with spondyloarthritis and clinical diagnosis of heel enthesitis: post hoc analysis from the phase 3 ACHILLES trial.

OBJECTIVE: To investigate the imaging characteristics and clinically assess heel enthesitis in spondyloarthritis (SpA) by applying in a post hoc analysis the Heel Enthesitis Magnetic Resonance Imaging Scoring system (HEMRIS) in blinded and centrally-read MRI data from the ACHILLES trial (NCT02771210). METHODS: ACHILLES included patients (≥18 years) with active psoriatic arthritis or axial SpA with clinical and MRI-positive heel enthesitis refractory to standard treatment. Patients were randomized to receive subcutaneous secukinumab 150/300 mg or placebo. At week 24, patients on placebo were switched to secukinumab treatment. MRI-positive heel enthesitis was confirmed in all patients by local investigators. MRIs were performed at 3 timepoints: screening and weeks 24 and 52. In the present analysis, all MRIs were re-evaluated by 2 blinded central readers in a consensus read fashion for a priori defined MRI parameters based on HEMRIS. RESULTS: At screening, 171/204 (83.8%) of patients presented with entheseal inflammation and/or structural damage, considering both the Achilles tendon and plantar fascia. Pathologies were more evident in the Achilles tendon area compared to the plantar aponeurosis. The most frequent pathologies were intra-tendon hypersignal and retrocalcaneal bursitis. The mean total entheseal inflammation score at screening in the Achilles tendon area was 2.99 (N=204) and the mean change (standard deviation [SD]) from screening to weeks 24 and 52 was - 0.91 (1.99) and - 0.83 (2.12) in the secukinumab group vs - 0.48 (1.86) and - 0.80 (1.98) in the placebo-secukinumab group, respectively. The mean total structural damage score at screening was 1.36 (N=204) and the mean change (SD) from screening to weeks 24 and 52 was 0.00 (0.65) and - 0.06 (0.56) in the secukinumab group vs 0.08 (0.48) and 0.04 (0.75) in the placebo-secukinumab group, respectively. CONCLUSIONS: Based on the newly developed HEMRIS, entheseal inflammation and/or structural damage was confirmed in 83.3% of ACHILLES patients. Pathologies were more evident in the Achilles tendon area compared to plantar fascia, with the inflammatory parameters being more responsive with secukinumab treatment compared to placebo. The present analysis, with detailed information on individual MRI parameters, contributes to the scientific debate on heel enthesitis. TRIAL REGISTRATION: ClinicalTrials.gov NCT02771210 .

Striking sex differences in magnetic resonance imaging findings in the sacroiliac joints in the population.

BACKGROUND: In patients with axial spondyloarthritis (axSpA), magnetic resonance imaging (MRI) is used to detect bone marrow edema (BME) in sacroiliac joints (SIJ) but SIJ BME are also detected in the population. Not much is known about sex differences in that regard. OBJECTIVE: To explore sex-specific differences associated with the extent of BME in the SIJ suggestive of axSpA in a general population cohort study. METHODS: Taking advantage of 793 recently evaluated MRIs of subjects < 45 years taking part in the SHIP cohort, we used negative-binomial (NB) count data regression to analyze factors associated with the extent of SIJ BME. Predictors were explored by model-based boosting (MBB), a machine learning approach. RESULTS: Estimates of NB regression showed strong effects of sex in interaction with age, BMI, back pain, and particularly HLA-B27. The NB regression model showed incidence rate ratios (IRR) for the main effect of sex (females vs. males): 0.94 [95% CI: 0.63; 1.41], HLA-B27: 4.32 [2.09; 9.8], and for the interaction of sex to HLA-B27: 0.22 [0.06; 0.75]. According to MBB, HLA-B27 positivity, BMI, current smoking, back pain in the last 3 months, the interaction of sex and HLA-B27, and delivery in the last 12 months were of highest importance to explain the extent of SIJ BME. CONCLUSIONS: Different factors were associated with the extent of SIJ BME in females and males. Most importantly, HLA-B27 was relevant only in males but not in females in whom a postpartal state was important. This finding may be relevant for the pathogenesis of axSpA.

[Development of quality standards for patients with axial spondyloarthritis for use in Germany]. / Entwicklung von Qualitätsstandards für Patient*innen mit axialer Spondyloarthritis zum Einsatz in Deutschland.

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.

[Answering epidemiologic rheumatologic questions by cooperation with the large population-based SHIP cohort-findings with relevance for the diagnosis of axial spondyloarthritis (axSpA)]. / Beantwortung epidemiologisch-rheumatologischer Fragestellungen durch Kooperation mit der bevölkerungsbasierten SHIP-Kohorte ­ Erkenntnisse für die Diagnostik der axialen Spondyloarthritis (axSpA).

This article presents how, based on the availability of new imaging methods and medications, objectives regarding the rheumatic disease axial spondyloarthritis (axSpA) have developed over the course of more than two decades into a rheumatologic research group. During recent years, cooperation with the Study of Health in Pomerania (SHIP) cohort has given rise to new fundamental aspects. This involved intensive cooperation between the Ruhr University Bochum (Rheumazentrum Ruhrgebiet) and the Greifswald University Hospital (Community Medicine research collective). The design of the SHIP cohort was published 10 years ago and the cohort approach presented in the Bundesgesundheitsblatt, which also described central methodologic questions in detail. In 2014, a cooperation project between the Ruhr Rheumatology Center/Ruhr University Bochum and the SHIP Department of Clinical and Epidemiologic Research (Klinisch-Epidemiologische Forschung, KEF; SHIP-KEF) was established, which has already resulted in publication of interesting results in high-ranking journals. In order to stress the potential of such corporations, important contents thereof are presented herein, with a focus on MRI and consideration of historical aspects.

The ASAS-OMERACT core domain set for axial spondyloarthritis.

BACKGROUND: The current core outcome set for ankylosing spondylitis (AS) has had only minor adaptations since its development 20 years ago. Considering the significant advances in this field during the preceding decades, an update of this core set is necessary. OBJECTIVE: To update the ASAS-OMERACT core outcome set for AS into the ASAS-OMERACT core outcome set for axial spondyloarthritis (axSpA). METHODS: Following OMERACT and COMET guidelines, an international working group representing key stakeholders (patients, rheumatologists, health professionals, pharmaceutical industry and drug regulatory agency representatives) defined the core domain set for axSpA. The development process consisted of: i) Identifying candidate domains using a systematic literature review and qualitative studies; ii) Selection of the most relevant domains for different stakeholders through a 3-round Delphi survey involving axSpA patients and axSpA experts; iii) Consensus and voting by ASAS; iv) Endorsement by OMERACT. Two scenarios are considered based on the type of therapy investigated in the trial: symptom modifying therapies and disease modifying therapies. RESULTS: The updated core outcome set for axSpA includes 7 mandatory domains for all trials (disease activity, pain, morning stiffness, fatigue, physical function, overall functioning and health, and adverse events including death). There are 3 additional domains (extra-musculoskeletal manifestations, peripheral manifestations and structural damage) that are mandatory for disease modifying therapies and important but optional for symptom modifying therapies. Finally, 3 other domains (spinal mobility, sleep, and work and employment) are defined as important but optional domains for all trials. CONCLUSION: The ASAS-OMERACT core domain set for AS has been updated into the ASAS-OMERACT core domain set for axSpA. The next step is the selection of instruments for each domain.

[Are SARS-CoV-2 reactive T cells detectable and potentially protective in patients under anti-CD20 treatment with an impaired humoral response?] / Sind SARS-CoV-2-reaktive T­Zellen bei Patienten unter Anti-CD20-Therapie mit einer beeinträchtigten humoralen Antwort nachweisbar und potenziell protektiv?

The pandemic attributable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has greatly changed life in most countries of the world for more than 1.5 years now. The spread could be more or less well-controlled and fatalities could partly be avoided by obligatory wearing of masks, contact restrictions and since the beginning of the year by vaccinations. Patients with chronic inflammatory diseases and organ transplant patients under immunosuppression, are somewhat more at risk to become ill with coronavirus disease 2019 (COVID-19). The probability and severity of an infection depends on the ability of the humoral and cellular immune systems to effectively combat the virus. This can be substantially improved by vaccination. The B cell depleting monoclonal antibody rituximab (RTX) is frequently employed in rheumatic diseases, whereby antibody formation against the new pathogen within the framework of vaccination is restricted. Recent study results in patients treated with RTX indicate that an effective cellular immune response can be developed despite the impaired humoral response.

[Threat of a SARS-CoV-2 endemic in a large hospital specialized in rheumatic diseases-relative all clear through consistent testing]. / Drohende Corona-Endemie in einer rheumatologischen Spezialklinik ­ relative Entwarnung durch konsequente Testung.

The severe acute respiratory coronavirus type 2 (SARS-CoV-2) pandemic is keeping most countries of the world in suspense. In Germany the prevalence of SARS-CoV­2 infections is under 2% but for weeks the numbers in Germany have also been increasing. The care in rheumatology was temporarily impaired by the first wave of the pandemic. This article reports the infection situation in the largest specialized rheumatology clinic in Germany, the Rheumatism Center Ruhrgebiet, because recently during the second wave for the first time several SARS-CoV­2 infections occurred here over one weekend, which led to considerable anxiety in many of those involved. The situation could be clarified by consistent testing of patients and personnel with the rapid antigen test and the situation could be mollified. Ultimately, only a few persons were tested positive and the courses by the patients have so far remained bland. This shows the effectiveness of the protective hygiene measures consistently implemented since April.

Which Magnetic Resonance Imaging Lesions in the Sacroiliac Joints Are Most Relevant for Diagnosing Axial Spondyloarthritis? A Prospective Study Comparing Rheumatologists' Evaluations With Radiologists' Findings.

OBJECTIVE: Pathologic sacroiliac (SI) joint changes on magnetic resonance imaging (MRI) are important for the classification of axial spondyloarthritis (SpA). In daily practice, radiologists play a major role in interpreting imaging findings. This study was undertaken to evaluate the impact of MRI SI joint findings on the identification of axial SpA by radiologists, in comparison to diagnosis by rheumatologists. METHODS: Patients age ≤45 years were prospectively included when referred for clinical suspicion of axial SpA and underwent a complete diagnostic evaluation including STIR- and T1-weighted MRI of the SI joint. Diagnosis made by an experienced rheumatologist with access to all relevant information was considered the gold standard. MRIs were evaluated by 2 experienced radiologists who were unaware of the clinical data, who indicated which MRI lesions were "critical" to the decision for or against axial SpA. RESULTS: Of the 300 patients included, 132 (44%) were diagnosed as having axial SpA. Mean age was comparable between the 2 groups, but patients with axial SpA and those with non-axial SpA differed with regard to symptom duration (58.6 ± 69.5 versus 33.9 ± 45.1 months, respectively; P = 0.003) and HLA-B27 positivity (75.6% versus 19%, respectively; P < 0.001). Rheumatologists and radiologists agreed on the diagnosis in 262 cases (87.3%), while 34 patients (11.3%) were diagnosed as having axial SpA by rheumatologists only (clinically), and 4 cases (1.3%) were judged as suggestive of axial SpA by radiologists only. Bone marrow edema (BME) and sclerosis showed the highest sensitivity, while erosions and fatty lesions showed the highest specificity, for axial SpA diagnosis. The combination of BME with erosions had the highest positive predictive value (86.5%). CONCLUSION: The MRI findings with the highest diagnostic value in patients in whom axial SpA is suspected are structural changes in the SI joint, alone or in combination with BME. Our findings indicate that while the absence of BME is usually not compatible with a diagnosis of axial SpA, the presence of BME does not necessarily confirm a diagnosis of axial SpA.

[Current state, goals and quality standards of outpatient care in rheumatology: position paper of the Professional Association of German Rheumatologists (BDRh)]. / Aktueller Stand, Ziele und Qualitätsstandards der ambulanten Versorgung in der Rheumatologie: Positionspapier des Berufsverbandes der deutschen Rheumatologen (BDRh).

Even in the era of modern guidelines, the treatment of rheumatic diseases is only as good as the framework of rheumatological care within which the treatment is carried out. The access to high-quality medical treatment for all patients is therefore essentially decisive for the prognosis of the patients. This article describes the current state of outpatient treatment in rheumatology and demonstrates which quality projects, such as treatment contracts, outpatient specialized medical treatment (ASV), digitalization and training as specialized rheumatological assistant (RFA), have been created in order to ensure the treatment of our patients. Furthermore, standards are defined that can guarantee a contemporary and guideline-conform treatment in outpatient rheumatological units. As an example it is an affirmation of the Professional Association of German Rheumatologists (BDRh) for ensuring optimal care for all rheumatology patients through early or emergency rheumatology clinics, treat to target, appropriate delegation of medical duties and diversification of treatment, thus an assurance of the quality and comprehensive treatment in rheumatology. The important topic of safeguarding the next generation of rheumatologists, which is indispensable for this, is also discussed.

[How well are patients with inflammatory rheumatic diseases protected against measles?] / Wie gut sind Patienten mit entzündlich rheumatischen Erkrankungen gegen Masern geschützt?

BACKGROUND: Patients with inflammatory rheumatic diseases have an increased risk of infections due to the autoimmune disease but also due to the immunosuppressive medication. Although vaccinations are known to be effective in the primary prophylaxis of infections, the vaccination rate in Germany is generally too low. Due to the recently increasing, sometimes epidemic-like occurrence of measles, the administration of live vaccine against measles has recently become required by law. OBJECTIVE: How many patients with inflammatory rheumatic diseases are currently sufficiently protected against measles? METHOD: Between December 2017 and October 2018 patients with inflammatory rheumatic diseases at the Ruhrgebiet Rheumatism Center were prospectively and consecutively included. Data on the disease and treatment at the level of substance classes, patient history of vaccination and infections were collated. All information on vaccinations were controlled in the vaccination certificate. Antibodies against measles were determined using ELISA. The threshold for sufficient protection against measles was set at 150 mIU/ml. RESULTS: Out of 975 patients 540 (55.4%) could present a vaccination certificate. In 201 patients with a certificate (37.2%) vaccination had been documented since birth. Overall, 45 out of 267 patients born after 1970 (16.9%) had sufficient protection against measles. The patient history of measles in childhood showed no differences between patients with and without protective measles IgG antibodies. Protective measles IgG antibodies were detected in 901 out of 928 patients with measurement of the measles IgG antibody level (97.1%). The different principles of action of the current immunosuppressive treatments had no influence on this. CONCLUSION: These data show that at least 2.9% of the patients did not have sufficient protection against measles. Interestingly, the majority of patients born after 1970 had protective antibodies despite the lack of vaccination against measles. The efforts in primary and also in the specialist medical care should be urgently strengthened in order to be able to guarantee an adequate infection prophylaxis in particularly endangered patients.

[Evaluation of the trabecular bone score (TBS) in routine clinical care of patients with inflammatory rheumatic and non-inflammatory diseases : Correlation with conventional bone mineral density measurement and prevalence of vertebral fractures]. / Evaluation des Trabecular Bone Score (TBS) in der täglichen Praxis bei Patienten mit entzündlich rheumatischen und nichtentzündlichen Erkrankungen : Korrelation mit konventioneller Knochendichtemessung und Prävalenz von Wirbelkörperfrakturen.

BACKGROUND: Osteoporosis-related fractures are common in patients with rheumatoid arthritis (RA). Bone mineral density (BMD) measurements using dual-energy x­ray absorptiometry (DXA) alone has only a limited value for predicting the risk of fractures. The trabecular bone score (TBS) is a surrogate parameter for trabecular microarchitecture of bone and a predictor of fracture risk independent of BMD. AIM: To examine the prevalence of BMD, TBS and osteoporosis-related vertebral fractures (VF) in patients with RA in comparison to controls with non-inflammatory musculoskeletal diseases. METHODS: Data from patients with RA diagnosed by a rheumatologist and with TBS and DXA measurements, who were assessed in this hospital between 2006 and 2014 were retrospectively analyzed. The RA patients were matched with controls with non-inflammatory musculoskeletal diseases. "Reduced bone health" was defined as a T­score <-1.0 and/or a TBS value <-1.31. Statistical analyses were carried out using the Mann-Whitney test and the Wilcoxon test. RESULTS: Data from 143 patients with RA (age 72.1 ± 11.1 years, 72% female) and 106 controls (age 69.6 ± 12.6 years, 75% female) were included. The RA patients more frequently had low BMD (n = 102, 71.3%) and low TBS values (n = 125, 87.4%) compared to controls (n = 63, 59.4% and n = 79, 74.5%, p = 0.049 and p = 0.009, respectively). The RA patients had more VF (n = 52, 36.4%) than controls (n = 24, 22.6%, p = 0.02). A total of 20 patients with VF (26.3%) had normal lumbar spine BMD and 9 (11.8%) also had a normal hip BMD. In patients with VF the combination of low TBS with normal spine BMD was more common than a normal TBS and low spine BMD (p = 0.008 for patients with RA, p = 0.025 for controls). DISCUSSION: It is known that VF can occur in patients with normal BMD. In patients with VF, a low TBS with normal spine BMD is found more frequently than normal TBS and low spine BMD. These results suggest that measurement of the TBS has the potential to be a useful tool to detect increased fracture risk in patients with RA and normal spine BMD.

[Clinical significance of determination of DFS70 antibodies to rule out connective tissue diseases]. / Klinische Wertigkeit der Bestimmung von DFS70-Antikörpern für den Ausschluss von Kollagenosen.

BACKGROUND: Connective tissue diseases (CTD) are autoimmune diseases highly associated with the presence of antinuclear antibodies (ANA). Since ANA and musculoskeletal symptoms are not uncommon in the general population, differential diagnostic challenges frequently occur for the treating physician. Dense fine speckled antibodies (DFS70) were recently discovered but their presence appeared to be rare in CTD. METHODS: In this cross-sectional study a total of 270 patients treated in the Rheumatism Center of the Ruhr Area (Rheumazentrum Ruhrgebiet) were preferentially included, when they were ANA+ (≥1:80). Other autoantibodies and DFS70 antibodies were also investigated. The diagnosis of CTD was confirmed by rheumatologists. The sensitivity, specificity and the positive predictive value of DFS70 antibodies were differentially evaluated for various ANA titers. RESULTS: In 91 (33.7%) of the ANA+ patients (33.7%) the diagnosis of CTD was confirmed and in 84 (92.3%) the ANA titer was ≥1:160. The DFS70 antibodies were detected in 17 out of 130 ANA+ patients without CTD (13.1%) versus 2 ANA+ patients (2.2%) with CTD (p = 0.027). None of the patients with ANA 1:80 had DFS70 antibodies. The specificity of DFS70 antibodies to detect the absence of CTD was 97.6%, the sensitivity was 13.1% and the positive predictive value was 89.5%. There was almost no effect of the strength of the different ANA titers. CONCLUSION: It was found that DFS70 antibodies are rarely present in ANA+ patients with CTD but the diagnosis of CTD cannot be reliably ruled out solely by the presence of DFS70 antibodies; however, the high specificity of DFS70 antibodies can be of clinical importance in unclear situations and in cases of anxious patients.

[Epionics SPINE-use of an objective method to examine spinal mobility in patients with axial spondyloarthritis]. / Epionics SPINE ­ Anwendung einer objektiven Untersuchungsmethode der Wirbelsäulenbeweglichkeit bei Patienten mit axialer Spondyloarthritis.

Axial spondylarthritis (axSpA) is a chronic inflammatory disease of the spine that can be associated with loss of physical function, mobility and upright postural impairment. Established tools for the assessment of function that are largely based on subjective perception are semiquantitatively recorded by standardized questionnaires (Bath ankylosing spondylitis functional index, BASFI), while measurement of spinal mobility of patients with axSpA is based on physical examination of various movement regions particularly the axial skeleton (Bath ankylosing spondylitis metrology index, BASMI). Recently, a performance test has been added to assess the range of motion and speed of certain tasks (AS performance-based improved test, ASPI); however, since these tests have limited reliability and reproducibility, more objective tests would be desirable. In this study the spinal mobility of patients with axSpA was quantified using the Epionics SPINE device (ES) and data were evaluated using the outcome measures in rheumatology (OMERACT) criteria. The ES automatically measures various patterns of spinal movements using electronic sensors, which also assess the range and speed of carrying out movements. Patients with back pain from other causes and persons without back pain served as controls. The measurement results obtained with ES differed between the groups and correlated with BASMI values (r = 0.53-0.82, all p = <0.03). Patients with radiographically detectable axSpA had more limited and slower mobility than those with non-radiographically detectable axSpA. Overall, the results presented here suggest that ES measurements represent a valid and objective measurement procedure of spinal mobility for axSpA patients.