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 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.

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.