Association of variably expressed KIR3dl1 alleles with psoriatic disease.

The purpose of this study is to examine the genetic interaction of variably expressed killer cell immunoglobulin-like receptor (KIR) 3DL1 alleles with their cognate ligand, human leukocyte antigen (HLA)-Bw4, in susceptibility to psoriatic disease (PsD). A novel allelic typing system was developed to differentiate KIR3DL1 alleles (*High, *Low, *Null expression, and 3DS1), in PsD patients, including those with psoriatic arthritis (PsA) and cutaneous psoriasis without arthritis (PsC) and healthy controls. Frequencies of each KIR3DL1 allele, Bw4-80I and Bw4-80T, as well as the genetic interaction between the KIR3DL1 alleles and the Bw4 epitope were analyzed. KIR3DL1 alleles were successfully genotyped in 392 PsA, 260 PsC, and 371 control subjects. Only the KIR3DL1*Null allele was associated with PsD (OR = 0.69, p = 0.008), both in the PsA (OR = 0.69, p = 0.02) and PsC patients (OR = 0.70, p = 0.04) compared to control subjects. No difference in the frequency of KIR3DL1*Null was found between the PsA and PsC patients. The presence of the HLA-Bw4 epitope was significantly associated with PsD, particularly in the PsA patients compared to controls. Bw4-80I was increased in PsD and PsA subjects, but not in PsC patients compared to controls. Bw4-80T was increased in PsA compared to both PsC patients or to controls. No interaction was detected between any of the KIR3DL1 alleles and HLA-Bw4, Bw4-80I, or Bw4-80T. The novel qPCR technique successfully identified the four variably expressed KIR3DL1 alleles. The HLA-Bw4 epitope was associated with psoriatic disease, particularly with PsA, but no genetic interactions with KIR3DL1 alleles were detected.

Magnetic Resonance Imaging in Psoriatic Arthritis: A Descriptive Study of Indications, Features and Effect on Treatment Change.

OBJECTIVE: The aims of this study were to describe the indications for, and features of, axial/peripheral joint magnetic resonance imaging (MRI) in psoriatic arthritis (PsA) and to examine the influence of MRI findings on clinical practice. METHODS: All axial and peripheral (hand and/or foot) MRI scans on patients attending the Toronto PsA clinic l between 2003 and 2014 were included. Scan details were garnered from the radiologist's official report. A chart review was performed to determine if MRI findings contributed to a change of treatment. RESULTS: One hundred sixty-eight scans were performed on 125 patients (135 axial and 33 peripheral). The mean age was 50.5 (SD, 11.5) years, with 51.2% being female. Mean duration of PsA was 11.2 (SD, 10.9) years. Of the axial scans, the majority were performed on the whole spine (excluding the sacrum) (27.4%) or the sacroiliac joints and spine together (45.2%). The predominant indications were for suspected inflammatory (51.1%) or degenerative (24.4%) disease. Magnetic resonance imaging revealed inflammatory and/or structural change in 34.1% versus 54.8% with degenerative changes. In MRI axial inflammation (n = 25), the majority (48%) had sacroiliac joint involvement, whereas 28% had inflammation at 2 or more sites.Of the periphery, 60.6% of scans were on hands and 21.2% were on feet alone. The main indications were for suspected subclinical synovitis (78.8%). Inflammatory arthritis was the MRI diagnosis in 72.7%. Magnetic resonance imaging findings influenced treatment change (n = 32) in 56.3%, but were insufficient to effect treatment change without clinical findings (100%). CONCLUSIONS: Magnetic resonance imaging is useful in evaluating patients with active PsA, particularly when suspecting inflammation and radiographic findings are unhelpful. In some cases, it can be used as an adjunct to clinical examination in determining treatment change.

Sensitivity and Specificity of Radiographic Scoring Instruments for Detecting Change in Axial Psoriatic Arthritis.

OBJECTIVE: There is no widely recognized method used to assess axial disease in psoriatic arthritis (PsA). We aimed to determine the sensitivity to change of the Bath Ankylosing Spondylitis Radiology Index for the spine (BASRI-s), the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), the Radiographic Ankylosing Spondylitis Spine Score (RASSS), and the PsA Spondylitis Radiology Index (PASRI) in axial PsA. METHODS: Radiographs of 105 patients with axial PsA were retrieved for 2 time points at least 2 years apart and subsequently anonymized. All radiographs were scored by 3 rheumatologists blinded to name and order of examination using an electronic application that allowed recording of disease manifestations specific to axial PsA and automatically calculated the BASRI-s, mSASSS, RASSS, and PASRI scores. An independent expert determined whether there was true radiographic progression from an overall impression after viewing the radiographs with knowledge of chronologic order. The sensitivity, specificity, and odds ratios for every 1-unit increase in the scores were determined to identify true change. RESULTS: Of the patients studied, 25 (24%) showed progression, as determined by the independent expert. The respective sensitivity and specificity values for an increase in score to detect true change were as follows: 0.48 and 0.78 (BASRI-s), 0.52 and 0.84 (mSASSS), 0.44 and 0.84 (RASSS), and 0.52 and 0.74 (PASRI). Logistic regression analyses showed that an increase of 1 point in the respective scores was associated with the following odds ratios for identifying true progression: BASRI-s 3.0, mSASSS 5.27, RASSS 3.70, and PASRI 3.06. CONCLUSION: Available scoring systems for quantifying radiographic axial PsA have moderate sensitivity but high specificity for detecting true change.

Attainment of Minimal Disease Activity Using Methotrexate in Psoriatic Arthritis.

OBJECTIVE: An international task force has recommended that disease remission or minimal disease activity (MDA) be the target of treatment for psoriatic arthritis (PsA) and that remission or MDA should be attained within 6 months of initiating medication. The aim of this study was to establish the proportion of patients with PsA who achieve MDA after 6 months of methotrexate (MTX) treatment. METHODS: Patients who initiated MTX and were naive to biologics between 2004 and 2014 were included. The primary outcome was the achievement of MDA after 6 months of MTX, defined as the presence of at least 5 out of the following 7: tender joint count ≤ 1, swollen joint count (SJC) ≤ 1, Psoriasis Area Severity Index (PASI) ≤ 1 or body surface area ≤ 3%, tender entheseal points ≤ 1, Health Assessment Questionnaire score ≤ 0.5, patient global disease activity visual analog scale (VAS) score ≤ 20, and patient pain VAS ≤ 15. Of 204 patients identified, 167 were treated with MTX for at least 3 months and had sufficient data for analysis at 6 months. RESULTS: At 6 months, 29 patients (17.4%) achieved MDA; 97 patients (58.1%) achieved an SJC ≤ 1 and 138 (82.6%) a PASI ≤ 1. Only 22 (13.2%) achieved the patient global disease activity criterion. Lower back pain and dactylitis were associated with a lower probability of achieving MDA. CONCLUSION: MTX use achieves MDA by 6 months in < 20% of patients. This compares unfavorably with data for tumor necrosis factor inhibitor use.

Clinical and Demographic Characteristics of Erosion-free and Erosion-present Status in Psoriatic Arthritis in a Cohort Study.

OBJECTIVE: Psoriatic arthritis (PsA) has been recognized as a severe erosive disease. However, some patients do not develop erosions. We aimed to determine the prevalence, characteristics, and predictors of erosion-free patients (EFP) as compared with erosion-present patients (EPP) among patients with PsA followed prospectively. METHODS: This is a retrospective analysis conducted on patients from the Toronto PsA cohort. Patients with at least 10 years of followup and radiographs were analyzed. Radiographs were scored with the modified Steinbrocker method. Baseline (first visit to clinic) characteristics were used to predict the development of erosions with logistic regression models. To examine the effect of time-varying covariates, Cox regression models were fit for the time to development of erosions from baseline. RESULTS: Among 290 patients, 12.4% were EFP and 87.6% were EPP over the study period. The mean time to development of erosion in the EPP over the course of followup was 6.8 ± 6.1 years. EFP were diagnosed with psoriasis at a younger age compared with EPP. In both models, actively inflamed joints and clinically damaged joints were predictive of the development of erosion, whereas a longer duration of psoriasis at baseline decreased the odds of developing erosion. EPP had a higher percentage of unemployment as compared with EFP at baseline and followup visits. CONCLUSION: Among patients with PsA followed for at least 10 years, 12.4% never develop erosions. The clinical and radiographic findings can ultimately assist in the stratification of a patient's prognosis regarding the development of erosions.

The Incidence and Predictors of Infection in Psoriasis and Psoriatic Arthritis: Results from Longitudinal Observational Cohorts.

OBJECTIVE: To investigate the rate, type, characteristics, and predictors of infection in a cohort of patients with psoriatic arthritis (PsA) and a cohort of patients with psoriasis without arthritis (PsC). METHODS: A cohort of patients with PsA and a cohort of patients with PsC were followed according to a standard protocol and information on the occurrence of infections was recorded. The rate of infection was estimated by fitting an exponential model. A Weibull regression model was fitted to estimate the relative risk of first infection associated with a number of covariates. Risk factors for recurrent infections were investigated using generalized estimating equations. RESULTS: There were 498 and 74 infections reported among 695 and 509 patients with PsA and PsC, respectively, with an incidence rate of 19.6 per 100 person-years in the PsA cohort compared with 12.2 in the PsC cohort. The HR of the time to the first infection in PsA versus PsC was 1.6 (p = 0.002), and higher in patients treated with biologics versus nonbiologics at 1.56 (95% CI 1.22-2.00) in PsA and 1.50 (95% CI 0.64-3.54) in the PsC cohorts. Female sex and treatment with biologics were associated with infection in the PsA cohort, whereas a lower Psoriasis Area and Severity Index score and a higher Functional Comorbidity Index were associated with infection in the PsC cohort. Ultraviolet treatment was protective against infection in both cohorts. No difference in rates of hospitalization was found (p = 0.66). There were no infection-related deaths in either cohort. CONCLUSION: The incidence rate of infection was higher in the PsA than the PsC cohort and higher among patients treated with biologics. The data confirm the association between infection and biologic treatment in psoriatic disease.

Fatigue in Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis: Analysis from a Longitudinal Observation Cohort.

OBJECTIVE: In this study, we aimed to address the prevalence of fatigue, its associated factors, and the effect of tumor necrosis factor inhibitors (TNFi) on this subgroup of patients in a large axial spondyloarthritis (axSpA) cohort. METHODS: The study included 681 patients [ankylosing spondylitis (AS) and nonradiographic axSpA (nr-axSpA)]. The Fatigue Severity Scale (FSS) and the Bath AS Disease Activity Index question 1 (BASDAI Q1) indices were used for fatigue assessment. Severe fatigue was defined as an FSS ≥ 4 or a BASDAI Q1 ≥ 5. Disease activity, function, and quality of life (QoL) measures were recorded. Patients who had been treated with TNFi were identified, and baseline and followup data were analyzed. RESULTS: Of the cohort, 67.3% had severe fatigue, and the prevalence was similar between AS (67.2%) and nr-axSpA (68.2%). Severely fatigued patients tended to have higher disease activity scores, increased acute-phase proteins, and decreased QoL measures. TNFi therapy was associated with improvement in disease activity, and although this treatment led to significantly decreased fatigue scores, this reduction was not optimal in the majority of patients with 80% continuing to have severe fatigue according to their posttreatment scores. Health Assessment Questionnaire, mean scores of BASDAI Q5 and Q6, and BASDAI enthesitis were independent predictors of fatigue severity. CONCLUSION: Fatigue is a common symptom in axSpA, and the burden of fatigue among patients with nr-axSpA is similar to that seen in AS. While biologics are effective in improving disease activity, their effect on fatigue is more limited. In axSpA, fatigue remains unresponsive to TNFi in nearly 80% of patients.

Further Evidence Supporting a Parent-of-Origin Effect in Psoriatic Disease.

OBJECTIVE: To further explore the "parent-of-origin" effect in a large cohort of well-phenotyped patients with cutaneous psoriasis without arthritis (PsC) and psoriatic arthritis (PsA). METHODS: Self-reported family history was obtained from PsA patients from Toronto and Newfoundland satisfying the Classification of Psoriatic Arthritis criteria, and PsC patients from Toronto, who were examined by a rheumatologist to exclude PsA. Proportions of probands with paternally and maternally transmitted psoriatic disease were compared by McNemar's and chi-square tests. Baseline clinical and genetic characteristics of probands with paternally and maternally transmitted disease were compared using logistic regression. RESULTS: A total of 849 probands reported a first-degree relative affected with psoriatic disease (PsC or PsA), of which 532 (63%) reported an affected parent. A significantly larger proportion of probands reported an affected father compared to an affected mother with psoriatic disease (289 [57%] versus 220 [43%], respectively; P = 0.003). This paternal transmission bias was evident in PsA (P = 0.006) and PsC probands, although it did not reach statistical significance in PsC probands (P = 0.20). Furthermore, the proportion of paternal PsC-proband PsA pairs (161 of 214 paternal transmissions [75%]) was significantly larger than maternal PsC-proband PsA pairs (103 of 161 maternal transmissions [64%]) (P = 0.02). Newfoundland probands with paternally transmitted disease had higher HLA-B*08 carriage (P = 0.04) and lower MICA-129Met carriage (P = 0.03). Males had higher HLA-B*38 carriage (P = 0.05) and a higher prevalence of nail lesions (P = 0.01). CONCLUSION: We have provided further epidemiologic evidence of a paternal transmission bias in psoriatic disease.

Tumour necrosis factor inhibitor therapy and infection risk in axial spondyloarthritis: results from a longitudinal observational cohort.

OBJECTIVES: Long-term data on infection risk in axial SpA (axSpA) are sparse. TNF inhibitors (TNFis) are increasingly being used in axSpA, with infection being the most important adverse event. We aimed to investigate the frequency of infections in axSpA and to identify factors predisposing to infection. METHODS: Data were extracted from a longitudinal observational cohort of patients with axSpA. Infection rates were calculated and multivariate analysis was performed to investigate the association of independent variables with infection. RESULTS: Data were analysed for 440 patients followed for a total of 1712 patient-years (pys). A total of 259 infections, of which 23 were serious, were recorded in 185 patients. The overall rate of any infection was 15 (95% CI 13, 17)/100 pys and the serious infection rate was 1.3 (95% CI 0.9, 2.0)/100 pys. There was no significant difference in the rate of any infection or serious infection in patients on TNFis compared with patients never on biologic agents. In the multivariate analysis, DMARD treatment, but not TNFi treatment, was associated with risk of infection. Age, disease duration, smoking status, BASFI, BASDAI, co-morbidity score and hospitalization were not associated with an increased risk of infection. CONCLUSION: The serious infection rate in axSpA in this observational cohort is low when compared with rates reported in other rheumatic diseases. Biologic use was not a significant risk factor for serious infection.

Obesity is associated with a lower probability of achieving sustained minimal disease activity state among patients with psoriatic arthritis.

AIM: To assess whether overweight and obese patients with psoriatic arthritis (PsA) are less likely to achieve sustained minimal disease activity (MDA) state compared to patients with normal weight. METHODS: A cohort of patients was assessed at the University of Toronto PsA clinic at 6-12-month intervals according to a standard protocol from 2003 to 2012. Patients were categorised into the following groups according to their body mass index (BMI): normal (<25), overweight (25-30), and obese (>30). Sustained MDA was defined as achieving low disease activity state in five or more of the following domains for at least 1 year: skin, enthesitis, tender and swollen joint counts, pain, patient global assessment and function. Proportional odds discrete time to event analysis was used to investigate the association between BMI category and the achievement of sustained MDA. RESULTS: Of the 557 patients included in the study, 36.2% were classified as overweight and 35.4% were obese. Overall, 66.1% of the patients achieved sustained MDA during the follow-up period. A dose-response association was found between obesity and the probability of achieving sustained MDA in the multivariate regression analysis. Patients in the higher BMI categories were less likely to achieve sustained MDA compared those in the lowest BMI category (overweight: OR 0.66 p=0.003; obese: OR 0.53 p<0.0001) after adjusting for potential confounding variables. CONCLUSIONS: Overweight and obese patients with PsA are less likely to achieve sustained MDA compared to those of normal weight.

Increased burden of inflammation over time is associated with the extent of atherosclerotic plaques in patients with psoriatic arthritis.

AIM: To investigate whether a higher burden of inflammation is associated with more severe atherosclerosis in patients with psoriatic arthritis (PsA). METHODS: Patients from a large PsA cohort were analysed. The cumulative effect of inflammation was measured by a time-adjusted arithmetic mean of all measurements from the first visit to the clinic. The following variables were considered as predictors: Psoriasis Activity and Severity Index (PASI), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, tender and swollen joint counts, C-reactive protein, Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity for PsA (DAPSA). Vascular ultrasound of the carotid arteries was performed, and total plaque area was measured. This measure represented the extent of atherosclerosis and was considered the outcome of interest. The association between inflammation over time and atherosclerosis was assessed by regression models adjusted for age, sex and cardiovascular risk factors. RESULTS: A total of 235 patients with PsA were analysed. Patients with more severe atherosclerosis were older (p<0.001), more likely to be obese (p=0.01), smokers (p=0.008) and have hypertension (p=0.001), diabetes (p<0.0001) and dyslipidaemia (p<0.0001). In a multivariate regression model adjusted for age and sex, higher ESR (p=0.009), WBC count (p=0.015) and DAPSA (p=0.04) were associated with more severe atherosclerosis. These associations were not significant after adjustment for traditional cardiovascular risk factors. No association was found between disease duration and atherosclerosis. CONCLUSIONS: Exposure to an increased burden of inflammation is associated with more severe atherosclerosis in patients with PsA. This association may be mediated by traditional cardiovascular risk factors.

Factors explaining the discrepancy between physician and patient global assessment of joint and skin disease activity in psoriatic arthritis patients.

OBJECTIVE: To assess the extent and determinants of discordance in scoring between patient global assessment (PtGA) and physician global assessment (PhGA) in patients with psoriatic arthritis (PsA). METHODS: A cross-sectional and longitudinal analysis of data was conducted in patients attending a large PsA clinic. The difference between PtGA and PhGA (each measured on a scale of 0-10, with 0 indicating best status and 10 indicating worst status) reflected the discrepancy between the PtGA and PhGA of joint and skin activity and could take values from -10 (higher rating of disease activity by the patient) to 10 (higher rating of disease activity by the physician). Multivariate regression identified variables that contributed significantly to each of the outcomes. The proportion of variability of each outcome explained by each predictor was expressed by the partial R(2) . RESULTS: A total of 565 patients were included in the analysis. Patients tended to score their disease worse than their physicians, with greater discordance for the joints than for the skin (mean ± SD 1.68 ± 2.41 PtGA-PhGA difference for joints, and 0.77 ± 2.66 for skin). Fatigue accounted for 21% of the variation in the difference between PtGA and PhGA for joints. Pain (Rpartial2 = 9%) and disability by Short Form 36 health survey (Rpartial2 = 1.2%) were also important factors, each of which led to higher patient rating; whereas increased tender joint count (Rpartial2 = 16%) and swollen joint count (Rpartial2 = 1.4%) resulted in a higher physician rating of arthritis. CONCLUSION: Fatigue, pain, disability, and tender and swollen joint counts were the most important factors contributing to discrepancy between patient and physician assessment of joint activity.

Minimal disease activity and anti-tumor necrosis factor therapy in psoriatic arthritis.

OBJECTIVE: A state of minimal disease activity (MDA) was defined and validated as target for treatment in psoriatic arthritis (PsA). We aimed to identify disease characteristics, outcome, and predictors of MDA in patients treated with tumor necrosis factor α (TNFα) blockers. METHODS: Patients fulfilling the Classification of Psoriatic Arthritis criteria treated with TNFα blockers were followed every 3-6 months. Patients were considered in MDA when they meet at least 5 of the 7 criteria. Sustained MDA was defined as an MDA state lasting ≥12 months. Patients achieving MDA were compared to non-MDA patients. A proportional odds discrete time survival analysis model was applied, adjusting for sex, age, PsA duration, abnormal erythrocyte sedimentation rate (ESR) and clinically damaged joint count at each visit to identify predictors for MDA. RESULTS: Of the 306 patients treated with TNFα blockers identified from our database, 23 patients were in an MDA state when treatment was commenced; 57 were taking TNFα blockers prior to enrollment. Therefore, 226 subjects were in a non-MDA state and constituted the study population. One hundred forty-five patients of 226 patients (64%) achieved MDA within a mean ± SD duration of 1.30 ± 1.68 years. The mean ± SD duration of MDA was 3.46 ± 2.25 years. At total of 17 patients withdrew from therapy and remained in an MDA state. Male sex (odds ratio [OR] 1.65, 95% confidence interval [95% CI] 1.08-2.53; P = 0.02) and normal ESR (OR 2.27, 95% CI 1.22-4.17; P = 0.009) increased the odds for achieving MDA. CONCLUSION: MDA is achieved in 64% of patients treated with TNFα blockers in a clinical setting. Male sex and normal ESR are predictors for MDA. On withdrawal or reduction in treatment, 11.6% of patients maintained MDA state.

Immunoglobulin G subclass analysis in psoriatic arthritis.

OBJECTIVE: The occurrence of monoclonal gammopathy of undetermined significance (MGUS) is common in chronic immune mediated disorders. This increased monoclonal antibody production could result from chronic stimulation of lymphocytes, with the immunoglobulin G (IgG) subtype accounting for the majority of cases in psoriatic arthritis (PsA). We aimed to identify IgG subclass profiles in patients with PsA and to determine association with specific disease characteristics. METHODS: Serum samples from 221 patients with PsA from a single cohort were analyzed for their serum IgG subclass levels. All patients fulfilled the ClASsification for Psoriatic ARthritis (CASPAR) criteria and were followed at 6-month to 12-month intervals according to a standard protocol. MGUS was defined as the occurrence of a discrete band in the gammaglobulin region on at least 2 separate serum protein electrophoresis tests performed 6 months apart. Patients with high abnormal IgG subclass levels were compared to patients with normal levels using descriptive tests. RESULTS: Elevations of IgG1-4 were common in PsA, with ∼20%-49% of patients having elevations of each subclass, IgG2 being the most common subclass abnormality. However, no clinical-serological correlation was found in the group with abnormal IgG2 levels. Of the 38 patients with MGUS, elevations in IgG1 were most common. Patients with an abnormal IgG1 subclass level were more likely to have a discrete band in the gammaglobulin region, higher prevalence of MGUS, and abnormal erythrocyte sedimentation rate or C-reactive protein levels. CONCLUSION: Determination of the IgG subclass concentration in PsA did not seem to add any significant value in identifying specific disease manifestations. However, this study provides insight into the pathological process leading to MGUS in PsA.

The effectiveness of leflunomide in psoriatic arthritis.

OBJECTIVES: This study aimed to evaluate the effectiveness and safety of leflunomide alone and in combination with methotrexate in the treatment of psoriatic arthritis (PsA). METHODS: Patients were followed at the University of Toronto PsA Clinic. PsA patients who received leflunomide alone or in combination with methotrexate were identified from the PsA clinic database. Effectiveness was defined by drug persistence, a ≥40% reduction in actively inflamed joints, a ≥40% reduction in swollen joint count, and PASI50 and PASI75 response following treatment with leflunomide. Descriptive statistics and logistic regression analyses with stepwise selection were used for data analysis. RESULTS: 85 patients were identified. 43 patients (50.6%) were on leflunomide alone and 42 (49.4%) patients were on combined leflunomide and methotrexate therapy. 30 patients discontinued leflunomide mainly due to toxicity. Of the 55 patients who continued the drug, 38%, 48% and 56% achieved a ≥40% reduction of actively inflamed joint count at 3, 6 and 12 months, respectively. PASI50 was achieved by 27%, 28% and 38% at 3, 6 and 12 months, whereas PASI75 was achieved by 19% at 3 and 6 months and 32% at 12 months. Longer duration of PsA and higher swollen joint count at baseline were predictive for improvement of the swollen joint count at 3 months. The use of concomitant MTX was predictive of achieving PASI50 at 12 months. CONCLUSIONS: Leflunomide led to improvement in almost 50% of the patients by 1 year. Those also taking methotrexate were more likely to achieve a PASI50 response.

Analysis of the effect of the oral contraceptive pill on clinical outcomes in women with ankylosing spondylitis.

OBJECTIVE: There are unexplained sex-specific changes in the clinical expression of ankylosing spondylitis (AS). We sought to examine the potential effect of exogenous estrogen in the form of oral contraceptive pills (OCP) on AS initiation and severity. METHODS: This cross-sectional study consisted of women with AS from the membership of the Spondylitis Association of America. Measures of disease severity included use of biological agents and hip replacement surgery, while Bath AS Functional Index (BASFI) scores served as a surrogate marker of disability. Information was obtained using a patient questionnaire on patient demographics, OCP use, pregnancy history, AS duration, medication use, and hip replacement. RESULTS: There were 571 women with AS who participated in our study, consisting of 448 OCP ever-users and 123 non-OCP users. The mean age of OCP users was 42.7 yrs (± 11.5) and of non-OCP users, 48.4 yrs (± 12.1). No difference was noted in the age at initial onset of back pain. However, OCP users were significantly younger at the time of diagnosis of AS (36.5 yrs vs 39.1 yrs, p = 0.02). There were no significant differences between the 2 groups in tumor necrosis factor inhibitor or opioid use, BASFI scores, pregnancy complications, or hip surgery. CONCLUSION: The use of exogenous estrogens in the form of OCP is not associated with a measurable effect on initiation or severity of AS. Biologic and social factors may contribute to earlier diagnosis of AS in OCP users. This is the largest study to date investigating the potential effect of exogenous estrogens in women with AS.

Depression and anxiety in psoriatic disease: prevalence and associated factors.

OBJECTIVE: (1) To determine the prevalence of depression and anxiety in patients with psoriatic arthritis (PsA) and to identify associated demographic and disease-related factors. (2) To determine whether there is a difference in the prevalence of depression and anxiety between patients with PsA and those with psoriasis without PsA (PsC). METHODS: Consecutive patients attending PsA and dermatology clinics were assessed for depression and anxiety using the Hospital Anxiety and Depression Scale. Patients underwent a clinical assessment according to a standard protocol and completed questionnaires assessing their health and quality of life. T tests, ANOVA, and univariate and multivariate models were used to compare depression and anxiety prevalence between patient cohorts and to determine factors associated with depression and anxiety. RESULTS: We assessed 306 patients with PsA and 135 with PsC. There were significantly more men in the PsA group (61.4% vs 48% with PsC) and they were more likely to be unemployed. The prevalence of both anxiety and depression was higher in patients with PsA (36.6% and 22.2%, respectively) compared to those with PsC (24.4% and 9.6%; p = 0.012, 0.002). Depression and/or anxiety were associated with unemployment, female sex, and higher actively inflamed joint count as well as disability, pain, and fatigue. In the multivariate reduced model, employment was protective for depression (OR 0.36) and a 1-unit increase on the fatigue severity scale was associated with an increased risk of depression (OR 1.5). CONCLUSION: The rate of depression and anxiety is significantly higher in patients with PsA than in those with PsC. Depression and anxiety are associated with disease-related factors.

Is the MAdrid Sonographic Enthesitis Index useful for differentiating psoriatic arthritis from psoriasis alone and healthy controls?

OBJECTIVE: To assess the usefulness of the MAdrid Sonographic Enthesitis Index (MASEI) in classifying patients as having psoriatic arthritis (PsA) and comparing entheseal abnormalities between patients with PsA, psoriasis alone (PsC), and healthy controls (HC). METHODS: Patients with PsC were assessed to exclude inflammatory arthritis. The MASEI scoring system was used to quantify the extent of ultrasonographic (US) entheseal abnormalities. The total MASEI score was categorized into items that reflected inflammatory abnormalities (MASEI-inflammatory) and chronic damage (MASEI-damage). Nonparametric tests were used to compare MASEI scores across the groups. A cutoff point of MASEI ≥ 20 was used to calculate the sensitivity and specificity of the MASEI to classify patients as having PsA. RESULTS: Patients with PsA (n = 50), PsC (n = 66), and HC (n = 60) were assessed. Total MASEI scores were higher in patients with PsA than in those with PsC, and both those groups were higher than HC (p < 0.0001). MASEI-inflammatory showed a similar trend (p < 0.0001). MASEI-damage was higher in patients with PsA compared to both patients with PsC and HC (p < 0.0001); however, no difference was observed between patients with PsC and HC. No significant difference in MASEI scores was found across the 3 groups in patients with a body mass index > 30. The sensitivity of the MASEI score to correctly classify patients as having PsA was 30% and the specificity was 95% when compared to HC and 89% when compared to PsC. CONCLUSION: The severity of US entheseal abnormalities is highest in patients with PsA followed by PsC and is lowest in healthy controls. MASEI can specifically classify patients as having PsA.

Tumour necrosis factor α blockers are more effective than methotrexate in the inhibition of radiographic joint damage progression among patients with psoriatic arthritis.

AIM: To determine whether tumour necrosis factor α (TNFα) blockers are more effective than methotrexate in inhibiting the progression of radiographic joint damage in patients with psoriatic arthritis (PsA). METHODS: A cohort analysis of patients followed prospectively in a large PsA clinic was conducted. Patients who received a TNFα blocker were compared to those treated with methotrexate. Patients who had records of at least 12 months of treatment with either medication for active peripheral PsA and had radiographic bone erosions were analysed. Radiographs of the hands and feet were performed at baseline, 1-2 years (time 1) and 3-4 years (time 2). Radiographic joint damage was scored according to the modified Steinbrocker score. The outcome of interest was the occurrence of radiographic progression. Multivariate logistic regression analysis using generalised estimating equations for repeated measures was used to compare progression in radiographic joint damage between the two treatment groups. RESULTS: 65 patients treated with TNFα blockers and 70 patients treated with methotrexate were analysed. The proportion of patients who demonstrated progression of radiographic damage score at time 1 and time 2 was higher in the methotrexate group compared to the TNFα blockers group (at time 1: 80% vs 58.9% p=0.005; at time 2: 88% vs 61% p=0.005). In the multivariate regression analysis methotrexate treatment was associated with an increase in radiographic damage compared to TNFα blockers (p=0.001). CONCLUSIONS: In a clinic setting, patients with erosive PsA receiving TNFα blockers had a better radiographic outcome compared to those treated with methotrexate.

Dactylitis in psoriatic arthritis: prevalence and response to therapy in the biologic era.

OBJECTIVE: To determine the prevalence of acute dactylitis in patients with psoriatic arthritis (PsA) and to compare the response of new acute dactylitis to treatment with traditional disease-modifying antirheumatic drug (DMARD) and anti-tumor necrosis factor-α (anti-TNF) agents in a longitudinal PsA cohort. METHODS: Patients with PsA followed at 6 months according to a standard protocol from January 2000 to January 2010 were included in our study. Acute dactylitis was defined as the presence of painful swelling of an entire digit. Response was defined as either complete resolution of dactylitis or > 50% improvement in the number of dactylitic digits. A multivariate generalized estimating equations analysis using a negative binomial model to account for repeated measures was conducted to determine predictors for response to treatment of dactylitis. RESULTS: Of the 752 patients seen in the clinic during this period, 294 had dactylitis in at least 1 visit, giving a prevalence of 39%. Patients with acute dactylitis and data available for response at 6 and 12 months (n = 252; 34% women, mean age 47 yrs, PsA duration 11 yrs) were included in the study on predictors of response to treatment. Multivariate analysis showed that treatment with anti-TNF agents was a significant predictor of improvement in dactylitis at 12 months (relative risk 0.528, 95% CI 0.283-0.985, p = 0.045). CONCLUSION: The prevalence of dactylitis on at least 1 visit was 39%. Treatment was associated with improvement of dactylitis. Patients treated with biologics had better response to treatment compared with those treated with nonbiologic DMARD alone.