Reproducibility of total and regional body composition using dual-energy X-ray absorptiometry in rheumatoid arthritis and ankylosing spondylitis.

Several studies have reported changes in body composition in rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Our study showed that body composition measurements obtained by absorptiometry were highly reproducible in patients suffering from these diseases. This study justifies the use of absorptiometry measurements in longitudinal studies in this population. PURPOSE: Our study aimed to assess the reproducibility of total and regional body composition in patients with rheumatoid arthritis (RA) and with ankylosing spondylitis (AS) and to compare them to healthy subjects. METHODS: The study enrolled 80 subjects including 32 healthy subjects, 31 RA patients, and 17 AS patients. Each subject had two scans in one day under the same standard conditions and none ate nor drunk before being repositioned on the table. The reproducibility was assessed through the coefficient of variation (CV), the least significant change (LSC), the intraclass correlation (ICC), and the smallest significant difference (SDD). RESULTS: Total body composition measurements obtained by dual-energy X-ray absorptiometry (DXA) were highly reproducible, and there was no statistically significant difference between reproducibility in healthy subjects, patients with RA, and patients with AS. For total body fat mass (FM), lean mass (LM), and bone mineral content (BMC) in the total population, CV values were 1.71%, 1.25%, and 1.74%, respectively; ICC values were 0.998, 0.996, and 0.993, respectively; LSC values were 4.88%, 3.7%, and 5.2%, respectively; and SDD values were ± 1.23 Kg, ± 1.47 Kg, and ± 126.0 g, respectively. For regional body FM, LM, and BMC in the total population, CV values in the arms were 8.46%, 4.17%, and 3.79%, respectively; in the legs 6.24%, 3.59%, and 2.04%, respectively, and in the trunk 5.02%, 2.92%, and 5.24%, respectively. CONCLUSION: Total body tissue mass, FM percentage, FM, LM, and BMC measurements obtained by DXA are highly reproducible in RA and AS.

Bone management in hematologic stem cell transplant recipients.

Autologous and allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for patients with some malignant and non-malignant hematological diseases. Advances in transplantation techniques and supportive care measures have substantially increased the number of long-term HSCT survivors. This has led to an increasing patient population suffering from the late effects of HSCT, of which, bone loss and its consequent fragility fractures lead to substantial morbidity. Altered bone health, with consequent fragility fractures, and chronic graft-versus-host disease (GVHD) are factors affecting long-term quality of life after HSCT. Hypogonadism, HSCT preparative regimens, nutritional factors, and glucocorticoids all contribute to accelerated bone loss and increased fracture risk. Management strategies should include bone mineral density examination, evaluation of clinical risk factors, and general dietary and physical activity measures. Evidence has accumulated permitting recommendations for more attentiveness to evaluation and monitoring of bone health, with appropriate application of osteoporosis pharmacotherapies to patients at increased risk of bone loss and fracture.

Vitamin D status and abdominal aortic calcification in postmenopausal women.

Vitamin D has an important role in bone metabolism and may be involved in the process of vascular calcification. The objective of this study was to evaluate the effect of vitamin D status on the presence of abdominal aortic calcification (AAC). We enrolled, in a cross-sectional study, 429 postmenopausal women [mean age, weight, and BMI of 59.5 ± 8.3 (50-83) years, 75.8 ± 13.3 (35-165) kg, and 29.9 ± 5.2 (14.6-50.8) kg/m2, respectively]. Lateral vertebral fracture assessment (VFA) images and scans of the lumbar spine and proximal femur were obtained using a Lunar Prodigy densitometer. Vertebral fractures (VFs) were defined using the Genant semiquantitative (SQ) approach. We used the Kauppila score to assess AAC extension. Clinical risk factors of osteoporosis were collected, and 25-hydroxy vitamin D was measured using electrochemiluminescence (Roche). Prevalence of osteoporosis and hypovitaminosis D (<20 ng/ml) was 21.0% and 78.1%, respectively. VFs grade 2/3 were identified in 76 patients (17.7%). Two thirds of the evaluable participants did not have any detectable AAC. The prevalence of significant atherosclerotic burden, defined as a radiographic 24-point AAC score of 5 or higher, was 7.9%. The group of women with extended AAC were older and had a statistically significant higher menopause duration and more prevalent grade 2/3 VFs. Compared to women with normal values of vitamin D, women with vitamin D insufficiency (<20 ng/ml) and deficiency (<10 ng/ml) had a lower BMD and more prevalent VFs. No difference was noted with regard to AAC among the three groups. Multiple stepwise conditional logistic regression analysis showed that the presence of AAC was associated significantly with age and the presence of VFs. Extended aortic calcifications are independently associated with prevalent VFA-identified VFs but not with serum vitamin D levels in postmenopausal women. VFA imaging using DXA may detect at the same time prevalent VFs and AAC, an important cardiovascular disease risk factor.

Polymorphisms of HLA-A, -B, -Cw and DRB1 antigens in Moroccan patients with ankylosing spondylitis and a comparison of clinical features with frequencies of HLA-B*27.

Ankylosing spondylitis (AS) is very often associated with human leukocyte antigen (HLA), particularly HLA-B*27. However, the strength of this association and clinical features may vary in different ethnic groups. Our study aims to assess the distribution of HLA-A, -B, -Cw and DRB1 alleles in Moroccan patients with AS and to compare the clinical features of AS and the frequencies of HLA-B27 in patients from Morocco with other series. Seventy-five patients diagnosed with AS and assessed for clinical manifestations were selected and compared to 100 healthy controls. HLA class I and II antigens were typed by polymerase chain reaction sequence-specific oligonucleotide. HLA-B27 subtypes were studied by polymerase chain reaction amplification with sequence-specific primers. HLA-B27 was found in 64% of patients. It was positively associated with younger age at disease onset, family history, and uveitis while it had a negative association with late onset. Six B*27 subtypes were identified in the AS group. HLA-B*2705 and B*2702 were the most common observed subtypes. Among other HLA genes, a significant increase in the prevalence of HLA-Cw*02 and HLA-DRB*15 was found in AS patients. HLA-B27 is involved in the predisposition of AS in the Moroccan population. HLA-B*2705 and B*2702 were the predominant subtypes supporting previous reports in Caucasian spondyloarthropathies. Other HLA genes, HLA-Cw*02 and HLA-DRB1*15, seem to confer predisposing effect to the disease. However, the lower frequency of HLA-B27 compared to the literature in our study suggests the existence of different genetic and/or environmental factors in Morocco.

Taxonomy of rare genetic metabolic bone disorders.

UNLABELLED: This article reports a taxonomic classification of rare skeletal diseases based on metabolic phenotypes. It was prepared by The Skeletal Rare Diseases Working Group of the International Osteoporosis Foundation (IOF) and includes 116 OMIM phenotypes with 86 affected genes. INTRODUCTION: Rare skeletal metabolic diseases comprise a group of diseases commonly associated with severe clinical consequences. In recent years, the description of the clinical phenotypes and radiographic features of several genetic bone disorders was paralleled by the discovery of key molecular pathways involved in the regulation of bone and mineral metabolism. Including this information in the description and classification of rare skeletal diseases may improve the recognition and management of affected patients. METHODS: IOF recognized this need and formed a Skeletal Rare Diseases Working Group (SRD-WG) of basic and clinical scientists who developed a taxonomy of rare skeletal diseases based on their metabolic pathogenesis. RESULTS: This taxonomy of rare genetic metabolic bone disorders (RGMBDs) comprises 116 OMIM phenotypes, with 86 affected genes related to bone and mineral homeostasis. The diseases were divided into four major groups, namely, disorders due to altered osteoclast, osteoblast, or osteocyte activity; disorders due to altered bone matrix proteins; disorders due to altered bone microenvironmental regulators; and disorders due to deranged calciotropic hormonal activity. CONCLUSIONS: This article provides the first comprehensive taxonomy of rare metabolic skeletal diseases based on deranged metabolic activity. This classification will help in the development of common and shared diagnostic and therapeutic pathways for these patients and also in the creation of international registries of rare skeletal diseases, the first step for the development of genetic tests based on next generation sequencing and for performing large intervention trials to assess efficacy of orphan drugs.

Age-adjusted incidence rates of hip fractures between 2006 and 2009 in Rabat, Morocco.

UNLABELLED: This study, characterizing the incidence of hip fracture in the province of Rabat, showed that age- and sex-specific rates remained stable between 2006 and 2009. The demographic projections estimated for Morocco indicate that between 2010 and 2030, the expected annual number of hip fractures would increase about twofold. INTRODUCTION: No data on hip fracture incidence trends exist from Africa. The aim of the study was to determine time trends in hip fracture rates for the province of Rabat and to forecast the number of hip fractures expected in Morocco up to 2030. METHODS: All hip fracture cases registered during the years 2006-2009 were collected at all the public hospitals and private clinics with a trauma unit and/or a permanent orthopedic surgeon across the province. RESULTS: Over the 4-year period, 723 (54.3%) hip fractures were recorded in women and 607 (45.6%) in men. The age- and gender-specific incidence of hip fracture rose steeply with advancing age. Hip fractures occurred later in women 75.0 (10.7) years than in men 73.3 (11.0) years (p=0.014), and its incidence was higher in women than in men [85.9 (95% CI 79.7-92.2) per 100,000 person-years vs. 72.7 (95% CI 66.9-78.5)]. The incidence remained globally stable over the period study, and the linear regression analysis showed no significant statistical difference. For the year 2010, there were 4,327 hip fractures estimated in Morocco (53.3% in women). Assuming no change in the age- and sex-specific incidence of hip fracture from 2010 to 2030, the number of hip fractures in men is expected to increase progressively from 2,019 to 3,961 and from 2,308 to 4,259 in women. CONCLUSION: The age-specific incidence of hip fracture between the years 2006 and 2009 remained stable in Morocco, and the number of expected hip fractures would double between 2010 and 2030.

Cancer-associated bone disease.

Bone is commonly affected in cancer. Cancer-induced bone disease results from the primary disease, or from therapies against the primary condition, causing bone fragility. Bone-modifying agents, such as bisphosphonates and denosumab, are efficacious in preventing and delaying cancer-related bone disease. With evidence-based care pathways, guidelines assist physicians in clinical decision-making. Of the 57 million deaths in 2008 worldwide, almost two thirds were due to non-communicable diseases, led by cardiovascular diseases and cancers. Bone is a commonly affected organ in cancer, and although the incidence of metastatic bone disease is not well defined, it is estimated that around half of patients who die from cancer in the USA each year have bone involvement. Furthermore, cancer-induced bone disease can result from the primary disease itself, either due to circulating bone resorbing substances or metastatic bone disease, such as commonly occurs with breast, lung and prostate cancer, or from therapies administered to treat the primary condition thus causing bone loss and fractures. Treatment-induced osteoporosis may occur in the setting of glucocorticoid therapy or oestrogen deprivation therapy, chemotherapy-induced ovarian failure and androgen deprivation therapy. Tumour skeletal-related events include pathologic fractures, spinal cord compression, surgery and radiotherapy to bone and may or may not include hypercalcaemia of malignancy while skeletal complication refers to pain and other symptoms. Some evidence demonstrates the efficacy of various interventions including bone-modifying agents, such as bisphosphonates and denosumab, in preventing or delaying cancer-related bone disease. The latter includes treatment of patients with metastatic skeletal lesions in general, adjuvant treatment of breast and prostate cancer in particular, and the prevention of cancer-associated bone disease. This has led to the development of guidelines by several societies and working groups to assist physicians in clinical decision making, providing them with evidence-based care pathways to prevent skeletal-related events and bone loss. The goal of this paper is to put forth an IOF position paper addressing bone diseases and cancer and summarizing the position papers of other organizations.

Osteoporosis management in hematologic stem cell transplant recipients: Executive summary.

BACKGROUND: Treatment advances have reduced the adverse events associated with hematopoietic stem cell transplant (HSCT) and led to an increased number of transplants performed. HSCT patients are living longer with concerns on long-term outcomes. Bone fragility and fracture are at the forefront for long-term morbidities post-HSCT. RESULTS: In HSCT recipients, evidence has accumulated to support recommendations for more extensive monitoring of bone fragility and more appropriate administration of osteoporosis pharmacotherapies for patients at high risk of bone loss and/or fracture. CONCLUSION: This executive summary reports and summarizes the main recommendations published previously, including bone assessment, dietary and lifestyle recommendations and osteoporosis medication.

Vertebral fracture assessment in Moroccan women: prevalence and risk factors.

INTRODUCTION: Vertebral fracture assessment (VFA) is a fast, low-radiation technique which produces images that are of sufficient quality to be used to diagnose the presence of vertebral deformity consistent with fracture. OBJECTIVE: To study prevalence and risk factors of vertebral fractures using VFA in asymptomatic Moroccan women. METHODS: The study cohort consists of a population of 328 consecutive women aged over 50 (mean age, weight and BMI of 65+/-6.5 (50-84) years, 72.0+/-12.8 (42-125) and 29.4+/-5.0 (17.1-45.8)kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: 68% of vertebrae from T4-L4 and 75% from T8-L4 were adequately visualized on VFA. Vertebral fractures (grades 2 or 3) were detected in 25.6% (84/328) of these women. Thirty-two of women with VFA-identified fracture (38.0%) had only a single vertebral fracture, while the other 61.9% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. Stepwise regression analysis showed that presence of vertebral fracture was mainly related to the spine osteoporotic status, age older than 65, history of peripheral fracture and more than six parities. CONCLUSION: Vertebral fractures are common in asymptomatic Moroccan women and are related to age, low BMD, history of fracture and multiparity.

Performance of calcaneus quantitative ultrasound and dual-energy X-ray absorptiometry in the discrimination of prevalent asymptomatic osteoporotic fractures in postmenopausal women.

Due to its low cost, portability, and nonionizing radiation, quantitative ultrasound (QUS) of the heel is an alternative to the measurement with dual X-ray absorptiometry (DXA) in the evaluation of bone status. The objective of the study is to compare in asymptomatic postmenopausal women the ability of QUS and DXA to discriminate between those with and without prevalent vertebral fractures (VFs). The study cohort consists of a population of 295 postmenopausal women aged between 60 and 84 (mean age, weight and BMI of 66.3 years, 72.0 kg and 29.4 kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. All women had a calcaneous QUS examination. The mean age of the women in our sample was 66.3 (+/-5.3) years, ranging from 60 to 84 years. Eighty-seven (29.3%) women had VFs Genant grade 2 and 3. Patients with VFs had an age and a number of years of menopause higher to those without VFs, but showed lower height, weight, and BMI. All densitometric and ultrasonometric measurements were significantly reduced in women with VFs. The intercorrelations of BMD at different sites were high, and the correlations of BUA with BMD were lower. BUA correlated weakly with total hip BMD (r = 0.36), lumbar spine BMD (r = 0.32), and much less with femur BMD (r = 0.30); all correlations were significant (P < 0.01). Analysis of the AUC for the ROC curves showed lumbar spine T-score below -2.5 to provide consistently the highest AUC (0.64). Age-adjusted ORs after correction for confounding variables (years of menopause, weight, height, and BMI) for QUS and BMD measurements showed that only lumbar spine T-score below -2.5 could predict significantly the presence of VFs (OR, 1.94; 95%CI, 1.02-3.41). Lumbar spine BMD (and not QUS) was able to discriminate asymptomatic postmenopausal women with prevalent VFs from women without VFs and independently contributed to determining the association with fracture. The combination of QUS and BMD did not improve the diagnostic ability of either individual technique.

Vertebral fracture assessment in healthy men: prevalence and risk factors.

INTRODUCTION: Vertebral fracture assessment (VFA) is a technology that can reliably and accurately diagnose vertebral fractures with greater patient convenience, less radiation exposure, and lower cost than standard spine radiography. OBJECTIVE: To study prevalence and risk factors of vertebral fractures using VFA in healthy men. METHODS: The study cohort consists of a population of 216 healthy men aged between 50 and 79 (mean age, weight and BMI of 63.8 years, 73.3 kg and 25.7 kg/m2, respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: Ninety-three percent of vertebrae from T4-L4 and 98% from T8-L4 were adequately visualized on VFA. Vertebral fractures were detected in 29.6% (64/216) of these men: 34/216 (15.7%) had grade 1 and 30/216 (13.8%) had grades 2 or 3. Twenty one of men with VFA-identified fracture (32.8%) had only a single vertebral fracture, while the other 67.2% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. This group of men had a statistically significant lower weight, height, calcium consumption and T-score than those without a VFA-identified vertebral fracture. Regression analysis showed that presence of vertebral fracture was mainly related to the osteoporotic status (OR: 9.0; 95% CI: 3.5-22.8). CONCLUSION: VFA allows evaluation of the majority of vertebral bodies in men. Vertebral fractures are common in healthy men and are related to low BMD.

Drug-induced lupus-like syndrome in ankylosing spondylitis treated with infliximab.

Specific antagonists of tumour necrosis factor (TNF-alpha) have rapidly gained popularity for the treatment of rheumatoid arthritis and ankylosing spondylitis (AS). Reported side effects from these agents include drug-induced autoimmune disorders. The monoclonal antibody against TNF-alpha, infliximab, has been associated with induction of systemic lupus erythematosus (SLE) in only one patient with AS in the literature. However, there have been no published reports of drug induced lupus-like syndrome (LLS) with positive anti-histone antibodies. We describe a 59-year-old woman with a 12-year history of refractory axial AS who developed signs and symptoms of LLS during treatment with infliximb with positive antinuclear and anti-histone antibodies. On diagnosis of LLS, infliximab was discontinued and the LLS-related symptoms promptly resolved.

Pulmonary Sarcoidosis following Etanercept Treatment for Ankylosing Spondylitis: A Case Report and Review of the Literature.

Antitumor necrosis factor therapies have revolutionized the treatment of some inflammatory diseases. However, the use of these agents is associated with the development of many paradoxical autoimmune diseases. Less well-recognized is the association with sarcoidosis. We report a 55-year-old female with long-standing ankylosing spondylitis who developed persistent dry cough and dyspnea while receiving etanercept therapy. High-resolution computed tomography scanning showed mediastinal lymphadenopathy and multiple nodules in both lung fields developed two months after the administration of etanercept. Lymph node biopsy was not practicable. Histopathological examination of minor salivary gland biopsy revealed noncaseating granulomata, and the serum angiotensin-converting enzyme was very elevated. All infectious studies were negative. Etanercept was discontinued plus a course of corticosteroids with a clinical improvement, and a follow-up high-resolution computed tomography scanning 4 months later showed evident regression of mediastinal lymph nodes and pulmonary nodules. Potential pathogenic mechanisms of this paradoxical effect of tumor necrosis factor-alpha blocking agents are discussed.

Discordance in diagnosis of osteoporosis using spine and hip bone densitometry.

Diagnostic discordance for osteoporosis is the observation that the T-score of a patient varies between skeletal sites, falling into 2 different diagnostic categories identified by the World Health Organization classification system. Densitometrists and clinicians should expect that at least 4 of every 10 patients tested by dual-energy X-ray absorptiometry (DXA) to demonstrate T-score discordance between spine and total hip measurement sites. T-score discordance can occur for a variety of reasons related to physiologic and pathologic patient factors and the performance or analysis of DXA itself.

Bone turnover and hormonal perturbations in patients with fibromyalgia.

OBJECTIVE: Studies of bone turnover in fibromyalgia (FM) have, to date, shown conflicting results. Although most patients with FM are women, only a few investigations have paid attention to the changes of sex hormones in FM. Moreover, FM is often viewed as a stress related disorder, and abnormalities of the hypothalamic-pituitary-adrenal (HPA) axis have been found in FM. The aim of the study was to assess bone turnover using serum osteocalcin and CTx in patients with FM and study correlation between bone turnover parameters and parathormon and hormones of the HPA axis. METHODS: A total of 81 subjects participated in this study: 41 healthy volunteers and 40 patients with FM. Serum osteocalcin, crosslaps (C-telopeptide: CTx), parathyroid hormone (PTH), testosterone, estrogen, prolactin, FSH, and LH were measured. The mean age of the study population was 49.5 (7.6) years (32-69) and the mean disease duration was 8.1 (12.0) years (4.5-30.7). RESULTS: No difference between patients and controls were observed in serum calcium, phosphorus, creatinine, albumin, osteocalcin, testosterone, and urinary calcium. Patients had lower serum levels of CTx, estrogen, PTH and prolactin than controls and higher serum levels of LH and FSH with a significant statistical difference. No significant statistical correlation was observed between intensity of pain and fatigue and bone turnover parameters and PTH or hormones of the HPA axis. CONCLUSION: Our study showed that patients with FM had low bone resorption and normal bone formation compared to a control group. This was not related to several hormonal perturbations observed in these patients and may reflect functional impairment as suggested in previous studies.

Influence of obesity on vertebral fracture prevalence and vitamin D status in postmenopausal women.

BACKGROUND: It is well established that weight is an important determinant of bone health. Whereas obesity is associated with increased mortality and morbidity from diabetes and cardiovascular diseases, high body weight is widely believed to be associated to hypovitaminosis D and protective against the development of osteoporosis and fracture risk. The objective of the study was to evaluate the effect of BMI on vitamin D status and on densitometric vertebral fractures (VFs) in a large series of asymptomatic women aged over 50 who had a VFA examination during their bone mineral density (BMD) testing. METHODS: We enrolled 429 postmenopausal women (mean age, weight and BMI of 59.5 ± 8.3 (50 to 83) years, 75.8 ± 13.3 (35 to 165) kgs and 29.9 ± 5.2 (14.6 to 50.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a Lunar Prodigy densitometer. VFs were defined using the Genant semiquantitative (SQ) approach. Clinical risk factors of osteoporosis were collected and 25-hydroxivitamin D was measured using electrochimiluminescence (Roche). RESULTS: Prevalence of osteoporosis and hypovitaminosis D (<20 ng/ml) was 21.0 % and 78.1 % respectively. VFs grade 2/3were identified in 76 (17.7 %). Comparison between women according to their BMI showed that obese women had a higher BMD and less proportion of women with osteoporosis and VFs grade 2/3 than lean and overweight women. The prevalence of VFs globally increased with age and as BMI and BMD declined. Stepwise regression analysis showed that the presence of osteoporosis was independently related to BMI and history of fractures while the presence of grade 2/3 VFs was independently related to age, hypovitaminosis D and years of menopause. CONCLUSION: Obese women had a higher BMD and lower prevalence of VFs. VFs were significantly related to age, hypovitaminosis D and years since menopause. However, among obese women, prevalence of VFs was increased in osteoporotic women.

Acute sacroiliitis as a manifestation of calcium pyrophosphate dihydrate crystal deposition disease.

While radiographic lesions of the sacroiliac joint (SIJ) are common in patients with calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, they are rarely accompanied by clinical symptoms. We report the case of a 69-year-old woman who presented with an acute sacoiliitis and a linear calcification in the right SIJ on CT scan. The patient recovered well after intra-articular steroid injections.

Cervical spine involvement in ankylosing spondylitis.

Our objective was to study cervical spine involvement in a Moroccan population of ankylosing spondylitis (AS) patients and evaluate correlations with disease symptomatic and structural severity. Patients were prospectively enrolled for a 1-year period. Clinical, biological, and radiological data were collected. The risk of cervical spine involvement was estimated using the Kaplan-Maier method. Sixty-one patients were enrolled: 38 males (62.2%) and 23 females of mean (SD) age 35.1 years [11] (range 17-66). The mean disease duration was 10.6 years [7] (0.5-30). Forty-three patients (70.4%) had a history of neck pain. Radiological involvement was present in 33 cases (54%). The concordance between clinical and radiological involvement was statistically significant (kappa=0.49; P<10(-6)). The risk of cervical spine involvement with regard to disease duration showed that 19.6% of patients had radiological involvement after 5 years, 29.9% after 10 years, 45.1% after 15 years and 70.0% after 20 years. Comparison between patients with and without cervical spine radiological involvement showed no difference in age of onset or sex. There was statistical difference in symptomatic severity parameters (Schöber, chest expansion, BASMI, BASFI, BASDI, BASG) and structural severity parameters (lumbar syndesmophytes score, BASRI). Our study confirms the greater severity of AS in North African countries. Cervical spine involvement increases with age and disease duration in AS and is more frequent in symptomatic and structural severe forms of the disease.

Involvement of the foot in patients with psoriatic arthritis. A review of 26 cases.

OBJECTIVE: To describe the clinical and radiological features of foot involvement in patients with psoriatic arthritis. METHODS: We retrospectively reviewed the medical records of patients admitted between 1972 and 1999 for psoriatic arthritis with involvement of the foot. We included all patients who had peripheral and/or axial, asymmetric, chronic inflammatory joint disease meeting or not Avila's radiological criteria for psoriatic arthritis, with or without other imaging findings suggestive of psoriatic arthritis and with or without psoriasis. RESULTS: Twenty-six patients were included. Inflammatory heel pain was reported by 14 patients, whereas forefoot involvement was found in only seven patients. Sausage toe was present in two patients. None of the patients had Bauer's toe (combining arthritis and psoriatic skin and/or nail changes) or psoriatic onychopachydermoperiostitis of the great toe. Radiological abnormalities were found in 20 patients. Half the patients had calcaneal changes. Osteoperiostitis of the great toe was noted in two patients and mushrooming in five. DISCUSSION: The features of psoriatic arthritis in Morocco seem similar to those in other countries. Hindfoot involvement was present in 53% of patients. Involvement of the forefoot was rarely recorded in the charts, suggesting missed cases because of insufficient attention to the forefoot during the physical examination and availability of anteroposterior radiographs only. Oblique views (Hirtz and Chaumet) should be obtained because they give a clearer image of the distal part of the toes, which is often difficult to analyze on anteroposterior films.