Erkan Kilic

Relationship Between Psychiatric Status, Self-Reported Outcome Measures, and Clinical Parameters in Axial Spondyloarthritis

AbstractThis article aims to compare the risks of depression and anxiety in patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (nr-axSpA) and investigate the relationship among self-reported outcome measures, clinical parameters, and physical variables of patients with axSpA.Patients with axSpA were recruited from Erciyes Spondyloarthritis Cohort. The patients met Assessment of Spondyloarthritis International Society classification criteria for axial SpA and were assessed in a cross-sectional study design for visual analog scale (VAS) pain, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Quality of Life questionnaire (ASQoL), and Ankylosing Spondylitis Disease Activity Score–C-reactive protein (ASDAS-CRP). Psychological status was evaluated using the hospital anxiety and depression scale (HADS). Multivariate logistic regression analysis was applied to determine the associations between psychological variables and clinical parameters after adjusting for confounding variables.Of the 316 patients (142 nr-axSpA, 174 AS), 139 (44%) had high risk for depression (HADS-D score ≥7) and 71 (22.5%) for anxiety (HADS-A score ≥10). HADS-D and HADS-A scores were similar between patients with AS and nr-axSpA. Patients with high risk for depression and anxiety had higher scores in BASDAI, BASFI, and ASDAS-CRP, and also poorer scores in VAS pain and ASQoL. Multivariate logistic regression analysis showed that the ASDAS-CRP, ASQoL, BASDAI, as well as educational level were factors associated with the risk of depression whereas the ASQoL and educational level were factors associated with the risk of anxiety.Patients with nr-axSpA and AS have similar burden of psychological distress. The quality of life (ASQoL) and educational level were factors associated with the risk of both depression and anxiety whereas disease activity (BASDAI and ASDAS-CRP) was the independent risk factor associated with depression but not anxiety in axSpA. These findings suggest that psychological status should be examined while assessing patients with axSpA including AS and nr-axSpA.

Ultrasonographic assessment of diurnal variation in the femoral condylar cartilage thickness in healthy young adults.

Objective In vivo measurement of articular cartilage thickness is a significant marker of structural joint damage in many inflammatory or noninflammatory diseases including rheumatoid arthritis or osteoarthritis. The aim of this study was to assess the diurnal variation of femoral condylar cartilage thickness (FCT) in young adults by using ultrasonography. Design The thickness of femoral articular cartilage was measured in healthy volunteers at 8:00–9:00 a.m. and 4:00–5:00 p.m. on the same day using standard sonographic methods. Three midpoint measurements were taken from each knee at the lateral femoral condyle, femoral intercondylar area, and medial femoral condyle. Results The FCT significantly decreased in all the areas assessed. The maximal decrease (in millimeters) in the mean (standard deviation) FCT was in the right lateral femoral condyle (0.21 [0.24]) and left medial femoral condyle (0.21 [0.21]) followed by the right medial femoral condyle (0.19 [0.23]), left lateral femoral condyle (0.19 [0.19]), left femoral intercondylar area (0.13 [0.30]), and right femoral intercondylar area (0.11 [0.33]). The mean diurnal change in FCT from a.m. to p.m. reached up to 10.6%. Conclusions This study suggests that the FCT significantly decreased in all of the measured areas from a.m. to p.m. Future studies, particularly those assessing the effect of any pharmacologic or nonpharmacologic applications on cartilage thickness in the weight-bearing joints, should be designed bearing in mind that cartilage thickness has diurnal variations. Assessment of diurnal variation in cartilage thickness in elderly osteoarthritic or nonosteoarthritic populations warrants further research.

Doppler US in rheumatic diseases with special emphasis on rheumatoid arthritis and spondyloarthritis.

Developments in digital ultrasonography (US) technology and the use of high-frequency broadband transducers have increased the quality of US imaging, particularly of superficial tissues. Thus, US, particularly color US or power Doppler US, in which high-resolution transducers are used, has become an important imaging modality in the assessment of rheumatic diseases. Furthermore, therapeutic interventions and biopsies can be performed under US guidance during the assessment of lesions. In this era of effective treatments, such as biologics, improvements in synovial inflammation in rheumatoid arthritis as well as changes in enthesitis in spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis, can be monitored effectively using gray-scale and/or power Doppler US. US is also a good imaging modality for crystal arthropathies, including gout and pseudogout, in which synovitis, erosions, tophi, and crystal deposition within or around the joint can be visualized readily. Vascular and tenosynovial structures, as well as the salivary glands, can be assessed with US in vasculitis and connective tissue disorders, including systemic lupus erythematosus and Sjögrens syndrome. Current research is focused on improving the sensitivity, specificity, validity, and reproducibility of US findings. In this review, we summarized the role of US, particularly power Doppler US, in rheumatic diseases and inflammation in superficial tissues.

Ulnar nerve compression possibly due to aberrant veins: sonography is elucidatory for idiopathic cubital tunnel syndrome

To the Editor, A 38-year-old man (waiter) was seen due to right elbow pain for the last 6 months. He declared that the pain was mainly localized on the medial side of the joint and sometimes radiated to the right fifth finger (worse with physical activity especially after carrying trays for long duration). The patient had been given a forearm splint with a diagnosis of medial epicondylitis; but his complaint had not improved despite 1 month of splint use. He denied having any trauma or neck pain, and the medical history was otherwise unremarkable. On physical examination, neck range of motions and spurling tests were normal. The right elbow joint motions were free and painless. The right cubital tunnel was tender to palpation with a positive Tinnel sign. Sensory examination revealed hypoesthesia on the right fifth digit. The rest of the neurological examination was unremarkable. Cervical X-rays were noncontributory. Segmental ulnar nerve conduction studies were performed bilaterally. Motor conduction velocities (below– above elbow, wrist-below elbow) were 52 and 65 m/s on the right; 62 and 63 m/s on the left side, respectively. Amplitude drop was not observed and sensory conductions were also normal. Thereafter, comparative sonographic imaging of the cubital tunnels was performed. While the ulnar nerves were similar on both sides, venous structures were detected on the right side (Fig. 1). Thereafter, the patient was consulted for a possible surgical treatment. Cubital tunnel syndrome (CuTS) is the second most frequent peripheral nerve entrapment syndrome only after carpal tunnel syndrome [1]. Other than factors related with overuse, some anatomical predisposition may also be present in CuTS. This encompasses several anatomic variations, such as the arcade of Struthers, cubital tunnel retinaculum, the humeroulnar aponeurotic arcade, the epitrochleoanconeus muscle and the ligament of Osborne [1]. Although very few, dilated veins or recurrent great vein compressing the ulnar nerve within the tunnel have been also mentioned [2]. However, these findings are almost always observed during surgery. In our case, along with the electrodiagnostic testing, we tried to image the cubital tunnel by sonography. Interestingly, we have observed two veins very close to the ulnar nerve in the tunnel. Keeping in mind the history of the patient, we have considered that intermittent venous compression might have possibly caused his complaints. Yet, venous stasis/ dilatation can ensue during isometric contraction of the upper limb muscles [3]. We also believe that the mild decrease in the nerve conduction velocity at the right cubital tunnel from 65 to 52 m/s could support our hypothesis. Herewith, we underscore the diagnostic role of sonographic imaging in CuTS patients who would otherwise be classified as idiopathic. Once again, we caution physicians to always rule out disorders of the cervical spine before they establish a diagnosis regarding entrapment of the peripheral nerves. This would especially be true for those planned to undergo surgery. E. Kılıç L. Özçakar Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey

Sciatic nerve paralysis following arteriovenous malformation embolization.

In the workup of a right gluteal mass, a 32-yr-old male patient was diagnosed on angiography with an arteriovenous malformation, which was fed from the posterior branch of the right internal iliac artery (Fig. 1A). Arteries participating in the arteriovenous malformation were successfully embolized (Fig. 1B). However, he felt numbness and weakness in his right foot 3 hrs after the procedure and was subsequently referred to our clinic. His physical examination revealed motor weakness in ankle dorsiflexion and big toe extension (muscle strength grade 0/5 in both), as well as the right gastrosoleus muscle complex (muscle strength grade 4/5). He had hypoesthesia in the right L5 and anesthesia of the right S1 dermatomes. Achilles’ tendon reflex was absent. Laboratory tests were unremarkable. The major cause of foot drop is weakness of the muscles of ankle dorsiflexion (particularly tibialis anterior) and the long extensors of the toes (extensor hallucis longus and extensor digitorum longus), all of which are innervated by the sciatic nerve. Most sciatic neuropathies occur in the hip but may also occur rarely in the thigh. The most common cause of sciatic neuropathy in recent years has been total hip arthroplasty. Intramuscular injections, vasculitis, arterial thrombosis, arterial bypass surgery, diabetes mellitus, postradiation therapy, benign tumors, malignant tumors, endometriosis, arterial aneurysms, persistent sciatic artery, myositis ossificans, and abscesses are other causes of sciatic nerve injury. To our knowledge, this is the first case of sciatic nerve paralysis after an arteriovenous malformation embolization procedure in the buttock region. We suggest that concurrent embolization of the arteries that nourish the sciatic nerve may have caused this paralysis. Clinicians should be aware of this interesting and unusual complication. Erkan Özgüçlü, MD Erkan Kıilıç, MD Department of Physical Medicine and Rehabilitation Hacettepe University Medical School Ankara, Turkey

BILATERAL FOOT DROP AFTER INTESTINAL SURGERY: PERONEAL NEUROPATHY UNABATED IN ELDERLY PATIENTS

between apolipoprotein E polymorphism and cardiovascular risk factors in an elderly population with longevity. Arq Bras Cardiol 2002;78:571–579. 5. Wilson PWF, Myers RH, Larson MG et al. Apolipoprotein E alleles, dyslipidemia, and coronary heart disease: The Framingham Offspring Study. JAMA 1995;272:1666–1671. 6. Formiga F, Alia P, Navarro MA et al. Apolipoprotein E genotypes in nonagenarians. J Am Geriatr Soc 2006;54:1471–1473. 7. Niu W, Guo X, Su Y et al. Apolipoprotein E and low-density lipoprotein receptor gene polymorphisms in dyslipidemias-associated essential hypertension. J Hum Hypertens 2007;21:337–339. 8. Imazu M, Yamamoto H, Toyofuku M et al. Association of apolipoprotein E phenotype with hypertension in Japanese-Americans: Data from the HawaiiLos Angeles-Hiroshima Study. Hypertens Res 2001;24:523–529. 9. Scuteri AS, Najjar SS, Muller D et al. ApoE4 allele and the natural history of cardiovascular risk factors. Am J Physiol Endocrinol Metab 2005;289: E322–E327. 10. Lima-Costa MF, Uchôa E, Guerra HL et al. The Bambuı́ Health and Ageing Study (BHAS). Methodological approach and preliminary results of a population-based cohort study of the elderly in Brazil. Rev Saude Pub 2000;34:126–135.

Acute charcot arthropathy of the wrist in a diabetic patient.

A 58-year-old female patient was treated for pain, edema and limited joint motions in her right hand. On detailed questioning, she described the pain to have ensued 1 day after she had lifted a heavy object. She had been previously examined in another center, where she had been diagnosed as complex regional pain syndrome with suggestive scintigraphic findings. Thereafter, she had been given corticosteroid and pregabalin treatment. The medical history of the patient was noncontributory except diabetes mellitus (under oral antidiabetic treatment) for 10 years. As her complaints persisted, she was later on admitted to our center with similar findings. Her physical examination revealed edema on her right hand and wrist (Fig. 1a), and pain during wrist and finger motions. Initial X-rays showed osteolytic lesions on distal ulna, radius and carpal bones (Fig. 1b). Additionally, ultrasound imaging illustrated the accompanying soft tissue involvement (Fig. 1c). Further, magnetic resonance imaging (MRI) was performed for better differentiation of ostemyelitis and acute neuropathic arthropathy. Overall, the patient was diagnosed to have acute neuropathic arthropathy (Charcot joint), and she was called for a control visit 3 weeks after a treatment of nonsteroidal anti-inflammatory drug, pregabalin and neutral wrist splint. The likely cause of Charcot arthropathy (CA) is the coexistence of peripheral sensorimotor and autonomic neuropathy [1, 2]. It rarely affects joints other than the foot and ankle in diabetes patients and only a very few cases of CA of the wrist have been reported so far [1, 3–6]. The relevant explanation of this rarity is the lesser degree of upper limb involvement due to sensorimotor and autonomic neuropathy in comparison with the lower limb. Further, this complication mainly affects weight-bearing joints, like the foot and ankle, which are subjected to continuous trauma [1]. Early CA is oft-overlooked, and many patients present with established joint deformities. Therefore, high index of suspicion is paramount in diabetic patients with swollen and warm joints—especially of the foot and ankle—in the presence of any known somatic or autonomic neuropathy [7]. Aside from clinical suspicion, initial X-ray imaging is needed to diagnose CA as well. While joint space narrowing, subchondral bone sclerosis and osteophytes are seen at early stages; soft tissue swelling, bone resorption, subluxations and fractures can be present in advanced cases [8, 9]. On the other hand, the radiographic findings may not always suffice to differentiate CA from osteomyelitis whereby imaging findings can be quite similar [8]. Herewith, differentiation of these conditions would be crucial with respect to the treatment of each condition. There is yet no specific pharmacological treatment for Charcot’s neuroarthropathy. Off-loading the affected joint with bracing for at least 2–3 months seems to be essential. Aside from pain management, good glycemic control is also a crucial part of the therapy. In severe acute cases, reduction in bone turnover with bisphosphonates would be necessary as well [8]. G. Çağlayan (&) E. Kılıç L. Özçakar Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey e-mail: gokhancaglayan@yahoo.com.tr

Management of Psoriatic Arthritis: Turkish League Against Rheumatism (TLAR) Expert Opinions

Objectives This study aims to establish the first national treatment recommendations by the Turkish League Against Rheumatism (TLAR) for psoriatic arthritis (PsA) based on the current evidence. Patients and methods A systematic literature review was performed regarding the management of PsA. The TLAR expert committee consisted of 13 rheumatologists and 12 physical medicine and rehabilitation specialists experienced in the treatment and care of patients with PsA from 22 centers. The TLAR recommendations were built on those of European League Against Rheumatism (EULAR) 2015. Levels of evidence and agreement were determined. Results Recommendations included five overarching principles and 13 recommendations covering therapies for PsA, particularly focusing on musculoskeletal involvement. Level of agreement was greater than eight for each item. Conclusion This is the first paper that summarizes the recommendations of TLAR as regards the treatment of PsA. We believe that this paper provides Turkish physicians dealing with PsA patients a practical guide in their routine clinical practice.

Effects of Exercise on Low Density Lipoprotein Receptor Related Protein 5 Gene Expression in Patients With Postmenopausal Osteoporosis

Objectives This study aims to investigate the effects of aerobic exercise on low density lipoprotein receptor related protein 5 (LRP5) gene messenger ribonucleic acid expression and evaluate the relationship between the clinical parameters and gene expression in patients with postmenopausal osteoporosis (OP). Patients and methods Seven patients with postmenopausal OP (mean age 60.0±5.3 years; range 51 to 66 years) were included in the study. An exercise protocol/program consisting of treadmill exercising for 30 minutes three days a week for six weeks was performed at a moderate intensity. LRP5 gene expression levels were evaluated before the onset of the exercise program and then four hours after the end of the first session and 12th (fourth week) and 18th (sixth week) sessions of exercise. Results Our results demonstrated variable changes in the LRP5 gene expression after the aerobic exercise sessions. Excluding one patient, the LRP5 gene expression levels showed a slight tendency to increase. In spite of this tendency, gene expression differences during the exercise sessions were not significant. Conclusion Our results suggest that interindividual variations of LRP5 gene expression exist after moderate intensity aerobic exercises in patients with postmenopausal OP. Despite of this variability, LRP5 gene expression levels increased slightly, except in peripheral blood in one patient. Future studies with larger sample sizes and different sampling time/tissues are required to shed more light on the impact of exercise at molecular level in OP.

An Older Woman with Buckling Spinal Deformity : A Spinal Tuberculosis Outcome

A 65-yr-old woman was admitted to our clinic with the complaints of back pain and gibbus deformity for the last 20 yrs. She declared that the pain had increased during the previous year and that it was especially worse with standing and/or walking. Her medical history was unremarkable other than spinal tuberculosis and kyphosis. She did not give any history of trauma, and she did not have any corrective surgery for kyphosis. The physical examination revealed prominent kyphosis at the thoraco-lumbar region. Passive and active low back range of motion was limited and painful. The neurologic examination was normal. Laboratory tests were unremarkable. Magnetic resonance imaging (Fig. 1) demonstrated kyphosis and collapse of several thoraco-lumbar vertebrae. Involvement of the spine is encountered in 1–2% among the estimated 400 million cases of tuberculosis worldwide. Thoracic disease is the most common (80%), followed by involvement of the lumbosacral (15%) and cervical spine (5%). Spinal tuberculosis is the most common cause for kyphotic deformity in many parts of the world. Severe kyphosis following spinal tuberculosis leads to cosmetically and functionally disabling results. Neurologic deficits are reported in 10–60% (mean 20%) of cases with spinal tuberculosis, and the clinical scenario encompasses somatosensory changes, paresthesias, and changes of bowel and bladder functions. Magnetic resonance imaging clearly shows the extent and pattern of bony destruction in these patients, who may also have compromised cardiopulmonary function and painful costopelvic impingement. Kyphosis and severe spinal deformity secondary to spinal tuberculosis causes neurologic deficits, pain, and disability. However, in this case, our patient did not have paraplegia or incontinence. To conclude, patients who have a history of spinal tuberculosis should be followed closely to prevent undesirable results.