Ho Yin Chung

HLA-B27 positive patients differ from HLA-B27 negative patients in clinical presentation and imaging: results from the DESIR cohort of patients with recent onset axial spondyloarthritis

Objective To clarify the influence of human leucocyte antigen B27 (HLA-B27) status on the phenotype of early axial spondyloarthritis (SpA). Methods 708 patients with inflammatory back pain (IBP) defined by Calin or Berlin criteria were recruited; 654 fulfilled at least one of the SpA criteria (modified New York, European Spondyloarthropathy Study Group, Amor or Assessment of SpondyloArthritis international Society classification criteria for axial SpA) and were included in the analyses. Clinical, demographic and imaging parameters were compared between HLA-B27 positive and negative groups. Significant parameters in univariate differences between HLA-B27 positive and negative groups were retested in multivariate models explaining various outcomes. Results Patients had a short duration of axial symptoms (mean 1.5 years) and HLA-B27 was present in 61.5%. In multivariate analysis, HLA-B27 positivity was associated with a younger age at onset of IBP (regression coefficient (B)=(−2.60), p<0.001), less delay in diagnosis (B=(−1.02), p=0.01), lower frequency of psoriasis (OR 0.59, p=0.01) and higher frequency of MRI inflammation of the sacroiliac joints (SIJ) (OR 2.13, p<0.001), MRI inflammation of the spine (OR 1.59, p=0.04) and radiographic sacroiliitis (OR 1.56, p=0.03). MRI inflammation of the SIJ was shown to be an intermediate variable between HLA-B27 positivity and radiographic sacroiliitis. Conclusion In early axial SpA, HLA-B27 is associated with earlier onset of IBP, less delay in diagnosis, axial inflammation (spine and SIJ), radiographic damage of the SIJ, decreased disease activity and lower frequency of psoriasis. It is not associated with physical function and MRI structural lesions of the SIJ.

Prevalence of depressive and anxiety disorders and validation of the Hospital Anxiety and Depression Scale as a screening tool in axial spondyloarthritis patients

To determine the prevalence of anxiety and depression in axial spondyloarthritis (SpA) patients by a psychiatrist using the Chinese‐bilingual Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition patient research version (CB‐SCID‐I/P), and to examine the effectiveness of the Hospital Anxiety and Depression Scale (HADS) as a screening tool.

Left ventricular myocardial dysfunction and premature atherosclerosis in patients with axial spondyloarthritis.

OBJECTIVEnTo evaluate left ventricular (LV) function and carotid intima-media thickness (IMT) in patients with axial SpA in relationship to underlying disease severity.nnnMETHODSnWe recruited 104 patients with axial SpA and 50 controls. Detailed transthoracic echocardiography was performed and analysed with two-dimensional speckle tracking strain analysis for systolic function and tissue Doppler-derived E/E for diastolic function assessment. Carotid IMT was measured by ultrasonography to evaluate subclinical atherosclerosis. Radiological severity of patients with axial SpA was assessed by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS).nnnRESULTSnDespite a similar LV ejection fraction [62.7% (s.d. 3.9) vs 62.8% (s.d. 3.8), P = 0.83], patients with axial SpA had impaired LV myocardial longitudinal strain (LS), circumferential strain (CS) and radial strain (RS) compared with controls [-18.1% (s.d. 2.4) vs -20.1% (s.d. 2.5), -17.2% (s.d. 2.2) vs -20.3% (s.d. 2.9) and 37.1% (s.d. 8.6) vs 43.2% (s.d. 10.9), respectively; all P < 0.01]. In addition, patients with axial SpA had a greater E/E [7.9 (s.d. 2.5) vs 7.0 (s.d. 1.7), P < 0.01] and carotid IMT [0.78 mm (s.d. 0.19) vs 0.69 mm (s.d. 0.10), P < 0.01] than controls. After adjusting for potential confounding factors, axial SpA remained independently associated with LV myocardial strains, E/E and carotid IMT. Importantly, multivariate linear regression analysis demonstrated that mSASSS was independently associated with LV longitudinal strain, E/E and carotid IMT.nnnCONCLUSIONnOur study demonstrated that patients with axial SpA had impaired LV systolic and diastolic function and increased carotid IMT. Importantly, mSASSS was independently associated with LV longitudinal strain, E/E and carotid IMT after adjusting for confounding factors. Speckle tracking echocardiography may be a useful tool for early detection of impaired LV function in patients with SpA and carotid IMT examination can provide valuable assessment of subclinical atherosclerosis in patients with SpA.

Comparison of performance of the Assessment of Spondyloarthritis International Society, the European Spondyloarthropathy Study Group and the modified New York criteria in a cohort of Chinese patients with spondyloarthritis

Early diagnosis of spondyloarthritis (SpA) is essential as anti-tumor necrosis factor therapy can achieve significant symptomatic relief and control of disease activity. This study aims to compare the clinical characteristics, disease activity, and functional status of a Chinese cohort of SpA patients who were re-classified into ankylosing spondylitis (AS) patients fulfilling the modified New York (MNY) criteria, those with undifferentiated SpA (USpA) fulfilling the European Spondyloarthropathy Study Group (ESSG) classification criteria only (USpA/ESSG) and those who fulfill Assessment of SpondyloArthritis International Society (ASAS) only (USpA/ASAS). Disease activity was evaluated by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), severity of morning stiffness, patient global assessment, and C-reactive protein. Functional status was evaluated by Bath Ankylosing Spondylitis Functional Index (BASFI), modified Schober index, and dimension of chest expansion. One hundred and twenty-eight patients with disease duration of 16.3u2009±u200910.4xa0years were recruited. Patients in USpA/ESSG and USpA/ASAS were significantly younger (pu2009=u20090.01), had shorter disease duration (pu2009<u20090.01), and lower BASFI (pu2009=u20090.03) than established AS patients. All three groups have active disease with comparable BASDAI >3. BASFI correlated inversely with dimension of chest expansion and negatively modified Schober index in AS patients (pu2009<u20090.01) and modestly with BASDAI (ru2009=u20090.25, pu2009<u20090.01). BASFI correlated moderately with BASDAI in USpA/ESSG (ru2009=u20090.61, pu2009<u20090.01) but not with chest expansion or modified Schober index. Compared with established AS patients recognized by MNY criteria, patients fulfilling USpA defined by ESSG or ASAS criteria had earlier disease, as active disease and less irreversible functional deficit.

Disease activity assessment in ankylosing spondylitis in a Chinese cohort: BASDAI or ASDAS?

Recently, the Ankylosing Spondylitis Disease Activity Score (ASDAS), a new index, has been shown to be validated and highly discriminatory in assessing ankylosing spondylitis (AS) disease activity. This study is to evaluate the performance of ASDAS in a local Chinese cohort of AS in a cross-sectional setting and to compare it with the existing instrument, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Consecutive patients with AS were recruited from a local rheumatology clinic. Data, including BASDAI, Bath Ankylosing Spondylitis Functional Index (BASFI), Visual Analogue Scale (VAS) for spinal pain, and patient and physician global assessments were gathered during clinic visit. Inflammatory markers, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and high-sensitivity (hs)-CRP were collected. ASDAS was calculated accordingly. The discriminatory capacity of BASDAI and ASDAS was compared by: (1) standardized mean difference statistics, (2) R2 in linear regressions, and (3) area under receiver operating characteristic curve (AUC) in logistic regression models. Both ASDAS and BASDAI showed satisfactory predictive value on disease activity with reference to patient and physician global assessment. R2 in linear regression models ranged from 0.6–0.7. Both indices also demonstrated good discriminatory capacity as evidenced by a relatively high AUC (> 0.8) under the logistic regression models using either patient or physician global assessment score ≥4 and <4 as cut off of high and low disease activity status, respectively. Although we could not demonstrate significant differences in the performance between them, subgroup analysis suggested better discriminatory ability of ASDAS in the high inflammatory marker subgroup. ASDAS and BASDAI showed similarly good performance in a cross-sectional setting in a local Chinese AS cohort. ASDAS performed better in subgroup with raised inflammatory markers.

The Discriminative Values of the Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Disease Activity Score, C-Reactive Protein, and Erythrocyte Sedimentation Rate in Spondyloarthritis-Related Axial Arthritis

Objectives The aims of this study were to determine the effectiveness of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score–C-Reactive Protein (ASDAS-CRP), Ankylosing Spondylitis Disease Activity Score–Erythrocyte Sedimentation Rate (ASDAS-ESR), and inflammatory markers in screening for axial-joint inflammation as detected by magnetic resonance imaging (MRI) and to find out factors that could affect scoring of the indices. Methods One hundred fifty-three Chinese spondyloarthritis patients were recruited. Clinical data and BASDAI were collected, and Bath Ankylosing Spondylitis Metrology Index was measured. Serum ESR and CRP were checked, and ASDAS-ESR and ASDAS-CRP were calculated. Radiographs of cervical and lumbar spine were performed for modified Stoke Ankylosing Spondylitis Spinal Score. All patients underwent MRI of the spine and sacroiliac joints. Axial-joint inflammation was evaluated by Spondyloarthritis Research Consortium of Canada MRI indices. Multivariate linear regressions were used to determine potential factors that could affect disease activity indices. Receiver operating characteristic curve was used to determine the effectiveness in screening for axial-joint inflammation. Results BASDAI was associated with current back pain (B = 0.89, P = 0.01), ASDAS-CRP with current back pain (B = 0.74, P = 0.04), and current dactylitis (B = 0.70, P = 0.03) ASDAS-ESR with current back pain (B = 0.95, P = 0.01), and current dactylitis (B = 0.99, 0.002). The ROC curve revealed that CRP was the only variable that successfully discriminated spondyloarthritis patients with and without axial-joint inflammation by MRI, although it had poor accuracy (area under the curve, 0.63; 95% confident interval, 0.53–0.72; P = 0.01). Conclusions Based on our results, MRI could be used to supplement traditional disease assessment tools for more accurate disease evaluation.

Ten-year progression of coronary artery, carotid artery, and aortic calcification in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with increased vascular calcification, although the rate of progress of calcification is uncertain. The aim of the study was to evaluate the progression of and the predictors for calcification in different vascular beds over 10xa0years. The 10-year actual coronary calcium score (CS) and 10-year predicted coronary CS, based on the pattern of the general population, were compared. Calcification of the coronary and carotid artery and the aorta was assessed by multi-detector computed tomography. Significant CS progression was determined by the difference between the square root of baseline and square root of follow-up calcium score (i.e., SQRT method). The 10-year predicted coronary CS was based on the mathematical formula derived by the Heinz Nixdorf Recall Study. A total of 49 patients (54xa0±xa011xa0years, 90% female) had a follow-up scan after 10.0xa0±xa00.2xa0years. The CS in all vascular beds was significantly increased; 55% of the patients had a significant progression of CS in the coronary, 29% in the carotid, and 80% in the aorta. Age and systolic blood pressure (SBP) were independently associated with calcification progression in all vascular beds. Importantly, the absolute increase in 10-year actual coronary CS was significantly higher than that predicted. In patients with RA, calcification in all vascular beds significantly increased over 10xa0years and was independently associated with age and SBP. Importantly, the absolute increase in 10-year actual coronary CS progression was significantly higher than that predicted.

Degos’ disease: a rare condition simulating rheumatic diseases

Dego’s disease is an uncommon thrombo-occlusive vasculopathy that presented with skin rash and thrombotic complications affecting internal organs that may simulate rheumatic diseases and may be brought to the attention of rheumatologists. We present here a case of a middle-aged woman who presented with acute bowel infarction, persistent fever, elevated inflammatory markers and reversed albumin/globulin ratio suspicious of systemic vasculitis clinically. The diagnosis of Dego’s disease was made from the classical skin lesions which were pink to brown papules with central depression and surrounding violaceous rim that were distributed over the trunk and extremities. Histology showed typical wedge-shaped infarction in the affected organs with endothelial proliferation and occlusion by thrombus. Our patient was put on aspirin but suffered from recurrent bowel infarction 1.5xa0years later and eventually succumbed to septic complications.

Spontaneous pneumomediastinum in a dermatomyositis patient with anti-melanoma differentiation-associated gene-5 antibody and interstitial lung disease despite an initial response to immunosuppressant

We report a 24‐year‐old man with anti‐melanoma differentiation‐associated gene‐5 (MDA5) antibody‐positive dermatomyositis (DM) and interstitial lung disease (ILD) who developed spontaneous pneumomediastinum. By comparing serial thoracic high‐resolution computed tomography scans, we demonstrated the distinct time course showing a paradoxical occurrence of pneumomediastinum despite a radiological improvement of ILD. Our case shows that pneumomediastinum in DM can occur regardless of associated ILD and it is a serious complication that should be considered in DM patients presenting with pulmonary manifestations. Cutaneous vasculopathy may be associated with pneumomediastinum and could potentially be a useful indicator of future disease.

Diffusion-weighted imaging versus short tau inversion recovery sequence: Usefulness in detection of active sacroiliitis and early diagnosis of axial spondyloarthritis

Objective To compare the utility of Diffusion weighted imaging (DWI) with short tau inversion recovery (STIR) sequence in the diagnosis of early axial spondyloarthritis (SpA). Methods Three hundred and five patients with chronic back pain were recruited consecutively from 3 rheumatology centers. Clinical, radiological and blood parameters were recorded. Patients with back pain duration no more than 3 years were classified as having early disease. STIR sequence and DWI of the sacroiliac joints were obtained and assessed using the Spondyloarthritis Research Consortium of Canada (SPARCC) method. The Assessment in Spondyloarthritis international Society definition was used to define positive STIR and DWI. Results were compared to expert diagnosed axial SpA. Results When compared to STIR sequence, DWI had similar sensitivity (STIR 0.29, DWI 0.30) and specificity (STIR 0.97, DWI 0.92) in diagnosing sacroiliitis. However, STIR sequence had better reliability (STIR 0.78, DWI 0.61). In early disease group, DWI was not better than STIR sequence in detecting active sacroiliitis (sensitivity DWI vs STIR: 0.34 vs 0.36; specificity DWI vs STIR: 0.93 vs 0.93; positive predictive value DWI vs STIR: 0.92 vs 0.92; negative predictive value DWI vs STIR: 0.36 vs 0.37). Using the Assessment in SpondyloArthritis international Society (ASAS) classification criteria, 67/98 patients with early disease (sensitivity 0.91 specificity 0.90) and 221/305 overall (sensitivity 0.90; specificity 0.92) were classified as axial SpA. Among the expert diagnosed axial SpA patients who did not meet the ASAS criteria, only 2 had positive DWI. Conclusion DWI and STIR have similar sensitivity in diagnosing axSpA in early disease. However, the use of DWI is limited by poorer reliability when compared with STIR.