Current Rheumatology Reviews - Volume 13, Issue 3, 2017

Background: Ankylosing Spondylitis (AS) is the prototype of a group of systemic rheumatic diseases collectively referred to as Spondylarthitides (SpA). It has now become clear that AS is not as rare as previously thought and, although it has an early onset in life affecting patients in their reproductive years, it has not been proved to adversely affect fertility in females. Objective: The aim of this review is to summarize all the recent data on AS and pregnancy in terms of fertility, disease course and pregnancy outcome from a clinical perspective. Method: A literature research was conducted based on the following medical databases: Pubmed/ Medline and the Cochrane Library. We searched for randomized controlled studies, casecontrol studies, cohort studies, patient and drug registers in relation to pregnancy and AS. Results: The existing data do not support a causal relationship between AS and infertility. The state of pregnancy is not associated with reduced disease activity in patients with AS. Additionally, AS tends to adversely affect health-related quality of life during pregnancy, in comparison with normal population and patients with rheumatoid arthritis. As far as the obstetrical outcome is concerned, there is no consensus on the significant association between AS and specific pregnancy, delivery and fetal complications. Conclusion: Previous studies are highly heterogenous and mainly retrospective and thus, the existing data are controversial and inconclusive. Subsequent studies are required to enlighten our knowledge on the interaction between AS and pregnancy.

Background: The aim of this review is to investigate systematically the presence of the most extensively studied Synovial Fluid (SF) and/or serum markers in patients with Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) and Osteoarthritis (OA), and their associations and correlations with laboratory and clinical data, with a view to providing insights for future research. Objective: Papers were selected using the PRISMA flow-chart. Search of the electronic databases according to the above criteria found a total of 55 papers. Examination led to the exclusion of 39 papers. Finally, 16 studies met the inclusion criteria and are reviewed. As regards to interleukins we found: Higher TNF-α levels in patients with early RA and PsA than in those with osteoarthritis (p<0.05); higher IL-6 levels in patients with inflammatory arthritis (RA and PsA) than in those with OA (p=0.032) and higher IL-17 levels in SF from PsA patients than RA patients (p=0.04) and a significant difference in serum levels between PsA patients and healthy controls (p=0.013) and higher IL-22 SF levels in PsA than OA patients (p<0.001) and in RA compared with OA patients (p<0.01). As regards chemokine, CCL-22 was higher in SF from RA and PsA patients than in OA patients (p<0.01). Method: Considering the sample size of the studies reviewed here, their findings need confirmation in larger samples, while the potential prognostic value of SF and/or serum biomarkers requires prospective investigation. Conclusion: The limitations of the biological SF assays and the problems encountered in the attempted use of cytokine assays for diagnostic purposes must be addressed.

Background: Fibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. People with FM also report activity limitations and impaired work ability. Objective: This article aims to compile the findings of recently published research on work ability in people with fibromyalgia, and to present how work ability is influenced by various aspects. Methods: A systematic search of the literature published from the year 2000 and onwards was conducted. Thirtyfour articles were included in the review. Result: Symptom severity was found to influence work ability in people with FM. Physically demanding jobs and work tasks were especially troublesome and were reported to constitute higher risks pof work disability. Working people with FM seemed to hold a careful balancing act to manage the risk of overload where well-functioning strategies such as making a career change, working part-time, and developing personal skills were necessary for managing work, in the short- and long term. The support of management and colleagues enabled people with FM to manage the risk of overload at work. Treatment studies evaluating work disability as outcome in FM are scarce. None of the included studies presented any effects on measures of sick-leave or work disability compared with a control group. Conclusion: More studies of treatment effects on outcomes related to work ability in people with FM, and more longitudinal studies to explore long-term effects of symptoms on work ability and sick leave, are needed in order to be able to plan evidence based rehabilitation to improve or maintain work ability in people with FM.

Background: Influenza vaccine is safe and effective for the general population as well as for patients with autoimmune diseases. However, although rare, vasculitis has been reported as an adverse event following influenza vaccination. Object: The aims of this literature review were to identify patients who developed vasculitis following influenza vaccination and to clarify the clinical manifestations of vasculitis in these patients. Methods: Using the PubMed database and search engine, we performed a search of the Englishlanguage literature by combining the term influenza vaccination with each term for a specific form of vasculitis from January 1966 through April 2016. Results: A total of 65 patients who developed vasculitis after influenza vaccination were identified from 45 published reports. The majority of patients were elderly, and the patients were predominantly female. The vasculitides included large vessel vasculitis (13 patients), medium vessel vasculitis (2), small vessel vasculitis (42), single organ vasculitis (5), vasculitis associated with systemic disease (1), and vasculitis associated with probable etiology (1). Although the majority of patients achieved complete recovery or remission, there were 3 deaths in patients with ANCA-associated vasculitis and severe long-term sequelae developed in 3 patients (1 with granulomatosis with polyangiitis, 1 with IgA vasculitis and 1 with unclassified small vessel vasculitis). Conclusion: Since vasculitis following influenza vaccination has been only rarely reported, routine influenza vaccination should not be restricted. However, caution should be required when patients with small vessel vasculitis, especially with ANCA-associated vasculitis following influenza vaccination or with post-influenza vaccination-reactivated IgA vasculitis, receive influenza vaccination again.

Background: Several Patient-Reported Outcome Measures (PROMs) have been used in studies of Rheumatoid Arthritis (RA). Most of these assess Health-Related Quality of Life (HRQL). The exception is the Rheumatoid Arthritis Quality of Life questionnaire (RAQoL). This scale measures the impact of RA and its treatment from the patient's perspective, making it suitable for determining the value patients gain from interventions. Objective: This review collates literature reporting on the efficacy of the RAQoL as a measure of patient value in clinical studies. Method: A literature search was conducted to identify published articles reporting on the use of the RAQoL. Psychometric and clinical research studies were included in the review. Results: Sixty-three full articles were identified. Psychometric analyses demonstrated that the RAQoL meets the requirements for internal consistency, reproducibility and construct validity. There is evidence to support the unidimensionality and responsiveness of the RAQoL. The measure has been used in a wide range of research studies including interventional, correlational and nonexperimental studies. Several studies found the RAQoL to be sensitive to change following interventions. Conclusion: The RAQoL has excellent psychometric properties and can detect the impact of both clinical and non-clinical interventions. As a patient-centric measure of patient value, the RAQoL will also prove valuable in big data analytics and for use in outcomes-based reimbursement (OBR).

Background: Systemic lupus erythematosus (SLE) is characterized by various clinical manifestations and immunologic abnormalities. Cardiovascular and respiratory system involvement are increasingly recognized as critical for patients’ prognosis. In this review, current knowledge concerning diagnosis, pathogenesis and treatment of the cardiac and pulmonary lupus manifestations are discussed. Method: Review of the literature. Results: Although pericarditis is the most frequent heart manifestation in the context of lupus, valvular disease and less often myocarditis may be detected. In the latter, treatment should be prompt and aggressive to prevent chronic sequelae like congestive heart failure. Later on disease course, accelerated atherosclerosis is considered as one of the most important co-morbidities of SLE with cardiovascular events being one of the leading causes of death at relatively young ages. Stratification of the patients at risk and stringent management of the traditional risk factors are warranted. Respiratory system involvement affects all anatomic structures of the lungs, pleura and pulmonary vasculature while its severity ranges from asymptomatic pleural disease to acute respiratory failure. The most common features include pleuritis, interstitial lung disease and pulmonary embolism on the background of antiphospholipid syndrome. Less usual complications include lupus pneumonitis, diffuse alveolar hemorrhage, shrinking lung syndrome and pulmonary arterial hypertension. Conclusion: There are no specific guidelines for the management of these manifestations and therapeutic approach remains empiric.

Purpose: Variants in the gene encoding Programmed Cell Death-1 (PDCD1) have been associated with susceptibility to Systemic Lupus Erythematosus and other autoimmune diseases. Given that clinically distinct autoimmune phenotypes share common genetic susceptibility factors, variants in PDCD-1 were tested for a possible association with Juvenile Idiopathic Arthritis (JIA). Methods: Four Single Nucleotide Polymorphisms (SNPS) in the PDCD1 gene were genotyped and analyzed: rs7421861, rs11568821, rs10204525, and rs7568402 in 834 cases and 855 controls of Northern European ancestry. Each variant was examined for possible associations with JIA and then analyzed for association with JIA categories. Results: PDCD1 variants showed no association with JIA in the cohort overall (rs7421861 p=0.63, rs11568821 p=0.13, rs10204525 p=0.31, and rs7568402 p=0.45). Stratification by JIA categories indicated a significant association between systemic JIA and PDCD1 rs7568402 (OR=0.53, p=0.0027), which remained significant after 10,000 permutations, but was not replicated in an independent multi-ethnic systemic JIA cohort. A nominal association between enthesitis-related arthritis and rs115668821 was also observed (OR=0.22, p=0.012). Conclusion: Unlike other multiple autoimmune disease associated genetic variants, there was no association between PDCD1 variants and JIA or JIA categories

Background: Rheumatoid arthritis is a chronic disease considerably affecting the quality of life of patients, their functional abilities and capability to work. In everyday clinical practice, the condition is commonly monitored by assessing the disease activity using a joint count and laboratory markers of inflammation with calculating the DAS28 or other systems for scoring the disease activity. Objectives: This study is aimed to evaluate the benefit of ultrasound examination with a standardized instrument and correlate its results with the quality of life of patients and their functional abilities as assessed by standardized questionnaire methods. Methods: 98 rheumatoid arthritis patients were assessed clinically for disease activity and ultrasound examination with assessment of German US 7 score was performed. The data from patientreported outcomes (Stanford Health Assessment Questionnaire and the EQ-5D instrument) were collected. Results: The results of ultrasound examination were correlated with both disease activity and patient- assessed quality of life and limitations to daily activities. A very good predictor of impaired quality of life mainly appears to be the presence of synovitis detected by grayscale (GS) ultrasonography, shown to be significantly negatively correlated with patient mobility (r=-0.268, p=0.017), self-care (r-0.349, p= 0.002) and usual activities (r=-0.264, p= 0.019) as well as with patients’ global health assessment (r=-0.243, p= 0.031). Conclusions: The study results showed a direct relationship between rheumatoid arthritis activity assessed with the US7 and patients’ impaired functional abilities, mobility, self-care and usual activities.

Background: Knee osteoarthritis (KOA) is a common chronic degenerative disorder. It causes joint pain, walking difficulties and a decline in general physical function. Many pain drugs and treatment modalities can be prescribed for KOA. Among traditional medicines in Morocco, Argan oil has been used in the treatment of knee osteoarthritis to reduce pain and improve physical activity, though there have been no medical-based evidence for such treatment. Argan oil is known to have anti-oxidant and lipid modulatory properties due to its content of many substances, such as tocopherols, phytosterols, saturated and unsaturated fatty acids. Objectives: This study was undertaken in order to investigate the effect of daily consumption of culinary argan oil on KOA symptoms. Patients and Methods: We conducted a randomized controlled clinical trial on patients with KOA according to the American College of Rheumatology (ACR) criteria. Patients were divided into 2 groups: argan oil group who received argan oil to be consumed every morning (30 ml per day) for 8 weeks and control group with no treatment. Clinical assessment before and after 8 weeks study was performed by several tests such as the Visual Analogue Scale (VAS) for pain, walking perimeter, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), and the Lequesne index. Results: The study included 100 patients. 51 patients were randomly assigned to argan oilgroup while 49 patients were randomly assigned to control group with no treatment. Mean age of our patients was 58.24 ± 7.2 years, with a majority of women (93%). Following 8 weeks of argan oil consumption, argan oil group had a very significant decrease of VAS for pain (p< 0.0001), with a significant decrease in WOMAC pain index (p < 0.0001), and improvement of WOMAC function index (p < 0.0001). Lequesne index (p < 0.0001) as well as walking distance (p =0,002) significantly improved. When data of argan oil group were compared to those of control group, we found statistically significant differences in all the above measured parameters: VAS of pain (P=0,02), WOMAC pain (p<0,0001), WOMAC function (p<0,0001), walking distance (p=0,001) and lequesne index (p<0,0001). Conclusion: Patient's consumption of argan oil seems to be safe and efficacious in improving clinical symptoms of KOA.

Background: Acquired hemophilia is a rare bleeding disease which might be associated with some autoimmune diseases. Acquired hemophilia may be the result of autoantibodies against factor VIII. Case Presentation: In this study, we describe a 55 year old patient who developed hematoma and hematuria due to acquired hemophilia secondary to systemic lupus erythematosus (SLE). Then, she developed arthritis and thrombosis after some evaluations. Laboratory data showed prolonged aPTT, normal PT and platelet, low FVIII, high FVIII inhibitor, ANA, anti-ds-DNA, and anticardiolipin. This patient was treated with corticosteroids, FEIBA and rituximab, so she recovered and was discharged about seven days later. Conclusion: We should consider lupus erythematosus in patients with acquired hemophilia. Some cases of acquired hemophilia may be an SLE manifestation, so we should consider this situation to diagnose the disease properly.