Modification of a sonographic enthesitis score to differentiate between psoriatic arthritis and young healthy volunteers

Objectives: We aimed to describe sonographic structural and inflammatory changes in entheses of patients with recently diagnosed psoriatic arthritis (PsA), patients with established PsA, and young healthy volunteers, and to investigate whether the MAdrid Sonographic Enthesitis Index (MASEI) enables us to distinguish these groups in an extreme comparison. Method: New and established PsA patients and healthy volunteers (aged 20–30 years) were recruited. The triceps, quadriceps, patellar, Achilles and elbow extensor tendon insertion, and plantar fascia entheses were investigated sonographically for structural changes, erosions, calcifications, increased thickness, bursitis, and power Doppler (PD) signal according to the MASEI. Results: The study included 25 new and 25 established PsA patients, and 25 healthy volunteers. Increased thickness and PD signal in knee entheses were common for patients and healthy volunteers, while changes at other locations predominantly occurred in patients only. PD was recoded (1, one spot; 1.5, two or three spots; 2, confluent signal; 3, severe confluent signal) and thickness of knee entheses excluded. This resulted in different modified MASEI scores between PsA patients and young healthy controls: median (interquartile range) modified MASEI of 13 (10–22.5) in new PsA, 13.5 (9.5–18) in established PsA, and 3 (1–8.5) in healthy volunteers (p = 0.002). Conclusions: Structural ultrasound changes and PD in entheses are common in both new and established PsA and healthy controls. MASEI score did not differentiate PsA patients from young healthy volu

Atlas of the OMERACT Heel Enthesitis MRI Scoring System (HEMRIS)

Objective: Assessment of enthesitis, a key feature in spondyloarthritis (SpA) and psoriatic arthritis (PsA), using objective and sensitive methods is pivotal in clinical trials. MRI allows detection of both soft tissue and intra-osseous changes of enthesitis. This article presents an atlas for the Outcome Measures in Rheumatology (OMERACT) Heel Enthesitis Magnetic Resonance ImagingMRI Scoring System (HEMRIS). Methods: Following a preliminary selection of potential examples of each grade, as per HEMRIS definitions, the images along with detailed definitions and reader rules were discussed at web-based, interactive meetings between the members of the OMERACT MRI in Arthritis Working Group. Results: Reference images of each grade of the MRI features to be assessed using HEMRIS, along with reader rules and recommended MRI sequences are depicted. Conclusion: The presented reference images can be used to guide scoring Achilles tendon and plantar fascia (plantar aponeurosis) enthesitis according to the OMERACT HEMRIS in clinical trials and cohorts in which MRI enthesitis is used as an outcome

Musculo-Skeletal Stress Markers in Bioarchaeology: Indicators of Activity Levels or Human Variation? A re-analysis and Interpretation.

Musculoskeletal stress markers (MSM) have been widely used by bio-archaeologists as indicators of physical activity. These markers occur at the sites of attachment of soft tissue to bone. They are anomalies of bone formation or destruction at these sites and often called enthesopathies in clinical literature. The aims of this research were firstly to determine the aetiology of these features; in particular, whether they can be used as indicators of physical activity. Secondly, to create a new digital and quantifiable recording method, that is both cheap and simple to use. To achieve the first aim, several literature reviews were undertaken: of the bio-archaeological literature; of the anatomy of the attachment sites; of the relationship between trauma and enthesopathy formation; and of the relationship between enthesopathy formation and disease. Many diseases, for example DISH and ankylosing spondylitis, were found to be associated with enthesopathy formation. Findings of these reviews indicated current bio-archaeological recording methods and interpretive practises are at odds with clinical literature. The second aim had to take these factors into account. Pilot studies were undertaken to develop a new recording method. The final method used visual recording and measurement of enthese along with digitalisation of the surface in two-dimensions using a profile gauge. The digital curves were then quantified using roughness parameters commonly used in materials science. These described the surfaces and could also be used to determine whether this method was applicable to differentiate between normal entheses and those with enthesopathies. Discriminant function analysis demonstrated that this was possible. Stringent diagnostic criteria were also set in place to remove any individuals with possible disease-related enthesopathies. Using the same method, it was found that these could (in some circumstances) also be differentiated from the normal samples.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Measuring Disease Activity and Outcomes in Early Psoriatic Arthritis

Psoriatic Arthritis (PsA) is a heterogeneous disease, characterized by manifestations of peripheral arthritis, dactylitis, enthesitis, spondylitis, and psoriasis. Patients with PsA experience the impact of disease as loss of functional ability, decreased health-related quality of life (HRQOL) and loss of productivity. Treatment is aimed at preventing these consequences. It is recommended that treatment is given as early as possible, with all manifestations taken into account, and in a treat-to-target strategy. In a treat-to-target strategy, treatment is intensified if a certain target – a composite disease activity measure – has not been achieved. Good measures of disease activity are needed to improve outcomes for patients with PsA. For this purpose, more information is needed on disease activity and outcomes early in the disease course. These are studied in the Dutch southwest Early Psoriatic Arthritis cohoRt (DEPAR) and related sub-studies. This thesis aims to investigate the following four aspects of disease activity and outcomes in early PsA: ultrasound abnormalities of the entheses, burden of disease at time of diagnosis and its relation with disease manifestations, the relation between time to minimal disease activity and outcomes, and the performance of disease activity measures

The structure and function of entheses and entheses organs

This thesis deals with the structure and innervation of 3 different types of attachments - the fibrous enthesis of the medial collateral ligament, the muscular attachment of the tibialis anterior onto the tibia, and the fibrocartilaginous enthesis organ of the Achilles tendon. Particular attention was paid to the latter and it was shown that in rats at all ages (neonate, 4 week, 4 month, and 2 month) only the retromalleolar fat pad of the enthesis organ was innervated. In the light of these findings, the fat was studied in further detail and an in vitro investigation determined whether nerve fibres are specifically attracted to the adipose tissue. In man, it was confirmed that the equivalent fat pad (Kager's fat pad) was also innervated and a number of anatomical and histopathological observations associated with this tissue in elderly dissecting room cadavers were described.  The relationship between weight, height and foot length with fat pad structure in human cadaveric tissue was investigated, and the effect of the appetite-inducing hormone, ghrelin on the size of the fat pad in the rat was also explored. As entheses are the primary target organs in the seronegative spondyloarthropathies (autoinflammatory rheumatic conditions), the presence of resident and inflammatory macrophages and neutrophils in the rat Achilles tendon enthesis organ was investigated at a variety of ages. Overall, it was concluded that adipose tissue associated with entheses may play a role in proprioception and be a source of pain in enthesopathies.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

The structure and function of entheses and entheses organs.

This thesis deals with the structure and innervation of 3 different types of attachments - the fibrous enthesis of the medial collateral ligament, the muscular attachment of the tibialis anterior onto the tibia, and the fibrocartilaginous enthesis organ of the Achilles tendon. Particular attention was paid to the latter and it was shown that in rats at all ages (neonate, 4 week, 4 month, and 2 month) only the retromalleolar fat pad of the enthesis organ was innervated. In the light of these findings, the fat was studied in further detail and an in vitro investigation determined whether nerve fibres are specifically attracted to the adipose tissue. In man, it was confirmed that the equivalent fat pad (Kager's fat pad) was also innervated and a number of anatomical and histopathological observations associated with this tissue in elderly dissecting room cadavers were described.  The relationship between weight, height and foot length with fat pad structure in human cadaveric tissue was investigated, and the effect of the appetite-inducing hormone, ghrelin on the size of the fat pad in the rat was also explored. As entheses are the primary target organs in the seronegative spondyloarthropathies (autoinflammatory rheumatic conditions), the presence of resident and inflammatory macrophages and neutrophils in the rat Achilles tendon enthesis organ was investigated at a variety of ages. Overall, it was concluded that adipose tissue associated with entheses may play a role in proprioception and be a source of pain in enthesopathies

Modification of a sonographic enthesitis score to differentiate between psoriatic arthritis and young healthy volunteers

<p><b>Objectives</b>: We aimed to describe sonographic structural and inflammatory changes in entheses of patients with recently diagnosed psoriatic arthritis (PsA), patients with established PsA, and young healthy volunteers, and to investigate whether the MAdrid Sonographic Enthesitis Index (MASEI) enables us to distinguish these groups in an extreme comparison.</p> <p><b>Method</b>: New and established PsA patients and healthy volunteers (aged 20–30 years) were recruited. The triceps, quadriceps, patellar, Achilles and elbow extensor tendon insertion, and plantar fascia entheses were investigated sonographically for structural changes, erosions, calcifications, increased thickness, bursitis, and power Doppler (PD) signal according to the MASEI.</p> <p><b>Results</b>: The study included 25 new and 25 established PsA patients, and 25 healthy volunteers. Increased thickness and PD signal in knee entheses were common for patients and healthy volunteers, while changes at other locations predominantly occurred in patients only. PD was recoded (1, one spot; 1.5, two or three spots; 2, confluent signal; 3, severe confluent signal) and thickness of knee entheses excluded. This resulted in different modified MASEI scores between PsA patients and young healthy controls: median (interquartile range) modified MASEI of 13 (10–22.5) in new PsA, 13.5 (9.5–18) in established PsA, and 3 (1–8.5) in healthy volunteers (p = 0.002).</p> <p><b>Conclusions</b>: Structural ultrasound changes and PD in entheses are common in both new and established PsA and healthy controls. MASEI score did not differentiate PsA patients from young healthy volunteers. After recoding of PD severity and excluding thickness of knee entheses, marked differences between PsA patients and healthy controls were observed.</p

Site-specific resolution of enthesitis in patients with axial spondyloarthritis treated with tumor necrosis factor inhibitors

Abstract Background Enthesitis is a hallmark of spondyloarthritis (SpA) with a substantial impact on quality of life. Reports of treatment effectiveness across individual enthesitis sites in real-world patients with axial SpA (axSpA) are limited. We investigated the evolution of enthesitis following tumor necrosis factor inhibitor (TNFi) initiation in axSpA patients, both cumulatively and at specific axial and peripheral sites. Methods AxSpA patients in the Swiss Clinical Quality Management Registry were included if they initiated a TNFi, had an available Maastricht Ankylosing Spondylitis Enthesitis Score, modified to include the plantar fascia (mMASES, 0–15), at start of treatment and after 6 and/or 12 months and ≥12 months follow-up. Logistic regression models were utilized to analyze explanatory variables for enthesitis resolution. Results Overall, 1668 TNFi treatment courses (TCs) were included, of which 1117 (67%) had active enthesitis at baseline. Reduction in mMASES at the 6- and 12-month timepoints was experienced in 72% and 70% of TCs, respectively. Enthesitis resolution at 6/12 months occurred in 37.9%/43.0% of all TNFi TCs and 40.7%/50.9% of first TNFi TCs. At 6 months, a significant reduction in the frequency of enthesitis was observed at all sites, except for the Achilles tendon and plantar fascia among first TNFi TCs, while at 12 months, reduction was significant at all sites in both TC groups. Enthesitis resolved in 60.3–77% across anatomical sites, while new incident enthesitis occurred in 4.0–13.5% of all TNFi TCs at 12 months. Both baseline and new-incident enthesitis occurred most frequently at the posterior superior iliac spine and the fifth lumbar spinous process. Younger age and lower mMASES at baseline were predictors of complete enthesitis resolution, while female sex and second- or later-line TNFi treatment were associated with persistence of enthesitis at 12 months. Conclusion In real-world axSpA patients treated with a TNFi, enthesitis improved in the majority of patients across all anatomical sites. Significant improvement at the Achilles and plantar fascia entheses was observed only at 12 months. Complete and site-specific enthesitis resolution occurred in ≥40% and ≥60% of TCs evaluated at 12 months, with a low incidence of new site-specific enthesitis. Trial registration Not applicable