Involvement Of Large Joints Research Articles

Reviewing imaging discoveries in tuberculosis affecting extraspinal osteoarticular regions

Abstract Tuberculosis (TB) remains a significant global health concern, affecting both pulmonary and extrapulmonary systems. While musculoskeletal TB represents a small portion of cases (1%–3%), it remains particularly problematic in developing regions like Asia and Africa. Tuberculous spondylitis, affecting the vertebral column, comprises about half of all musculoskeletal TB cases. Although large joint involvement and para-articular regions are common, isolated soft tissue TB is rare. The introduction of advanced imaging techniques, with magnetic resonance imaging as the preferred method, has revolutionized the diagnosis of musculoskeletal TB. Early detection of bone and joint TB is vital for optimizing treatment outcomes and reducing the risk of complications, including deformities. This review article consolidates clinical and radiological insights into extraspinal osteoarticular TB, stressing the importance of heightened awareness among radiologists and clinicians. It underscores the role of advanced imaging in ensuring accurate diagnoses, particularly in regions with high TB prevalence, and in initiating timely and effective patient management to prevent complications.

Miyoshi myopathy associated with spine rigidity and multiple contractures: a case report

BackgroundDysferlinopathy is a phenotypically heterogeneous group of hereditary diseases caused by mutations in the DYSF gene. Early contractures are considered rare, and rigid spine syndrome in dysferlinopathy has been previously reported only once.Case presentationWe describe a 23-year-old patient with Miyoshi myopathy with a rigid spine and multiple contractures, a rare phenotypic variant. The disease first manifested when the patient was 13 years old, with fatigue of the gastrocnemius muscles and the development of pronounced contractures of the Achilles tendons, flexors of the fingers, and extensors of the toes, followed by the involvement of large joints and the spine. Magnetic resonance imaging revealed signs of connective tissue and fatty replacement of the posterior muscles of the thighs and lower legs. Edema was noted in the anterior and medial muscle groups of the thighs, lower legs, and the multifidus muscle of the back. Whole genome sequencing revealed previously described mutations in the DYSF gene in exon 39 (c.4282 C > T) and intron 51 (c.5785-824 C > T). An immunohistochemical analysis and Western blot showed the complete absence of dysferlin protein expression in the muscle fibers.ConclusionsThis case expands the range of clinical and phenotypic correlations of dysferlinopathy and complements the diagnostic search for spine rigidity.

Течение ревматоидного артрита у пациентки с дебютом заболевания в старческом возрасте

A description of the clinical case of a female patient with the onset of rheumatoid arthritis (RA) in an old age is presented. The disease began acutely against the background of comorbid pathology and was manifested by high activity, multiple involvement of large and small joints, and their swelling. A thorough examination was performed to exclude paraneoplastic syndrome. Comorbid conditions and impaired renal function did not allow the prescription of basic drugs; a good effect was obtained from methylprednisolone. Management of elderly and senile patients with RA requires an individual approach, taking into account concomitant diseases and drug tolerability.

Elderly-Onset Rheumatoid Arthritis: Characteristics and Treatment Options.

Elderly-onset rheumatoid arthritis (EORA) is a distinct clinical entity defined as the onset of rheumatoid arthritis (RA) in individuals aged over 60 years. EORA presents unique clinical features, including a more equitable distribution of sexes, a potential predilection for male involvement, a higher incidence of acute onset characterized by constitutional symptoms, a propensity for systemic manifestations, elevated sedimentation rates at disease onset, a reduced occurrence of rheumatoid factor positivity, increased titers of anti-citrullinated protein antibodies, a preference for involvement of large joints, elevated disease activity, the presence of bone erosions, and heightened patient disability. RA is recognized to consist of three partially overlapping subsets. One subset mirrors the classical RA clinical presentation, while the remaining subsets exhibit either a polymyalgia rheumatica-like phenotype or present with remitting seronegative symmetrical synovitis accompanied by pitting edema syndrome. In the initial stages of EORA management, non-steroidal anti-inflammatory drugs (NSAIDs) are not typically the first-line treatment choice, because seniors are much more prone to develop side effects due to NSAIDs, and the use of NSAIDs is in reality contraindicated to the majority of seniors due to comorbidities. Disease-modifying antirheumatic drugs (DMARDs), frequently methotrexate, are introduced immediately after the diagnosis is made. In cases where elderly patients demonstrate resistance to conventional DMARD therapy, the introduction of biological or targeted synthetic DMARDs becomes a viable treatment option. EORA presents a unique clinical profile, necessitating tailored treatment strategies. Our study emphasizes the challenges of NSAID use in seniors, highlighting the imperative shift toward DMARDs such as methotrexate. Future research should explore personalized DMARD approaches based on disease activity, comorbidities, and safety considerations, aiming to optimize treatment outcomes and minimize glucocorticoid reliance, thereby enhancing the quality of care for EORA patients.

Efficacy and gastrointestinal tolerability of methotrexate in late-onset rheumatoid arthritis patients: a prospective cohort study

BackgroundThe proportion of the late-onset forms of disease is growing in rheumatoid arthritis (RA) population. Concerns about comorbidities and drug adverse events lead to delay or ineffective treatment in these patients. The aim of this study is to analyze the tolerability and efficacy of methotrexate therapy in late-onset RA (LORA) patients and compare the baseline characteristics, efficacy, and gastrointestinal (GIT) adverse effects of methotrexate treatment between LORA and young-onset RA patients (YORA).ResultsPatients whose symptoms began after 65 years or older were classified as LORA. Baseline characteristics, rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) status, C-reactive proten (CRP) levels, disease activity scores, and radiographs of hands and feet were recorded. Patients were started to methotrexate therapy and followed for 6 months. Female gender was predominant in both LORA and YORA. LORA patients had less seropositivity (RF or anti-CCP), higher CRP levels, and higher DAS 28 scores. More than half of the patients (58%) had large joint involvement. Remission rates were higher in LORA patients, and total remission and low disease activity rates were similar. Methotrexate withdrawal due to gastrointestinal adverse events (nausea and vomiting) was lower than YORA patients. Logistic regression analysis demonstrated that DAS 28 score was the only predictor for disease remission (p: 0.000), and no predictive factor was found for methotrexate-related adverse events.ConclusionMethotrexate-related gastrointestinal adverse events do not increase in LORA patients, and nausea-vomiting is seen lower than YORA. Methotrexate is well tolerated and effective in LORA patients, and a large amount of patients achieve treatment targets after 6 months of treatment with MTX. Methotrexate should be started immediately in LORA without additional concerns on adverse effects.

Rheumatoid Arthritis

Rheumatoid Arthritis Abstract. Rheumatoid Arthritis (RA) is the most frequent chronic inflammatory joint disease with a prevalence of approximately 1% worldwide. The pathogenesis is a complex interplay of genetic, epigenetic, and environmental factors, which are still incompletely understood. The disease is characterized by a polyarticular synovitis with symmetrical involvement of small and large joints. The majority of patients has detectable autoantibodies in the serum, rheumatoid factor and anti-CCP antibodies which are specific for RA. The uncontrolled chronic joint inflammation results in destructive changes of joint cartilage and bone. An early diagnosis and initiation of treatment is therefore of central importance. Disease-modifying anti-rheumatic drugs (DMARD) are able to inhibit joint destruction and should be started as soon as possible. Therapy should be targeted to reach a state of remission. The introduction of highly effective biologic and targeted synthetic DMARD has allowed to reach this goal of therapy in many patients and to prevent disability. However, risks of medication need to be considered, as well as comorbidities.

Prevalence, Clinical Manifestations, and Treatment Pattern of Patients with Rheumatoid Arthritis Attending the Rheumatology Clinic at Tikur Anbessa Specialized Hospital, Ethiopia: A Cross-Sectional Study.

BackgroundRheumatoid arthritis (RA) is an a chronic inflammatory disease characterized by symmetric polyarticular inflammation that can lead to progressive joint damage. It is said to be rare among black Africans, even though there have been limited reports from some African countries and no study has been done on RA in Ethiopia. This study determined the prevalence, clinical features, and treatment of rheumatoid arthritis in Tikur Anbessa Specialized Hospital (TASH).MethodsA cross-sectional study design was conducted on diagnosed patients with RA attending the rheumatology clinic at TASH from November 2018 to February 2019. Data was collected through patient interviews and chart reviews. The dataset was subjected to descriptive statistical analysis using the Statistical Package for Social Sciences (SPSS) version 25.ResultsA total of 1116 patients attended a rheumatologic clinic with rheumatologic complaints. The prevalence of rheumatoid arthritis was 18.5% (206/1116). Females were mostly affected (F:M 4.6:1). One hundred nineteen (57.8%) were between 35 and 64 years of age. The seropositivity for rheumatoid factor was 47.1%. Almost all patients had morning stiffness (89.8%) and joint pain (97.1%), with the majority (74.8%) having both small and large joint involvement. Nearly half of the patients, 99 (48.1%), had a joint deformity. Comorbid conditions seen in this study were hypertension (17%), overweight in 43 (20.9%), and obesity in 8 (3.9%). Methotrexate was the most prescribed agent (82.5%), both as monotherapy and along with other medications, but 139 (67.5%) of them were on prednisolone, which 2/3 (122) of patients took for 6 months in duration.ConclusionRA accounted for nearly one-fifth of the patients coming to the rheumatology clinics, with females affected more, which is similar to reports from some African countries. Disease-modifying anti-rheumatic drugs are the most prescribed agents, but most patients are on a prolonged dose of prednisolone.

Clinical variables, including novel joint index, associated with future patient-physician discordance in global assessment of rheumatoid arthritis (RA) disease activity based on a large RA database in Japan.

Discordance between patient global assessment (PGA) and physician global assessment (PhGA) of rheumatoid arthritis (RA) disease activity is mainly determined by pain and functional disabilities. This study aimed to investigate the shift in PGA-PhGA discordance and the variables associated with future positive discordance (PGA > PhGA) based on the NinJa database in Japan. We examined 7557 adults with RA registered in both NinJa 2014 and 2018, with a discordance cutoff of 3 on a 10-cm scale. The affected joint distribution was investigated using the joint indices x, y, and z, which were calculated as indices for the upper joint, lower joint, and large joint involvement, respectively. The variables in NinJa 2014 that were associated with positive discordance in NinJa 2018 were examined using binary stepwise logistic regression analysis. Due to the small number of patients with RA categorized as having negative discordance (PGA < PhGA), we focused on patients with RA categorized as having either concordance or positive discordance. Logistic regression analysis revealed that positive discordance in NinJa 2018 was associated with age, pain, modified Health Assessment Questionnaire (mHAQ) score, corticosteroid use, and existent positive discordance and was inversely associated with C-reactive protein (CRP) and x at baseline (NinJa 2014). The same findings were observed when patients with RA were divided based on the discordance status at baseline. Persistence (positive discordance to positive discordance) was associated with pain and mHAQ scores but inversely associated with CRP. Positive discordance may persist. Circumventing this requires adequate management of pain and functional impairment.

Distal Interphalangeal Joint Involvement May Be Associated with Disease Activity and Affected Joint Distribution in Rheumatoid Arthritis.

We investigated the relationship between distal interphalangeal (DIP) joint involvement and disease activity in 10,038 patients with adult-onset rheumatoid arthritis (RA). The affected joint distribution was investigated using the joint indices (JI) x, y, and z, corresponding to the upper and lower joints, and the predominance of large-joint involvement, respectively. DIP joint involvement (defined by the presence of tenderness and/or swelling in DIP joints) was present in 206 (2.1%) of 10,038 patients with RA. Patients with RA exhibiting DIP joint involvement were significantly younger, and more frequently women. DIP joint involvement was positively associated with Disease Activity Score-28 using C-reactive protein, and clinical variables related to high RA disease activity, including JIs x and y, and was negatively associated with JI z. JI x was significantly higher than JI y in RA patients with DIP joint involvement. An odds ratio analysis revealed that small-to-medium sized and upper-extremity joints ranked first, second, and fourth among the eight variables significantly associated with DIP joint involvement. The correlation coefficients revealed that small-sized and upper-extremity joints ranked first and second among the five significant variables. DIP joint involvement, albeit rare, is significantly associated with high RA disease activity with predominance of small-sized and upper-extremity joints.

O006. Clinical features of paediatric HIV arthropathy

Abstract Background Advanced HIV infection is associated with an inflammatory arthritis, however few reports have described this disorder in children. This study aimed to describe the clinical features of HIV arthropathy in a case series of children in South Africa and compare these with features of JIA. Methods Retrospective data were collected from HIV-infected children with HIV arthropathy enrolled in a Paediatric Rheumatology clinic in Cape Town, South Africa. Data from a recently described, published cohort of children with JIA enrolled in the same clinic were included for comparison. Ethical approval was granted by the Human Research Ethics Committee of the University of Cape Town, with a waiver for consent. Results Eleven cases of HIV arthropathy were identified. Cases predominantly affected boys (8/11), and the median age of onset was 10.3 years (IQR 6.9–11.6). Most cases presented in the setting of advanced immunosuppression, with a median absolute CD4+ count of 389 cells/uL (IQR 322–449) and median CD4+ proportion of 19.5% (IQR 14.8–25.0) at presentation. The clinical presentation was variable, with both oligoarthritis (6/11) and polyarthritis (5/11) being prevalent. All cases exhibited large joint involvement, which was usually asymmetrical. In addition, four children had asymmetrical small joint involvement. Associated features included enthesitis (4/11) and dactylitis (1/11). The most consistent laboratory feature was elevated acute phase reactants, and typical ultrasonographic findings were joint effusions and synovial hypertrophy. JIA and HIV arthropathy presented at a similar age, with median age at HIV arthritis onset of 10.3 years (IQR 6.9–11.6) versus 9.25 years (IQR 4.5–12.3) at arthritis onset in the JIA subgroup. HIV arthropathy cases were predominantly male (M/F ratio 3.0), whereas JIA cases had an equal sex distribution (M/F ratio 0.9). Oligo-articular disease was more frequently described in children with HIV arthropathy (55%), compared to those with JIA (38%). Conclusion In this series, most cases of HIV arthropathy exhibited asymmetrical large joint oligoarthritis or polyarthritis, and presented in older boys with advanced immunosuppression. HIV arthropathy appears to present at a similar age to JIA, with a comparable pattern of joint involvement to oligo-articular and poly-articular JIA subtypes.

Large joints are progressively involved in rheumatoid arthritis irrespective of rheumatoid factor status\u2014results from the early rheumatoid arthritis study

This study aimed to examine the progression of large joint involvement from early to established RA in terms of range of movement (ROM) and time to joint surgery, according to the presence of rheumatoid factor (RF). We used a historical longitudinal cohort of early RA patients. Patients were deemed RF negative if all repeated assessments were negative. The rate of progression from normal to any loss of range of movement (ROM) from years 3 to 14 were modelled using generalized estimating equations, for elbows, wrists, hips, knees and ankle, adjusting for confounders. Time to joint surgery was analysed using multivariable Cox models. A total of 1458 patients were included (66% female, mean age 55 years) and 74% were RF-positive. The prevalence of any loss of ROM, from year 3 through to 14 was highest in the wrist followed by ankle, knee, elbow and hip. Odds of loss of ROM increased over time in all joint regions assessed, at around 7–13% per year from year 3 to 14. Time to surgery was similar according to RF-status for the wrist and ankle, but RF-positive cases had a lower hazard of surgery at the elbow (HR 0.37, 0.15–0.90), hip (HR 0.69, 0.48–0.99) and after 10 years at the knee (HR 0.41, 0.25–0.68). Large joints become progressively involved in RA, most frequently affecting the wrist followed by ankle, which is overlooked in composite disease activity indices. RF-negative and positive cases progressed similarly. Treat-to-target approaches should be followed irrespective of RF status.

English

Tuberculosis (TB) is the leading cause of mortality among infectious diseases with estimated 1.5 million deaths from TB in 2018 -19 and presented as a public health concern. In 1897, the Frenchman Antonin Poncet first described Poncet's disease (PD) as a rare syndrome, where polyarthritis in an acute stage of TB, resolved without joint damage. Similar reports on patients of tuberculosis and joint pain led authors to improve the definition, and in 1978, PD was described as a para infective arthritis by Bloxham and Addy. Regardless of its doubtful existence, cases have been continued to be reported over the years. Poncet's disease is a form of reactive arthritis which is characterized by articular affection in patients diagnosed with TB where there is immune reaction to the tuberculous protein but there is no direct invasion by the micro-organism.1,2 PD is to be differentiated from tuberculous arthritis where there is monoarticular and direct tubercular involvement of the joint. Before more obvious features develop, the sole manifestation of the disease is joint involvement. Crippling pain is experienced during polyarthritis which limits the mobility and activities of patients. Polyarthritis can also occur in common causes such as rheumatological diseases as a symptom and thus can be easily misdiagnosed. Polyarthropathy, that is multiple large and small joints involvement in the body, is the one of the rarest presentations in both active pulmonary and extrapulmonary tuberculosis. This polyarticular impairment observed in patients with active TB, a form of reactive arthritis is known as Poncet’s disease. Since there is no direct bacillary invasion of the joints, it is an aseptic form of arthritis. It is not to be confused with tuberculous arthritis, which is usually monoarticular and where there is direct tuberculin infection. Poncet's disease remains a diagnosis of exclusion. Since case reports are very rare even in countries where tuberculosis is common thus no accepted diagnostic criteria is set for Poncet's disease. This diagnostic possibility becomes increasingly important as the use of corticosteroids, immune suppressants or biologicals can risk further dissemination of the disease. We describe the case of a 50-year-old woman, who presented with active tuberculosis where polyarthralgia was the first and only symptom for four months. Polyarthritis patients were being treated with both non-steroidal anti-inflammatory drugs and antitubercular therapy and to the surprise patients with antitubercular treatment had complete resolution of symptoms after 6-week therapy whereas non-steroidal anti-inflammatory drugs (NSAIDS) offer no benefit. The total duration of therapy was 6 months.

Foot Involvement as the First Manifestation in Rheumatoid Arthritis Patients in Lahore.

ObjectiveThe objective of this study was to determine the involvement of the foot as the first manifestation in rheumatoid arthritis (RA).MethodsThis study was conducted on 100 patients who presented to the outpatient department of the Rheumatology Department at Fatima Memorial Hospital and College of Medicine and Dentistry in Lahore, Pakistan. The period of this cross-sectional study was three months - from October 2017 to December 2017. One hundred patients aged more than 16 years, who were diagnosed as cases of RA with foot involvement, and with a disease duration of less than two years (to minimize recall bias), were enrolled for the study.ResultsOut of the 100 patients, 20% were male and 80% were female. The mean age of the study population was 41.16 ± 12.343 years. Foot Involvement as the first manifestation was noted in 29 (29%) of the cases. The pattern of foot involvement shows a 59% forefoot involvement, 27% hindfoot involvement, and 14% midfoot involvement. Walking difficulty was most common in forefoot involvement (71.42% of cases), followed by hindfoot involvement (20% of cases), and least common in midfoot involvement (8.57% of cases) (p=0.0001).ConclusionFoot involvement as the first manifestation is quite common in RA and should not be ignored, especially in patients with large joint involvement sparing the hands.

Clinical characteristics of 10 patients with uremic tumoral calcinosis

Objective: To analyze the clinical characteristics of patients with uremic tumoral calcinosis (UTC). Methods: A total of 10 patients with UTC were enrolled in this study, who were admitted in the Department of Nephrology, China-Japan Friendship Hospital and Beijing Chuiyangliu Hospital from March 2013 to February 2019. Results: The average age of 4 male and 6 female patients on regular hemodialysis was (39.90±8.57) years. The average dialysis duration was(5.90±2.57) years. Three patients presented as single lesion of one joint, the other 7 patients as involvement of multiple large joints. Serum calcium was elevated in 2 patients,both over 2.75 mmol/L. Serum hyperphosphatemia was seen in all patients with average level 2.22 (1.94,2.44) mmol/L. Serum intact parathyroid hormone (iPTH) was remarkably increased in 9 patients with average level 1 348.0(854.8,1 800.0) ng/L, while only 1 patient reported slight elevation (92.4 ng/L).High-sensitivity C-reactive protein increased in all 10 patients with average 35.81 (17.60,74.20) mg/L. The imaging findings before treatment suggested that a large number of irregular masses of calcification shadows deposited in the soft tissue adjacent to the joints. The outlines of calcification were clear without significant bone absorption. Nine patients with severe secondary hyperparathyroidism (SHPT) were treated with parathyroidectomy, resulting in lesions diminishing or even disappearing. A total of 32 parathyroid glands were resected, and pathological results showed that 7 parathyroids were diffuse hyperplasia, 11 as diffuse/nodular hyperplasia, the rest 14 as nodular hyperplasia. At least one hyperplastic parathyroid gland was seen in each patient. Only 1 patient received medical therapy yet no obvious improvement was observed. Conclusion: UTC is a rare complication in patients on regular hemodialysis, which is usually associated with severe SHPT. Parathyroid surgery may improve the clinical outcome.

Hip and knee replacement in patients with ochronosis: Clinical experience and literature review.

Patients with alkaptonuria can present ochronotic degenerative arthropathy due to the accumulation of pigments in the cartilages. Ochronotic arthropathy initially affects the spine, then there is the involvement of the other large joints, with greater frequency of the knees. In this article we will present two patients with alkaptonuria who have been effectively treated with knee and hip replacement, comparing our experience with what is available in the literature.

THU0174 ANTI-IL-6 RECEPTOR ANTIBODY AMELIORATES DISEASE ACTIVITY OF RHEUMATOID ARTHRITIS PATIENTS WITH KNEE JOINT INVOLVEMENT -ANSWER COHORT STUDY-

Background:It has been reported that rheumatoid arthritis (RA) patients who have large joint involvement associated with higher serological inflammatory markers and more functional disability1. Moreover, a previous report showed that these patients were more difficult to achieve clinical remission. However, it remains unclear which biologics are effective in the patients with RA who have large joint involvement.Objectives:The aim of this study is to investigate the efficacy of anti-IL-6 receptor antibody (aIL-6) or TNF-inhibitor (TNFi) in the treatment of RA patients who have knee joint involvement.Methods:We enrolled the 784 patients who visited our hospitals in 2003 to 2019 and were treated with aIL-6 or TNFi more than 12 weeks. We divided the patients into 2 groups with or without knee joint involvement for further analysis. Knee joint involvement was defined as the patients had at least one swelling joint of knee at baseline. We investigated the CDAI levels at baseline and 12 weeks after the initiation of biologics.Results:Interestingly, the patients who had knee joint involvement with aIL-6 significantly ameliorated ΔCDAI (n=95, 15.0±10.8; mean±SD) compared to those with TNFi (n=148, 11.4±10.3) at 12 weeks (P=0.003). aIL-6 group consists of 95 tocilizumab treated patients. TNFi group includes 25 adalimumab, 25 certolizumab pegol, 14 etanercept, 54 golimumab and 30 infliximab treated patients. Baseline clinical characteristics of the 243 RA patients who had knee joint involvement were shown in Table 1. Mean ages, sex and disease durations were not significantly different between the two groups. Baseline CDAI levels of aIL-6 group (24.8±11.8) were slightly elevated compared to those of TNFi group (21.7 ±10.9). Multivariate analysis adjusted for age, gender and baseline CDAI levels revealed that aIL-6 significantly improved ΔCDAI levels compared to TNFi (P=0.04). By contrast, in the RA patients who had no swelling of knee joints, there was no significant difference of ΔCDAI improvement between aIL-6 group (n=156, 5.5±7.4) and TNFi group (n=385, 6.7±8.9).Table 1.Baseline clinical characteristics of 243 RA patients who had knee joint involvementaIL-6 group(n=95)TNFi group(n=148)p ValueAge (mean±SD)60.7±15.261.9±14.40.58Gender (female, %)80.079.10.97Duration (year)9.3 ±10.38.4±10.50.56DAS28ESR (mean±SD)5.3±1.25.2 ±4.80.03CDAI (mean ±SD)24.8±11.821.7 ±10.90.04MTX use, (%)45.462.20.02MTX dose (mg/day)8.7 ±3.39.0 ±3.50.61PSL use, (%)44.345.60.74PSL dose (mg/day)5.5 ±3.55.1 ±2.90.55Conclusion:Thus, these findings suggest that anti-IL-6 receptor antibody was more effective in the RA patients with knee joint involvement compared to TNF- inhibitor.

NEURAXIAL ULTRASOUND A VALUABLE ADJUNCT IN DIFFICULT SPINE; WHAT THE EYE CANNOT SEE- THE ULTRASOUND DOES- ANESTHESIOLOGIST'S THIRD EYE.

Progressive pseudorheumatoid skeletal dyplasia is a rare genetic disorder involving axial skeleton, as well as small peripheral joints. Overtime involvement of large joints and the spine causes significant joint contractures, spine fusion, fixed flexion deformity of hips and knees, so abnormal posturing. Ultrasonography-assisted neuraxial block is an advanced technique for use in patients with difficult spinal anatomy. Recently ultrasound imaging of the spine has emerged as a useful tool to overcome many of the shortcomings of the traditional central neuraxial blockade.

Incidence and progression of hand osteoarthritis in the Johnston county osteoarthritis project

Purpose: Although hand osteoarthritis (HOA) is common and frequently leads to pain, stiffness and disability, studies of HOA are limited - particularly with regard to incidence and progression of disease. In this analysis, we sought to describe the incidence and progression of radiographic and symptomatic HOA in a large community-based cohort, including African American and white men and women. Methods: Data were obtained from adult participants (age ≥ 45 years) in the Johnston County Osteoarthritis (JoCo OA) Project, an ongoing population-based prospective observational cohort study monitoring the occurrence and natural history of OA in Johnston County, North Carolina. After exclusion of 109 participants due to missing radiographs or data regarding HOA status, 800 individuals were included for analysis. Radiographic HOA (rHOA) was defined as Kellgren-Lawrence grade (KLG) of 2 or more in at least 1 of 30 hand joints. We defined symptomatic HOA (sxHOA) as the presence of symptoms (either self-reported pain, aching, or stiffness or tenderness on palpation) and rHOA within the same hand. Two groups were defined: those with baseline rHOA and those without. Among those without baseline HOA, various incidence definitions were assessed, with incidence typically involving new HOA during follow-up (specific definitions in Table 1). Similarly, among those with baseline HOA, various progression definitions were assessed, with progression typically involving worsening HOA during follow-up (specific definitions in Table 2). Incidence and progression were assessed over an average of 12 years involving a baseline (T1: 1999-2004) and two follow-up time-points (T2: 2006-2010 and T3: 2013-2015). Proportions were computed for dichotomous variables and medians (interquartile range) for continuous variables. Differences between sex and race were assessed using the Chi-square test for dichotomous variables and the non-parametric Wilcoxon rank sum test for continuous variables (all showing skewed distributions). P-values associated with each test are shown in Table 1 and 2 and are unadjusted for covariates or multiple comparisons. Results: Of the 800 included participants, 2/3 were women and 1/3 African American, with mean ± SD age 60 ± 8 years, and mean ± SD BMI of 31 ± 6 kg/m2. Those with baseline HOA (n=327) tended to be older and were more often white and women than those without baseline HOA (n=473). Incidence of rHOA (Table 1) was generally comparable between women and men, although the incidence of sxHOA was more than twice as high in women (16% in women vs. 7% in men). Most rHOA and sxHOA incidence definitions were statistically significantly higher among whites than African Americans with exception of PIP, thumb IP and MCP rHOA, which were similar. Progression of rHOA and sxHOA (Table 2) was similar between sexes aside from thumb base OA (50% in women vs. 36% in men), MCP OA (58% in men vs. 39% in women) and change in total KLG (median 16 points in women vs. 14.5 in men). Whites were more likely to have progression of sxHOA compared with African Americans (44% vs. 28%). Whites also had greater change in number of rHOA joints and total KLG sums. Conclusions: In this large, community-based cohort, the incidence of rHOA was similar between men and women, although the incidence of sxHOA was higher in women. The progression of rHOA and sxHOA was similar between sexes aside from a small difference in pattern of radiographic joint involvement. In general, incidence and progression of radiographic and symptomatic HOA was higher in whites than in African Americans, supportive of our findings in prior work of more large joint involvement, and less hand OA, among African American participants.

Hydroxychloroquine is a safe and effective steroid-sparing agent for immune checkpoint inhibitor-induced inflammatory arthritis.

Immunotherapy for cancer treatment continues to evolve, and immune checkpoints have proven successful therapeutic targets. With success has come the challenge of managing the commonly associated immune-related toxicities. Arthralgias and arthritis are a common immune-related adverse event (IrAE), well described in the literature (Pardoll Nat Rev Cancer 12:252-264, 2012; Diesendruck and Benhar Drug Resist Updat 30:39-47, 2017; Cappelli et al. Arthritis Care Res 69:1751-1763, 2017; Brahmer et al. J Clin Oncol 36:1714-1768, 2018; Smith and Bass (2017). The optimal management of immune checkpoint inhibitor (ICI)-induced arthritis remains unclear. We describe the first series using hydroxychloroquine as a first-line disease-modifying antirheumatic drug (DMARD) for patients without pre-existing autoimmune disease, who developed arthritis secondary to ICI's. This was a single-center retrospective observational study reporting all patients evaluated by rheumatologists affiliated with the University of Alberta, a large tertiary health care center in Northern Alberta, Canada, deemed to have inflammatory arthritis (IA) following ICIs. We identified 11 patients, without pre-existing autoimmune disease, who developed IA following ICIs. Most patients presented with a symmetrical polyarthritis with both large and small joint involvement. All patients were treated according to the outlined treatment protocol with hydroxychloroquine as a first-line steroid-sparing agent: either as monotherapy or in combination with tapering doses of systemic corticosteroids (3) or intra-articular steroid injections (6). One patient required the addition of methotrexate to control symptoms and none required biologic therapy. There were no reported adverse effects from hydroxychloroquine. Inflammatory arthritis is an important complication of ICIs leading to significant impact on patient quality of life. In our experience, in patients without pre-existing autoimmune disease, hydroxychloroquine is an effective first-line therapy for IA secondary to ICI therapy.

RHEUMATOID ARTHRITIS IN ELDERLY PEOPLE

Rheumatoid arthritis (RA) is a chronic, systemic connective tissue disease, characterized by progressive, destructive polyarthritis with internal organs involvement due to active, systemic inflammation. The onset of disease occurs usually in 4th or 5th decade of life. Since the general population is ageing, beginning of RA in older age is more and more common. The term elderly onset of rheumatoid arthritis (EORA) describes the disease with onset at age over 60. Several observational studies indicated, that proportion of women and men is comparable in EORA. Clinical course of the disease is characterized by sudden onset with general constitutional symptoms, high disease activity and inflammatory parameters. Involvement of large joints is more common, specially shoulder joints. Antibodies typical for RA (rheumatoid factor, anti-citrullinated peptide) are usually negative. More advanced destructive changes of joints and functional impairment are also characteristic for EORA patients in comparison with younger onset of RA (YORA). In clinical practice the use of methotrexate and biological drugs is less common, and glucocorticosteroids more common in EORA. Due to high RA activity, patients with EORA should be treated in the same way as YORA, with careful monitoring due to higher risk of adverse events associated with treatment.