Prevalence of Sjögren's syndrome according to 2016 ACR-EULAR classification criteria in patients with systemic lupus erythematosus

Abstract Background Diagnosis of SS is a complex task, as no symptom or test is unique to this syndrome. The American-European Consensus Group (AECG 2002) and the American-European classification criteria of 2016 (ACR/EULAR 2016) emerged through a search for consensus. This study aims to assess the prevalence of Sjögren's Syndrome (SS) in patients with Systemic Lupus Erythematosus (SLE), according to AECG 2002 and ACR-EULAR 2016 classifications, as well as clinical and histopathological features in this overlap. To date, there is no study that has evaluated SS in SLE, using the two current criteria. Methods This cross-sectional study evaluated 237 SLE patients at the outpatient rheumatology clinic between 2016 and 2018. Patients were submitted to a dryness questionnaire, whole unstimulated salivary flow (WUSF), "Ocular Staining Score" (OSS), Schirmer's test I (ST-I), and labial salivary gland biopsy (LSGB). Results After verifying inclusion and exclusion criteria, a total of 117 patients were evaluated, with predominance of females (94%) and mixed ethnicity (49.6%). The prevalence of SS was 23% according to AECG 2002 and 35% to ACR- EULAR 2016. Kappa agreement between AECG 2002 and ACR-EULAR 2016 were 0.7 (p < 0.0001). After logistic regression, predictors for SS were: anti/Ro (OR = 17.86, p < 0.05), focal lymphocytic sialadenitis (OR = 3.69, p < 0.05), OSS ≥ 5 (OR = 7.50, p < 0.05), ST I positive (OR = 2.67, p < 0.05), and WUSF ≤ 0.1 mL/min (OR = 4.13, p < 0.05). Conclusion The prevalence of SS in SLE was 23% (AECG 2002) and 35% (ACR-EULAR 2016). The presence of glandular dysfunction, focal lymphocytic sialadenitis, and anti/Ro were predictors of SS in SLE. The greatest advantage of the new ACR-EULAR 2016 criteria is to enable an early diagnosis and identify the overlapping of these two diseases. ACR- EULAR 2016 criteria is not yet validated for secondary SS and this study is a pioneer in investigating prevalence based on the new criteria.

Is vitamin D status relevant to psoriasis and psoriatic arthritis? A retrospective cross-sectional study

Abstract BACKGROUND: Psoriasis is a systemic, immune-mediated disease characterized by inflammatory manifestations in the skin and joints. Vitamin D deficiency is currently considered a pandemic and is associated with comorbidities including psoriasis and psoriatic arthritis (PsA). OBJECTIVES: To determine the prevalence of hypovitaminosis D [25(OH)D] in patients with plaque psoriasis, with and without PsA, and of independent predictors of serum 25(OH)D levels. DESIGN AND SETTING: Retrospective cross-sectional study conducted among 300 patients at an outpatient clinic in a university center in Juiz de Fora, Minas Gerais, Brazil. METHODS: Demographic and clinical data (psoriasis area and severity index [PASI], family history, age at onset, disease duration, and the presence of PsA according to Classification Criteria for Psoriatic Arthritis), skin phototype, and season of the year were reviewed. RESULTS: Hypovitaminosis D (< 30 ng/mL) was highly prevalent in patients with psoriasis with and without PsA (82.2% and 74.9%, respectively). An inverse correlation between PASI and vitamin D was found (without PsA r = -0.59 and, PsA r = -0.52, P < 0.001), and multivariate regression revealed that hypovitaminosis D was associated with disease severity, season, and phototype. It was confirmed by binary logistic regression between PASI and vitamin D deficiency (< 30 ng/mL), (odds ratio, OR 1.78 CI: -0.20-0.53, P < 0.001). CONCLUSION: Hypovitaminosis D (< 30 ng/mL) was highly prevalent in psoriatic patients with and without PsA. Season and skin phototype were associated with 25(OH)D levels. An inverse association between PASI and serum 25(OH)D levels was established.

The heterogeneity of systemic lupus erythematosus: Looking for a molecular answer / La heterogeneidad del lupus eritematoso sistémico: buscando una respuesta molecular

ABSTRACT The heterogeneity of SLE is a major limitation when designing clinical trials and understand ing the mechanisms of the disease. The analyses conducted before the new technologies for the identification of the single cell transcriptome focused on the detection of molecular patterns such as interferon signature in total blood or through the analysis of major sepa rate cell populations, such as CD4+ T cells. The analyses of molecular patterns have mainly focused on the transcriptome and DNA methylation changes. The first studies on single cell transcriptomics have now been published for mononuclear blood cells and tissues or the knowledge derived from them, total kidney, tubules and skin keratinocytes. The latter have defined patterns of nonresponse to treatment. However, much work still needs to be done to be able to use these methods in clinical practice.

RESUMEN La heterogeneidad del lupus es una limitante al momento de diseñar estudios clínicos, así como también para nuestra facultad de comprender los mecanismos de la enfermedad. Los análisis previos a las nuevas tecnologías para la detección del transcriptoma de célula única trabajaron en la identificación de patrones moleculares, como la firma del interferón en sangre total, o a través del análisis de poblaciones celulares principales separadas, como son las células T CD4+. Los análisis de patrones moleculares se han enfocado primordialmente en el transcriptoma y en los cambios de metilación del ADN. Ya se han publicado los primeros estudios de transcriptoma de célula única para células sanguíneas mononucleares y para tejidos, riñón total, túbulos y queratinocitos de piel. Estos últimos han definido patrones de no-respuesta al tratamiento. Aún falta mucho para que los métodos o los conocimientos derivados de los mismos sean de utilidad en la práctica clínica.

Clinical value of 2019 European League Against Rheumatism/American College of Rheumatology classification criteria in childhood-onset systemic lupus erythematosus / 中华实用儿科临床杂志

Objective:To compare the performance among the American College of Rheumatology (ACR) 1997, the Systemic Lupus International Collaborating Clinics (SLICC) 2012 and the 2019 European League Against Rheumatism (EULAR)/ACR criteria, in a childhood-onset systemic lupus erythematosus(CSLE) cohort.Methods:A medical chart review study was conducted of 182 cases of SLE patients and 163 controls with defined rheumatic diseases in pediatrics department of Renji Hospital, Shanghai Jiaotong University School Medicine, from January 2013 to May 2017, to establish each ACR1997, SLICC2012 and 2019EULAR/ACR criterion.The performance of the three criteria was statistically analyzed.Results:(1) Comparing the patients with SLE and controls, the difference in fever(21.4% vs.8.0%), skin lesions(54.9% vs.31.9%), nonscarring alopecia(3.8% vs.0), renal disorder(41.2% vs.5.5%), neurologic disorder(7.7% vs.1.8%), hematologic disorder [leukopenia(32.4% vs.1.8%), thrombocytopenia(31.9% vs.0)], low complement(83.5% vs.12.9%), anti-nuclear antibody(98.4% vs.23.3%), anti-dsDNA antibody(94.0% vs.8.6%), anti-Sm antibody(19.2% vs.0%), and antiphospholipid antibodies(16.5% vs.3.7%)had statistical significance (all P<0.05). But the difference in oral ulcers, synovitis, serositis and positive Coombs test had no statistical significance (all P>0.05). (2) Sensitivities of ACR1997, SLICC2012 and 2019EULAR/ACR criteria were 67.0%(122/182 cases), 95.6% (174/182 cases)and 97.8% (178/182 cases)( P<0.001), with specificities 99.4%(162/163 cases), 98.2% (160/163 cases)and 94.5%(154/163 cases) ( P=0.016), respectively.In terms of accuracy, the three classifications were 82.3%(284/345 cases), 96.8% (334/345 cases)and 96.2%(332/345 cases), respectively, the difference was statistically significant ( P<0.001). (3) Only 120 cases (65.9%) of patients with SLE met all 3 criteria.Eight cases of SLE patients who only met the 2019EULAR/ACR criteria exhibit high rate of single organ involvement (7 cases). Four cases of SLE patients were missed by the 2019EULAR/ACR, 3 cases of which were antinuclear antibody negative.(4) The SLICC2012 and 2019EULAR/ACR criteria had increased sensitivity for major organ damage than ACR1997.The total score of 2019 EULAR/ACR criteria correlated positively with SLE disease activity ( R2= 0.451, P<0.001). Conclusions:In this SLE population, the 2019EULAR/ACR criteria is more sensitive than ACR1997 and SLICC2012 criteria, allowing earlier classification and recognition of patients with single or major organ damage.Although the specificity is slightly lower than the previous two criteria, it is still worthy of clinical promotion.

Questions as regards the recognition of elderly-onset primary Sjögren's syndrome: Where we are and where we would rather be / Preguntas sobre el reconocimiento del síndrome de Sjögren primario con inicio en la edad avanzada: ¿dónde estamos y dónde preferiríamos estar?

ABSTRACT Several epidemiological studies have suggested that the prevalence of the onset of primary Sjögren's Syndrome in the elderly (EOpSS) is significantly higher (between five to eight times) than in other age groups. However, when a literature review was performed, the number of patients with EOpSS was much lower than epidemiologically expected. An evaluation was performed on Sjögren (sicca) syndrome, including immunological markers, labial salivary glands biopsy, and some extra-glandular manifestations. These could be confounding factors in the elderly patients, much more so than in other age groups, and lead to a misdiagnosis of EOpSS. This article presents a review of the most common difficulties that may be present in the recognition of EOpSS, and highlights the lack of elderly patient-centred studies as the most important unmet need.

RESUMEN Varios estudios epidemiológicos han sugerido que la prevalencia del síndrome de Sjögren primario (SSp) en la población de edad avanzada (Elderly-Onset primary Sjögren's Syndrome [EOpSS], según la clasificación inglés) es considerablemente mayor (entre 5 y 8 veces) que en grupos de edad diferente. Sin embargo, una revisión sistemática de la literatura mostró que el número de pacientes con EOpSS era mucho menor de lo que se esperaba epidemiológicamente. La evaluación del síndrome de sicca, los marcadores inmunológicos, la biopsia de las glándulas salivales labiales y algunas manifestaciones extraglandulares podrían convertirse en factores de confusión en pacientes de edad avanzada mucho más frecuentemente que en personas de otros grupos de edad, lo que favorecería un diagnóstico erróneo del EOpSS. En este artículo se revisan las principales dificultades que pueden afectar al reconocimiento del EOpSS, destacando la falta de estudios centrados en el paciente anciano como la necesidad insatisfecha más importante.

Validade dos critérios de classificação da osteoartrite de joelho: ELSA-Brasil Musculoesquelético (ELSA-Brasil ME) / Validity of the knee osteoarthritis classification criteria: ELSA-Brasil Musculoskeletal (ELSA-Brasil ME)

Introdução: Vários critérios de classificação de osteoartrite (OA) de joelhos estão disponíveis na literatura, geralmente divididos em clínicos, clínico-radiográficos e radiográficos. A existência de diferentes critérios de classificação de OA de joelhos dificulta uniformizar e comparar resultados em estudos epidemiológicos, assim como a investigação de fatores de risco e manifestações clínicas associados à OA de joelhos. O conhecimento sobre a capacidade desses diferentes critérios em discriminar indivíduos com e sem OA, assim como conhecer a força de associação de fatores de risco, da presença de dor e de limitação funcional com os diferentes critérios, é essencial para se compreender as vantagens e limitações do uso de cada um deles. Objetivo: avaliar a validade de diferentes critérios de classificação de OA de joelhos em uma amostra de servidores públicos acompanhados pelo Estudo Longitudinal de Saúde do Adulto, ELSA-Brasil Musculoesquelético (ELSA-Brasil ME). Método: trata-se de um estudo transversal de validação de diferentes critérios de classificação de OA de joelho, a saber: OA sintomática, OA radiográfica, OA pelo American College of Rheumatology (ACR clínico e clínico-radiográfico) e OA pela definição do National Institute for Health and Care Excellence (NICE). Os participantes do estudo foram provenientes da coorte ELSA-Brasil ME, um estudo ancilar ao Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). O ELSA-Brasil ME acompanha 2901 servidores públicos, ativos e aposentados, em um dos seis centros de investigação do ELSA-Brasil, localizado no estado de Minas Gerais, Brasil. O presente estudo foi realizado em uma subamostra de conveniência com 250 participantes do ELSA-Brasil ME, de ambos os sexos, com idade entre 39 e 78 anos. A avaliação foi feita por uma reumatologista (RCCM) no período de fevereiro de 2014 a junho de 2015. Apenas um joelho por indivíduo foi incluído, aquele com OA pela reumatologista. Quando ambos ou nenhum dos joelhos apresentava OA, foi feita a seleção por sorteio aleatório simples. Avaliou-se o desempenho dos critérios de classificação de OA descritos anteriormente, tendo como padrão-referência a avaliação clínico-radiográfica da reumatologista. Foram apresentados dados de prevalência, sensibilidade, especificidade, valores preditivos positivo e negativo e acurácia (IC 95%;α=5%). Posteriormente, a validade de construto convergente desses critérios foi avaliada a partir da associação entre a presença de OA de joelho identificada pelos critérios e as seguintes variáveis explicativas: índice de massa corporal (IMC), dor atual e limitação funcional (subjetiva e objetiva). A presença da dor atual em joelhos e a limitação funcional subjetiva foram avaliadas pelo Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) e a limitação funcional objetiva pelo teste sentar e levantar repetido. Associações foram testadas por modelos de regressão logística binária e multinomial (IC 95%;α=5%). Resultados: a idade média foi de 56,1 anos (DP=8,7), 51,2% eram homens. A maior prevalência de OA ocorreu na avaliação da reumatologista (39,2%), seguido de OA pelo NICE (36,8%) e pelo critério OA radiográfica (22,0%). OA radiográfica demonstrou sensibilidade e especificidade de 51,0% e 96,7%, respectivamente. A definição pelo NICE apresentou sensibilidade de 57,0% e especificidade de 76,3%. Os demais critérios mostraram boa especificidade, mas sensibilidade menor que 30,0%. Na avaliação de validade de construto convergente, IMC, dor atual e limitação funcional subjetiva se associaram à OA de joelho identificada por todos os critérios, sendo a magnitude da associação particularmente forte entre dor atual e OA segundo o critério ACR clínico (OR 21,7; IC95% 7,12-66,12) e entre limitação funcional subjetiva e OA segundo o NICE (OR 32,5; IC95% 13,4-79,0). Limitação funcional objetiva apresentou associação com os critérios OA sintomática e ACR clínico e clínico-radiográfico. Conclusões: o presente estudo demonstrou que dentre os critérios avaliados a OA radiográfica demonstrou melhor desempenho quanto à sensibilidade e especificidade, seguido pela definição de OA pelo NICE. Os critérios OA sintomática e OA pelo ACR clínico e clínico-radiográfico não se mostraram adequados para estudos que objetivam avaliar prevalência, devido à baixa sensibilidade dos mesmos. Entretanto, podem ser uma alternativa em estudos longitudinais nos quais é favorável o uso de critérios com boa especificidade. Quanto à validade de construto convergente, de forma geral, os resultados encontrados oferecem suporte para todos os critérios investigados, já que houve associação de IMC, dor atual e limitação funcional subjetiva com todos os critérios e a limitação funcional objetiva apenas não se associou à OA radiográfica e ao NICE. É importante ressaltar que a escolha de qual critério utilizar em um estudo requer levar em conta qual combinação melhor atende aos objetivos preconizados pelo estudo.

Introduction: the classification criteria for knee osteoarthritis (OA) available in the literature are usually divided into three main groups; clinical, clinical-radiographic and radiographic. The existence of different knee OA classification criteria makes it difficult to standardize and compare results in epidemiological studies, and also to investigate risk factors and clinical manifestations associated with knee OA. It is essential to understand the extent to which these different criteria are able to discriminate between subjects with and without OA. It is also important to know the strength of association of the following items with the different criteria: risk factors, the presence of pain and the functionality Objective: To evaluate the validity of different knee osteoarthritis (OA) classification criteria: radiographic OA, symptomatic OA, clinical and clinical-radiographic criteria of the American College of Rheumatology (ACR) and the OA definition proposed by the National Institute for Health and Care Excellence (NICE). Method: A cross-sectional study of the validity of different knee OA classification criteria, radiographic OA, symptomatic OA, clinical and clinical-radiographic criteria of the American College of Rheumatology (ACR) and the OA definition proposed by the National Institute for Health and Care Excellence (NICE). The subjects were from the ELSA-Brasil Musculoskeletal cohort (ELSA-Brasil MSK), an ancillary investigation on musculoskeletal disorders of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The ELSA- Brasil MSK follows 2901 active and retired civil servants at one of the six ELSA-Brasil investigations centers, located in the State of Minas Gerais, Brazil. The present study was carried out using a convenience subsample with 250 male and female subjects aged between 39 and 78 selected from ELSA-Brasil MSK. The assessment was made by a rheumatologist (RCCM) between February 2014 and June 2015. Only one knee per subject was included i.e., the one that had OA according to the rheumatologist and, when both or none of the knees were affected, one knee was randomly selected for analysis. The performance of the classification criteria of knee OA described before was evaluated, using as reference-standard the clinicalradiographic evaluation of the rheumatologist. OA prevalence, sensitivity, specificity, positive and negative predictive values and accuracy were presented (CI 95%; α = 5%). After that the construct validity of the criteria was evaluated by the relationship between the presence of knee OA identified by the criteria and the following explanatory variables: body mass index (BMI), pain and the functional limitation. The presence of current pain in knees and the subjective functional limitation were evaluated using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the objective functional limitation was evaluated by the five-times sitto-stand test (FTSTS). Associations were tested by bivariate and multinomial logistic regression models (CI 95% ;α=5%). Mean age was 56.1 years (SD=8.7); 51.2% were male. The highest knee OA prevalence was observed in OA according to the rheumatologist, followed by the NICE definition (36,8%) and radiographic OA (22.0%).The sensitivity and the specificity of radiographic OA were 51% and 96.7%, respectively, while the NICE definition showed 57.0% and 76.3%, respectively. The other OA criteria showed good levels of specificity, but the levels of sensitivity were below 30%. In the convergent construct validity evaluation, BMI, current pain and subjective functional limitation were associated with knee OA identified by all criteria. The magnitude of the estimates were particularly strong between current pain and OA according to the ACR clinical criteria (OR 21.7; 95%CI 7.12-66.12) and between subjective functional limitation and OA according to NICE (OR 32.5; 95%CI 13.4- 79.0). The objective functional limitation was associated with symptomatic OA and with clinical and clinical-radiographic ACR criteria. Conclusions: the present study demonstrated that among the evaluated criteria, radiographic OA showed the best performance, followed by the NICE OA definition. The other criteria, namely symptomatic OA, clinical ACR and clinical-radiographic ACR were not adequate for studies that aim to evaluate prevalence, due to the low sensitivity of these criteria. However, they may be an alternative in longitudinal studies in which it is appropriate to use criteria with good specificity. Regarding the convergent construct validity, overall, our results offer support for all of the investigated criteria, since there was an association of BMI, pain and subjective functional limitation with all the criteria and the objective functional limitation was not radiographic OA and NICE. It is important to emphasize that the choice of criteria for a study requires deciding which the combination best meets the study objectives.

Comparison among ACR1997, SLICC and the new EULAR/ACR classification criteria in childhood-onset systemic lupus erythematosus

Abstract Background: To date there are no specific classification criteria for childhood-onset systemic lupus erythematosus (cSLE). This study aims to compare the performance among the American College of Rheumatology (ACR) 1997, the Systemic Lupus International Collaborating Clinics criteria (SLICC) and the new European League Against Rheumatism (EULAR)/ACR criteria, in a cSLE cohort. Methods: We conducted a medical chart review study of cSLE cases and controls with defined rheumatic diseases, both ANA positive, to establish each ACR1997, SLICC and EULAR/ACR criterion fulfilled, at first visit and 1-year-follow-up. Results: Study population included 122 cSLE cases and 89 controls. At first visit, SLICC criteria had higher sensitivity than ACR 1997 (89.3% versus 70.5%, p < 0.001), but similar specificity (80.9% versus 83.2%, p = 0.791), however performance was not statistically different at 1-year-follow-up. SLICC better scored in specificity compared to EULAR/ACR score ≥ 10 at first visit (80.9% versus 67.4%, p = 0.008) and at 1-year (76.4% versus 58.4%, p = 0.001), although sensitivities were similar. EULAR/ACR criteria score ≥ 10 exhibited higher sensitivity than ACR 1997 (87.7% versus 70.5%, p < 0.001) at first visit, but comparable at 1-year, whereas specificity was lower at first visit (67.4% versus 83.2%, p = 0.004) and 1-year (58.4% versus 76.4%, p = 0.002). A EULAR/ACR score ≥ 13 against a score ≥ 10, resulted in higher specificity, positive predictive value, and cut-off point accuracy. Compared to SLICC, a EULAR/ACR score ≥ 13 resulted in lower sensitivity at first visit (76.2% versus 89.3%, p < 0.001) and 1-year (91% versus 97.5%, p = 0.008), but similar specificities at both assessments. When compared to ACR 1997, a EULAR/ACR total score ≥ 13, resulted in no differences in sensitivity and specificity at both observation periods. Conclusions: In this cSLE population, SLICC criteria better scored at first visit and 1-year-follow-up. The adoption of a EULAR/ACR total score ≥ 13 in this study, against the initially proposed ≥10 score, was most appropriate to classify cSLE. Further studies are necessary to address if SLICC criteria might allow fulfillment of cSLE classification earlier in disease course and may be more inclusive of cSLE subjects for clinical studies.

New progress in classification and diagnosis of Sjögren's syndrome / 国际眼科杂志(Guoji Yanke Zazhi)

@#Sjögren's syndrome(SS)is a complex connective tissue disease, with an incidence only secondary to rheumatoid arthritis. The initial record was case reports in the late 19th century. In 1930, Henrik Sjögren proposed the conception of “Keratoconjunctivitis Sicca”for the first time, and preliminarily realized that SS was a systemic disease. Subsequently, the discovery of specific autoantibodies and the application of labial biopsy technique significantly improved the accuracy for SS diagnosis. As the understanding the disease improving, different classification criteria were proposed to improve the diagnostic accuracy. However, there still no classification criteria that can be applied as diagnostic criteria so far due to uncovered pathological mechanism of the disease. Currently, comprehensive managements are required with the cooperation of rheumatology, ophthalmology, and stomatology department. Further exploration of the pathogenesis and development of new diagnostic tools are expected to improve the diagnosis of SS. The paper aims to review the development of the classification criteria and to propose new ophthalmic examinations in order to improve the diagnosis of SS.

Performance of the 2015 American College of Rheumatology/European League against Rheumatism Classification Criteria for Gout in Korean Patients with Acute Arthritis

BACKGROUND: We aimed to assess the performance of the 2015 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for gout in Korean patients with acute arthritis and to compare the performance of the ACR/EULAR criteria to that of other sets of criteria for gout classification. METHODS: Patients with acute arthritis who underwent diagnostic arthrocentesis at one of the four participating rheumatology clinics were consecutively enrolled between February and December 2017. Crystal-proven gout was diagnosed upon confirming the presence of monosodium urate (MSU) crystals in patients with a clinical impression of gout as judged by the rheumatologist. The performance of the ACR/EULAR and other gout classification criteria, including the Rome, New York, American Rheumatism Association (ARA), Mexico, and Netherlands criteria, was analyzed regardless of the presence/absence of MSU crystals. RESULTS: The study enrolled 118 gout patients (all crystal-proven) and 95 non-gout patients. According to the area under the curve, the diagnostic performance was the highest for the ACR/EULAR classification criteria (sensitivity, 80.5%; specificity, 95.8%; area under the curve, 0.966), followed by the Netherlands, Rome, ARA, New York, and Mexico criteria. All six sets of criteria demonstrated lower sensitivity in patients exhibiting the first episode of acute arthritis. CONCLUSION: In Korean patients with acute arthritis, the ACR/EULAR classification criteria outperformed other sets of gout classification criteria even in the absence of information regarding the presence of MSU crystals. However, to enhance diagnostic sensitivity, synovial fluid analysis should be considered in patients with the first episode of acute arthritis.

Performance and agreement between classification criteria and rheumatologist's diagnosis of the most widely used SpA classification criteria in a Colombian group of patients with chronic low back pain / Acuerdo entre los criterios más utilizados para la clasificación de las espondiloartritis (SpA) y el diagnóstico clínico hecho por un reumatólogo experto en un grupo de pacientes jóvenes con dolor lumbar coránico

Abstract Objective: To evaluate the performance of the most widely used SpA classification criteria in a Colombian group of patients with chronic low back pain. Methods: We assessed the ASAS and the European Spondyloarthropathy Study Group (ESSG) classification criteria in a group of 133 patients who attended consecutively over a period of six months at outpatient clinic of low back pain. All the patients were evaluated with the same protocol. The patients were divided into two groups according to the diagnosis. The diagnosis was compared with the diagnosis made by a expert rheumatologist blinded to patient information. Results: 81 patients with SpA and 52 with other diagnoses were included. There were no differences in age and age of onset of symptoms between the two groups. The SpA group included 55 males and more common clinical findings were: enthesitis, arthritis, sacroiliitis, HLA-B27-positive, previous infection, and dactylitis. The sensitivity and specificity of criteria were: ASAS criteria 96% of sensibility and 80% of specificity, and ESSG criteria 95% and 100% respectively. The agreement between the classification criteria and the diagnosis established by the rheumatologist showed a Cohen's kappa index of 0.938 for ESSG criteria (95% CI: 0.877-0.998) and 0.790 for the ASAS criteria (95% CI: 0.682-0.898). Conclusion: In a Colombian group of SpA patients, the new ASAS classification criteria have a good concordance with clinical diagnosis but are not superior to the ESSG criteria.

Resumen Objetivo: Evaluar el acuerdo entre los criterios de clasificación para SpA y el diagnóstico de un experto reumatólogo en un grupo de pacientes con dolor lumbar. Métodos: Se evaluó el comportamiento de los criterios de ASAS y del ESSG en 133 pacientes que acudieron de forma consecutiva durante seis meses a la clínica ambulatoria de dolor lumbar. Todos los pacientes se evaluaron con el mismo protocolo. Los pacientes fueron divididos en dos grupos de acuerdo con el diagnóstico. Posteriormente se estableció del acuerdo diagnóstico con el de un experto reumatólogo ciego a la información previa de los pacientes. Resultados: 81 pacientes con SpA y 52 con otros diagnósticos fueron incluidos. No hubo diferencias en la edad y la edad de aparición de los síntomas. El grupo SpA incluyó a 55 varones y los hallazgos más comunes fueron: entesitis, artritis, sacroileitis, infección previa, HLA-B27, y dactilitis. La sensibilidad y especificidad de los criterios fueron: ASAS 96% de sensibilidad y 80% de especificidad, y ESSG 95% y 100% respectivamente. El acuerdo entre los criterios de clasificación y el diagnóstico del reumatólogo mostró un índice kappa de 0,938 con criterios ESSG (IC del 95%: 0,877-0,998) y 0,790 para los criterios ASAS (IC del 95%: 0,682-0,898). Conclusión: En un grupo de pacientes colombianos SpA, los nuevos criterios de clasificación ASAS tienen una buena concordancia con el diagnóstico clínico, pero no son superiores a los criterios ESSG.

EpiFibro (Brazilian Fibromyalgia Registry): data on the ACR classification and diagnostic preliminary criteria fulfillment and the follow-up evaluation / EpiFibro (Registro Brasileiro de Fibromialgia): dados sobre a classificação do ACR e preenchimento dos critérios diagnósticos preliminares e avaliação de seguimento

Abstract Introduction: EpiFibro (Brazilian Epidemiological Study of Fibromyalgia) was created to study Fibromyalgia patients. Patients were included since 2011 according to the 1990 American College of Rheumatology Classification Criteria for Fibromyalgia (ACR1990). Objectives: To determine how many patients still fulfill the ACR1990 and the ACR2010 criteria in 2014; to determine the correlation between the impact of FM and to describe data on the follow-up evaluation. Methods: This is a cross sectional study in a multicenter cohort of patients. The data was collected between 2013 and 2015. Physician included patients that fulfilled the ACR1990 criteria on the date of entry. The follow-up data were considered only for patients with at least two evaluations. A minimally significant change was considered to be a 30% variation of parameters scores. Results: 810 patients’ data were analyzed. Patients presented a mean age of 51.8 ± 11.5 years old. There were 786 female. Most patients met both criteria. There was a greater fulfilling of the ACR2010. There was a moderate correlation between Polysymptomatic Distress Scale and Fibromyalgia Impact Questionnaire. Three hundred fourteen patients with more than one assessment were found, but 88 patients were excluded. Thus, 226 patients with one follow-up monitoring parameter were considered (Fibromyalgia Impact Questionnaire: 222; Polysymptomatic Distress Scale: 199; both: 195). The mean follow-up time was 9.1 ± 7.5 months (1–44). Most patients became stable. Conclusion: InEpiFibro, most patients fulfill simultaneously the ACR1990 and ACR2010. A larger number of patients fulfill the ACR2010 at the time of the evaluation. There was a moderate correlation between the Polysymptomatic Distress Scale and the Fibromyalgia Impact Questionnaire. Most patients remained stable over time.

Resumo Introdução: O EpiFibro (Estudo Epidemiológico Brasileiro de Fibromialgia) foi criado para estudar pacientes com fibromialgia. Foram incluídos pacientes desde 2011 de acordo com os critérios de classificação para a fibromialgia do American College of Rheumatology de 1990 (ACR1990). Objetivos: Determinar quantos pacientes ainda atendem aos critérios ACR1990 e ACR2010 em 2014; determinar a correlação entre o impacto da FM medido pelo Questionário de Impacto da Fibromialgia (FIQ) e pela Polysymptomatic Distress Scale (PDS) e descrever dados sobre a avaliação de seguimento. Métodos: Estudo transversal em uma coorte multicêntrica de pacientes. Os dados foram coletados entre 2013 e 2015. O médico incluiu pacientes que atenderam aos critérios ACR1990 no momento da entrada. Consideraram-se os dados de seguimento apenas dos pacientes com pelo menos duas avaliações. Uma variação de 30% nos escores dos parâmetros foi considerada uma alteração minimamente significativa. Resultados: Analisaram-se os dados de 810 pacientes. Os pacientes apresentaram média de 51,8 ± 11,5 anos. Havia 786 mulheres. A maior parte dos pacientes atendeu a ambos os critérios. Houve um maior atendimento aos critérios ACR2010. Houve uma correlação moderada entre a PDS e o FIQ. Encontraram-se 314 pacientes com mais de uma avaliação, mas 88 pacientes foram excluídos. Assim, foram considerados 226 pacientes com um parâmetro de monitoramento no seguimento. (FIQ: 222; PDS: 199; ambos: 195). O tempo médio de seguimento foi de 9,1 ± 7,5 meses (1 a 44). A maior parte dos pacientes tornou-se estável. Conclusão: No EpiFibro, a maior parte dos pacientes atendia simultaneamente ao ACR1990 e ao ACR2010. Uma maior quantidade de pacientes atendia ao ACR2010 no momento da avaliação. Houve uma correlação moderada. A maior parte dos pacientes manteve-se estável ao longo do tempo.

Performance of the 2015 ACR/EULAR classification criteria compared with other classification criteria for diagnosis of gout in Chinese patients / 北京大学学报(医学版)

Objective:To evaluate the ability of 2015 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria to diagnose gout compared with the widely used 1977 American Rheumatism Association (ARA) criteria and other criteria in clinical practice in Chinese patients,and to compare the sensitivity and specificity of different classification criteria for gout in early and established diseases.Methods:The patients who had ankle arthritis and visited the Department of Rheumatology and Clinical Immunology,Peking University First Hospital between February 2012 and February 2016 were screened.The patients who had been already diagnosed with gout or pyrophosphate deposition disease through arthrocentesis or tissue aspiration and those who had been diagnosed with rheumatoid arthritis,spondyloarthritis,and osteoarthritis were excluded.The patients were diagnosed by two experienced rheumatologists and all of them were followed up for at least one year.Early disease was defined as symptom onset of no more than 2 years;established disease was defined as symptom duration of more than 2 years.The 2015 ACR classification criteria were divided into clinical form with clinical parameters included and complete form with not only clinical parameters but also synovial fluids tests,imaging findings and monosodium urate (MSU) included.The two forms above were short for "clinical form (incorporating clinical parameters)" and "complete form (incorporating imaging and MSU data) " respectively.Results:In this study,284 patients suffering from ankle arthritis were included in the study,219 of them were classified as gout and 65 of them had alternative diagnoses.The sensitivity and specificity of 2015 ACR complete form (incorporating imaging and MSU data) for diagnosing gout were 88.13％ and 95.38％,respectively.The area under the curves (AUC) of 2015 ACR "complete form (incorporating imaging and MSU data)",2015 ACR "clinical form (incorporating clinical parameters) ",2010 Netherlands criteria and 1977 ARA criteria were 0.982,0.983,0.963,and 0.928,respectively.For the 94 early gout patients,the AUC of the above criteria were 0.973,0.968,0.916,and 0.910,respectively.For the established gout patients,the AUC were 0.987,0.991,0.982,and 0.936,respectively.For the patients with disease duration within two years,the odd ratio (OR) for sensitivity of 2015 ACR "complete form (incorporating imaging and MSU data)",2015 ACR "clinical form (incorporating clinical parameters)",2010 Netherlands criteria and 1977 ARA criteria were 1.562 (1.003-2.435),1.500 (1.001-2.346),and 1.812 (1.177-2.791),nevertheless,for the patients with established gout,the OR were 1.702 (1.300-2.229),1.607 (1.224-2.110),and 1.821 (1.396-2.377),respectively.Conclusion:The 2015 ACR/EULAR criteria are more accurate in gout diagnosis compared with the 1977 ARA criteria by elevating the sensitivity and specificity,in respective of the disease duration.The 2015 ACR/EULAR criteria may serve as new diagnostic tools in daily clinical practice in Chinese patients.

CLASSIFICATION OF ADULT CUBOID FRACTURE AND EFFECTIVENESS ANALYSIS / 中国修复重建外科杂志

OBJECTIVE: To study the classification criteria of adult cuboid fracture and its guidance feasibility and effect of treatment. METHODS: A retrospective analysis was made on the clinical data of 415 adult patients (416 feet) with cuboid fractures who had complete CT data treated between May 2009 and April 2014. There were 337 males and 78 females, aged 19 to 64 years (mean, 38.8 years). The left foot, right foot, and bilateral feet were involved in 220 cases, 194 cases, and 1 case respectively. The causes of injury were sprain in 106 cases, traffic accident in 65 cases, falling from height in 129 cases, and heavy crushing in 115 cases. The interval of injury and hospitalization was 2 hours to 3 days (mean, 8.5 hours). Based on CT findings, the classification criteria of cuboid fracture was proposed and methods of treatment was statistically analyzed. The external fixation surgery was performed in patients of type I (285 feet), type IIa (18 feet), and type III (5 feet); open reduction and internal fixation were performed in patients of type IIb (41 feet) and type III (67 feet), and bone grafting was used to repair defects in 58 feet (type III). RESULTS: All patients were followed up 1 year to 5 years and 11 months (mean, 2 years and 3 months). Primary healing of incision was obtained. In patients with type I fracture, fracture healed in 165 feet at 4-6 weeks (mean, 5.5 weeks), fracture did not heal in the other 120 feet; the American Orthopaedic Foot and Ankle Society (AOFAS) score was 95-100(mean, 96.7) at last follow-up. In patients with type II fracture, fracture healed in all feet at 6-8 weeks (mean, 6.5 weeks); the AOFAS score was 92-100(mean, 95.5) at last follow-up. In patients with type III fracture, malunion was observed at 6-8 weeks in 5 feet undergoing external fixation, and in 9 feet undergoing open reduction and internal fixation with foot lateral column shortening, forefoot abduction deformity, osteoarthritis, lateral foot pain; fracture healed at 8-12 weeks in 58 feet undergoing open reduction and internal fixation, without osteoarthritis, cuboid bone shortening, and pain at cuboid bone; and AOFAS score was 75-97(mean,93.5) at last follow-up. CONCLUSIONS: The classification criteria of cuboid fracture proposed based on CT examination is feasible and has guiding significance to the choice of treatment method.

Human brucellosis mimicking axial spondyloarthritis: a challenge for rheumatologists when applying the 2009 ASAS criteria / 华中科技大学学报（医学）（英德文版）

Although the development of the 2009 SpA classification criteria by Assessment of SpondyloArthritis international Society (ASAS) represents an important step towards a better definition of the early disease stage particularly in axial spondyloarthritis (axSpA), the specificity of the criteria has been criticized these days. As the commonest zoonotic infection worldwide, human brucellosis can mimic a large number of diseases, including SpA. This study was performed to determine the frequency of rheumatologic manifestations in patients with brucellosis and the chance of misdiagnosing them as having axSpA in central China. The results showed that clinical manifestations of axSpA could be observed in brucellosis. Over half of patients had back pain, and one fifth of the patients with back pain were less than 45 years old at onset and had the symptom for more than 3 months. Two young males were falsely classified as suffering from axSpA according to the ASAS criteria, and one with MRI proved sacroiliitis was once given Etanercept for treatment. Therefore, differential diagnosis including human brucellosis should always be kept in mind when applying the ASAS criteria, even in traditionally non-endemic areas.

Concordancia de los nuevos criterios ACR/EULAR y los ACR 1980 para la clasificación de la esclerosis sistémica / Concordance of the new ACR/EULAR criteria and the ACR 1980 for the classification of systemic sclerosis

Objetivo: Evaluar cumplimiento, y así mismo concordancia y discordancia de los criterios de clasificación de Esclerosis Sistémica (ES) ACR/EULAR 2013 y ACR 1980 en pacientes con diagnóstico clínico de la enfermedad. Método: Se incluyeron 169 pacientes con diagnóstico de Esclerosis Sistémica. Resultados: El 72,2 por ciento cumplía los criterios ACR 1980, y el 99,4 por ciento (168 pacientes) cumplía los criterios ACR/EULAR 2013. La concordancia absoluta de toda la muestra fue 72,7 por ciento, para el subtipo limitado 35,2 por ciento, y 100 por ciento el difuso. Se subanalizaron los pacientes con limitada que sólo cumplían criterios ACR/EULAR 2013, y se comparó con el resto de las limitadas. Los primeros presentaron en forma estadísticamente significativa menor esclerodactilia distal a MCF, menor presencia de úlceras digitales y pitting scars, menor afectación intersticial pulmonar, y mayor daño microvascular en la capilaroscopia. Conclusión: Los nuevos criterios de clasificación de Esclerosis Sistémica serían más adecuados para detectar esclerodermias limitadas, siendo dicho hallazgo estadísticamente significativo.

Objective: To evaluate the performance, and likewise concordance and discordance of the classification criteria of Systemic Sclerosis ACR/EULAR 2013 and ACR 1980 in a group of patients with clinical diagnosis of SSc. Methods: We enrolled 169 patients with diagnosis of Systemic Sclerosis. Results: 72.2 percent met the 1980 ACR criteria, and 99.4 percent met the ACR/EULAR 2013 criteria. The absolute agreement of the entire sample was 72.7 percent, 35.2 percent for the limited subtype, and 100 percent for the diffuse. Those patients with limited subtype who only met the ACR/EULAR 2013 criteria were compared with the rest of limited patients. The first group had statistically significantly lower sclerodactyly distal to MCF, lower presence of digital ulcers and pitting scars, less interstitial lung involvement, and greater abnormal nail fold capillaries. Conclusion: The new classification criteria for systemic sclerosis seem to be more suitable for detecting limited scleroderma. In the present study, statistically significant discrepancy was found in the limited subtype.

Espondiloartropatía juvenil: una visión desde la pediatría / Juvenile spondyloarthropathy: a view from pediatrics

La espondiloartropatía juvenil (EAPj) representa un grupo de artropatías crónicas que se inician en la infancia y que corresponden a entidades cuyas clasificaciones se han modificado en el transcurso de las décadas. Las clasificaciones actuales las incluyen sólo parcialmente. Las manifestaciones clínicas incluyen compromiso articular periférico asimétrico, entesis, sacroilíaco y menos frecuentemente de columna han permitido agruparlas en cinco categorías entre el que se encuentra la forma anquilosante juvenil relacionada con HLA B27 (+), el prototipo de EAPj y que podría representar a la forma de inicio de espondiloartropatía anquilosante del adulto. Los recientes avances en los estudios genéticos, en la patogenia, el desarrollo de mejores técnicas de imagenología tales como la ecografía musculo-esquelética y resonancia magnética aplicada a la Reumatología pediátrica podrían contribuir a generar criterios de clasificación de manera tal que faciliten la comunicación científica con los Reumatólogos de adultos. Un diagnóstico precoz, la aplicación de medidas de actividad de la enfermedad validadas y el oportuno manejo terapéutico obtendrán un pronóstico más favorable. Los resultados terapéuticos en EAPj presentan evidencia limitada aún requiriéndose mayor tiempo de evolución para obtener resultados a largo plazo.

Juvenile spondyloarthropathy (EAPj) represents a heterogeneous group of juvenile articular inflammatory entities and their classification have been changed during the last decades. The current classifications include only partially. The clinical manifestations of diseases involves peripheral joints, enthesis, sacroiliac and less frequently spine and they are classified in five specific subgroups among which is the juvenile ankylosing HLA B27 (+); the EAPj’s prototype and that may represent one of ankylosing spondyloarthropathy adult diseases. Recently, novel insights into the epidemiology, pathogenesis, and development of the imaging techniques such as muscle-skeletal ultrasound and magnetic resonance applied to pediatric rheumatology could be contributing to new classification criteria in order to facilitate the scientific communication with Rheumatologist of adult patients. An early diagnosis a validated measures of disease activity and treatment can change the course and outcome of disease.

Ocular Manifestations of Sjögren Syndrome / 한양의대학술지

Sjögren Syndrome (SS) is one of the most frequent systemic autoimmune disorders, mainly involving the eye and mouth due to inflammation of lacrimal and salivary glands. Exocrine glands affected with a typical focal lymphocytic infiltration potentially lead to dry eyes and dry mouth. In addition to the known pathogenic mechanism of SS through autoimmunity, corneal neuropathy, as a peripheral neuropathy which is a relatively frequent extraglandular systemic manifestation of SS, recently draws attention as a possible pathogenic mechanism of ocular symptoms and dry eye induction. The diagnostic criteria of SS changed recently, proposed by the American College of Rheumatology/Sjögren's International Collaborative Clinical Alliance (ACR/SICCA) in 2012, and the ocular surface staining score is the only required test for ocular manifestation of SS. However, other diagnostic methods evaluating tear film status, though excluded from the new criteria, are still important for the staging and treatment planning, including direct observation of tear film, tear film break up time, Schirmer test, and measurement of the tear film levels of inflammatory mediators. Eye-specific symptoms and signs and ocular treatment options for SS including tear substitutes, secretogogue, topical anti-inflammatory therapy with corticosteroids and cyclosporine, punctal occlusion, autologous serum, and mucolytic therapy were summarized and discussed in this review article.

Evaluation of the World Health Organization 2009 classification of dengue severity in autopsied individuals, during the epidemics of 2011 and 2012 in Brazil

Abstract: INTRODUCTION: The dengue classification proposed by the World Health Organization (WHO) in 2009 is considered more sensitive than the classification proposed by the WHO in 1997. However, no study has assessed the ability of the WHO 2009 classification to identify dengue deaths among autopsied individuals suspected of having dengue. In the present study, we evaluated the ability of the WHO 2009 classification to identify dengue deaths among autopsied individuals suspected of having dengue in Northeast Brazil, where the disease is endemic. METHODS: This retrospective study included 121 autopsied individuals suspected of having dengue in Northeast Brazil during the epidemics of 2011 and 2012. All the autopsied individuals included in this study were confirmed to have dengue based on the findings of laboratory examinations. RESULTS: The median age of the autopsied individuals was 34 years (range, 1 month to 93 years), and 54.5% of the individuals were males. According to the WHO 1997 classification, 9.1% (11/121) of the cases were classified as dengue hemorrhagic fever (DHF) and 3.3% (4/121) as dengue shock syndrome. The remaining 87.6% (106/121) of the cases were classified as dengue with complications. According to the 2009 classification, 100% (121/121) of the cases were classified as severe dengue. The absence of plasma leakage (58.5%) and platelet counts <100,000/mm3 (47.2%) were the most frequent reasons for the inability to classify cases as DHF. CONCLUSIONS: The WHO 2009 classification is more sensitive than the WHO 1997 classification for identifying dengue deaths among autopsied individuals suspected of having dengue.

Can mastalgia be another somatic symptom in fibromyalgia syndrome?

OBJECTIVE: The purposes of this study were to determine the coexistence of mastalgia and fibromyalgia, to investigate the effects of this combination on pain patterns, and to discuss the status of breast pain in the diagnostic algorithm of fibromyalgia syndrome. METHODS: Sixty-one female patients reporting breast pain during the last three months and 53 female patients diagnosed with fibromyalgia syndrome were enrolled in this study. The Breast Pain Questionnaire was administered to all participants in the mastalgia group and to those in the fibromyalgia syndrome group who had experienced mastalgia during the past three months. The patients in the fibromyalgia syndrome group were evaluated using the 2010 preliminary American College of Rheumatology classification criteria. All of the patients in the mastalgia group were evaluated for the diagnosis of fibromyalgia syndrome by a single physiatrist. The coexistence and pain patterns of mastalgia and fibromyalgia were assessed statistically. RESULTS: Approximately half of the patients with fibromyalgia syndrome (47.2%) reported having mastalgia at the time of admission and 37.7% of the patients with mastalgia met the diagnostic criteria for fibromyalgia syndrome. The patients with mastalgia in the fibromyalgia syndrome group had significantly higher total breast pain scores compared with the women in the mastalgia group. In addition, the patients with fibromyalgia syndrome in the mastalgia group had significantly higher Widespread Pain Index and Symptom Severity Scale scores than the patients with fibromyalgia syndrome. CONCLUSIONS: We suggest that mastalgia can be an aspect of the central sensitivity syndrome and can be added to the somatic symptoms of fibromyalgia.

The diagnostic value of the early rheumatoid arthritis classification criteria and clinical efficacy of knee arthroscopic synovectomy for early RA / 中国基层医药

Objective To evaluate the diagnostic value of the early rheumatoid arthritis (RA) classification criteria for early RA and to assess the clinical efficacy of knee arthroscopic synovectomy for RA.Methods A total of 62 patients who had arthritic complaints with disease duration less than one year were treated with knee arthroscopic synovectomy.Patients were diagnosed as RA confirmed by changes of synoviomorphous under arthroscopy,synovial biopsy,immunological biochemical laboratory and MRI,and compared with the preoperative ERA diagnosis.The efficacy was assessed at the third months and more than 12 months after operation,including Health Assessment Questionnaire (HAQ),Lysholm score,laboratory parameters of erythrocyte sedi-mentation rate (ESR) and C-reactive protein (CRP).Results The sensitivity and specificity in the early RA classification criteria for RA diagnosis were 81.58％ and 91.67％.38 patients diagnosed as RA and the remaining 24 patients were significantly improved of HAQ,Lysholm score,ESR,CRP compared with preoperation,showed statistical difference (P ＜ 0.01).There were still statistical differences between the follow-up results of the group of patients with RA in different period after operation (P ＜ 0.01).Conclusion The early RA classification criteria is worthy of clinical application,because it has the advantages of simple,practical,and is beneficial to early diagnosis of RA.The early RA patients should be treated with knee arthroscopic synovectomy as far as possible.It can improve not only the knee function,but also the general symptoms,and it can interrupt the RA pathological process,effective maintain curative effect after operation.