Relationship between psychological status and disease activity and quality of life in ankylosing spondylitis

Our aim in this study was to compare the depression and anxiety risk in patients with AS and healthy controls and also to determine the relationship between disease activity, quality of life and psychological well-being. Two hundred and forty-three patients with ankylosing spondylitis (AS) and 118 age-, sex- and education-matched healthy controls were enroled into the study. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Functional Index, and Metrology Index, Health Assessment Questionnaire for Spondyloarthropathies (HAQ-S), Hospital Anxiety and Depression Scale (HADS) including depression subscale (HADS-D) and anxiety subscale (HADS-A), Ankylosing Spondylitis Quality of Life (ASQoL) Scale, duration of morning stiffness, pain-visual analogue scale (VAS), patient and physician??s global assessment of disease activity (100?mm VAS) were used to assess clinical and psychological status. Patients had similar HADS-D but higher HADS-A than healthy controls. Patients with high risk for depression and anxiety had higher scores in BASDAI, BASFI and also poorer scores in VAS pain, patient global assessment, physician global assessment, HAQ-S and ASQoL. There was a negative correlation of HADS-D and HADS-A scores with educational level of the patients. Higher scores in HADS-D and HADS-A indicated poorer functional outcome and quality of life. Multivariate logistic regression analysis revealed that the HADS-D (OR?=?6.84), HAQ-S (OR?=?1.76), VAS pain score (OR?=?1.03) and ESR (OR?=?1.02) were independent risk factors for higher anxiety scores whereas HADS-A (OR?=?1.36) and ASQoL (OR?=?1.24) were independent risk factors for higher depression scores. The psychological status had close interaction with disease activity and quality of life in patients with AS.     

Plasma homocysteine status in patients with ankylosing spondylitis

Homocysteine (Hcy), a sulfur-containing amino acid, is eliminated through B vitamins-dependent pathways. Hyperhomocysteinemia has been found to be an independent risk factor for atherosclerotic cardiovascular, cerebrovascular, and peripheral vascular diseases. Recently, psoriasis, lupus, and rheumatoid arthritis were reported to be associated with hyperhomocysteinemia. This study was aimed to evaluate the changes of plasma Hcy level before and after sulfasalazine and MTX therapy in patients with ankylosing spondylitis (AS). One hundred and two patients with AS and ten normal controls were enrolled in the cross-sectional case-control study. Fasting plasma Hcy levels were determined by ELISA kits (IMX, Abbott). Hcy levels were compared to their Bath AS disease activity index (BASDAI) and the usage of sulfasalazine and/or MTX. Active disease was defined by BASDAI as more than 3 in a 10-cm scale with ESR >20 mm/h. For those patients with plasma Hcy ≥15 μmol/l, a perspective trial of daily supplement of vitamin B-12 0.5 mg, B-6 50 mg, and folic acid 5 mg for 2 weeks were also tested for the efficacy. Plasma Hcy level increased significantly in AS patients under sulfasalazine (10.4±3.8 μmol/l, p<0.05), MTX (11.9±4.7, p<0.05) and sulfasalazine/MTX combination treatment (11.2±2.6, p<0.05) compared with normal controls (8.6±1.2 μmol/l) and AS patients without DMARD(9.4± 2.6μmol/l). No correlation between disease activity and plasma Hcy level was found. Daily supplement of vitamin B-12 0.5 mg, B-6 50 mg, and folic acid 5 mg can lower Hcy level in 2 weeks (32.3±24.0 vs 15.6±11.1 μmol/l, p=0.007). Plasma homocysteine level did significantly increase in AS patients under sulfasalazine or MTX treatment. B-vitamins should be considered as a routine supplementation for patients who underwent sulfasalazine and/or MTX treatment. Further longitudinal studies are required to confirm the conclusions.     

Protein oxidation status in patients with ankylosing spondylitis

OBJECTIVES: Ankylosing spondylitis (AS) is a chronic inflammatory disease with unknown aetiology. Since various functions of neutrophils are increased in AS, neutrophil activation-mediated oxidative stress may have an important role in the pathogenesis of AS. Therefore, the importance of neutrophil activation as the main source of oxidative stress was investigated in patients with AS. METHODS: Forty-one patients with AS, divided into active and inactive groups according to their CRP and ESR, and 30 healthy volunteers were entered into the study. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the visual analogue scale (VAS) were also used in all patients before the study. In addition, the patients were evaluated according to spinal involvement and peripheral involvement. Plasma myeloperoxidase (MPO) activity, representing neutrophil activation, and oxidative stress biomarkers, such as advanced oxidation protein products (AOPP) and thiol levels, were measured. RESULTS: There were significant increases in plasma MPO activity and AOPP but decreases in thiol levels in the total AS patient group and in the subgroups, compared with controls. All parameters, except thiol, were higher in active and peripheral involvement groups than in the inactive and spinal patients, respectively; but the highest levels were observed in the peripheral subgroup. In addition, AOPP was found to be positively correlated with ESR, CRP and BASDAI in the total patient group and with white blood cell and neutrophil count in the peripheral involvement subgroup. BASDAI was positively correlated with VAS, ESR and CRP; but MPO was negatively correlated with thiol/albumin ratio, both in total and active AS patients. Negative correlations were also observed between albumin and ESR, and between CRP and neutrophil counts in the peripheral subgroup. CONCLUSIONS: This is the first study suggesting neutrophil-MPO-hypochlorous acid-mediated AOPP formation in AS. Therefore, active neutrophils and chlorinated oxidants of neutrophil origin may be considered to be important factors in the pathogenesis of AS which are related to oxidative stress, notably protein oxidation.     

Disease expression of ankylosing spondylitis in males and females

The clinical features of 35 female patients with ankylosing spondylitis were compared with 70 male controls individually matched for disease duration. Mean age of onset and presenting symptoms were similar in both groups. No differences were observed as regards spinal symptoms, chest expansion, peripheral arthritis, extraarticular features or functional outcome. However, males had significantly greater spinal radiological change that was positively associated with hip arthritis. Our findings suggest that although axial disease is more severe in males the overall pattern of clinical disease is similar in both sexes.     

强直性脊柱炎治疗现状及其进展

强直性脊柱炎(AS)是一种以累及脊柱和骶髂关节为特征的系统性炎性疾病.随着对AS致病因素研究的深入,虽然对其致病机制仍未完全明了,但在治疗方面,除了传统的治疗措施的研究,近年来其治疗的新策略也取得了可喜的新经验,尤其是在生物制剂方面的研究更是有了进一步的了解,并展现出良好的应用前景.     

Exercise and changes in health status in patients with ankylosing spondylitis

BACKGROUND: Although exercise is a commonly recommended treatment for ankylosing spondylitis (AS), little is known about the effectiveness of unsupervised recreational and back exercises. We examined the effects of recreational exercise and back exercises on patient-reported pain severity, stiffness severity, and functional disability in a prospective longitudinal study of 220 patients with AS. METHODS: Participants provided information on exercise habits and health status every 6 months using mailed questionnaires (median follow-up, 4.5 years). Pain severity and stiffness severity were measured using visual analog scales, and functional disability was measured using the Health Assessment Questionnaire (HAQ) Disability Index. RESULTS: Among all patients, there were no associations between either the number of exercise minutes per week or the number of days of back exercise per week and short-term (6-month) changes in pain, stiffness, or HAQ Disability Index. However, among those who had AS for 15 years or less, pain scores were 0.18 points lower (on a scale of 0-3; P =.04), and stiffness scores were 6.4 points lower (on a scale of 0-100; P =.005) during periods with more than 200 minutes per week of exercise compared with periods with 0 to 30 minutes of exercise per week. Among those who had AS for more than 15 years, pain scores were 0.11 points lower (on a scale of 0-3; P =. 03), and HAQ Disability Indexes were 0.08 points lower (on a scale of 0-3; P<.001) during periods with 5 to 7 days per week of back exercise compared with periods when back exercises were not performed. Less intense levels of exercise were not associated with improvements in health status. CONCLUSIONS: Unsupervised recreational exercise improves pain and stiffness, and back exercise improves pain and function in patients with AS, but these effects differ with the duration of AS. Health status is improved when patients perform recreational exercise at least 30 minutes per day and back exercises at least 5 days per week. Arch Intern Med. 2000;160:2969-2975     

Sleep quality and associated factors in ankylosing spondylitis: relationship with disease parameters, psychological status and quality of life

The aim of this study is to investigate sleep quality in patients with ankylosing spondylitis (AS) and to evaluate the relationship of the disease parameters with sleep disturbance. Eighty AS patients (60 males and 20 females) fulfilling the modified New York criteria, and 52 age- and gender-matched controls (33 males and 19 females) were enrolled in the study. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Pain was measured by visual analogue scale. The disease activity and functional status were assessed by the Bath AS disease Activity Index and the Bath AS Functional Index. The Bath AS Metrology Index was used to evaluate mobility restrictions, and the Bath AS Radiology Index was employed to evaluate the radiological damage. The psychological status and quality of life were assessed with the hospital anxiety-depression scale and AS quality of life scale. The patients with AS had significantly more unfavourable scores in the subjective sleep quality, habitual sleep efficiency domains (p < 0.001) and the total PSQI score (p < 0.05). Poor sleep quality (total PSQI score) was positively correlated with increased pain, poor quality of life, higher depressed mood, higher disease activity and mobility restrictions. Pain was also an independent contributor to poorer sleep quality (p = 0.002). The sleep quality is disturbed in patients with AS. The lower quality of sleep is greatly associated with the pain, disease activity, depression, quality of life and increased limitation of mobility.     

Fatigue in patients with ankylosing spondylitis: prevalence and relationships with disease-specific variables, psychological status, and sleep disturbance

This study aims to evaluate the frequency of fatigue in Moroccan patients with ankylosing spondylitis (AS), and its relationships with disease-specific variables, psychological status, and sleep disturbance. A cross-sectional study included patients fulfilled the modified New York classification criteria for ankylosing spondylitis. To assess fatigue, the first item of Bath ankylosing spondylitis disease activity index (BASDAI) and the multidimensional assessment of fatigue (MAF) was used. The evaluation included the activity of the disease (BASDAI), global well-being (Bath ankylosing spondylitis global index), functional status (Bath ankylosing spondylitis functional index), metrologic measurements (Bath ankylosing spondylitis metrological index), and visual analog scale of axial or joint pain. The erythrocyte sedimentation rate and C-reactive protein were measured. To assess psychological status, the hospital anxiety and depression scale (HADS) was used. Sleep disturbance was assessed by the fourth item of Hamilton anxiety scale. One hundred and ten patients were included, of average age 38.0?years?±?12.6. In our data, 66.4% experienced severe fatigue (BASDAI fatigue ≥5). The mean total score of MAF was 26?±?12.77. The disease-specific variables contributed significantly with both BASDAI fatigue and MAF as dependent variables, accounting for 71.3 and 65.6% of the variance, respectively. The contribution of the depression, anxiety, and sleep disturbance were 24.9, 18.4 and 15.4%, respectively. This study state the importance of fatigue in AS patients. Even though disease activity was the most powerful predictor of fatigue, the effects of psychogenic factors and sleep disturbance, should be taken into consideration in the management of AS.     

Imaging in ankylosing spondylitis

The introduction of symptomatically highly effective anti-tumour necrosis factor alpha therapies for ankylosing spondylitis (AS) has generated interest in the use of imaging to evaluate the potential structure-modifying properties of these agents. Several approaches have been developed to score the plain radiographic abnormalities in AS. Of these, the modified Stoke AS Spinal Score is the most responsive to change, although responsiveness is limited and requires a minimum of 2 years before significant change becomes apparent in patients on standard therapies. Magnetic resonance imaging (MRI) is the most sensitive imaging abnormality, and the advent of fat-suppression imaging allows detection of bone marrow inflammation in the sacroiliac joints as one of the earliest abnormalities in AS. Limited studies have shown that spinal inflammation can be scored reliably using either a system that evaluates the entire spine or a system that limits evaluation to only the most severely affected spinal segments. Both methods also demonstrate excellent responsiveness. The prognostic significance of acute changes on MRI remains unclear. Reliable approaches to the evaluation of chronic changes are yet to be developed. MRI represents a major advance in the diagnostic evaluation of AS.     

Osteoporosis in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disorder, characterized by an inflammatory enthesopathy progressing to ossification and ankylosis. Osteoporosis is a well‐reported complication of AS. Bone loss begins early in the disease at the spine, and later progresses to the hip. This reduction in bone density leads to an increased risk of fractures. However, there is a lack of awareness regarding this common complication, thus adding to the morbidity associated with AS. Early recognition, appropriate assessment and timely treatment of this complication will help reduce the attendant fracture risk due to decreased bone mass.     

Assessments in ankylosing spondylitis

Assessment of disease status and response to therapy in ankylosing spondylitis is a rapidly expanding area of research. The assessment in ankylosing spondylitis international working group has contributed greatly to this development, defining core sets of health domains for use in daily practice and in clinical trials, developing and validating measurement instruments corresponding to these health domains, and developing response and remission criteria for use in clinical trials. This chapter reviews available measures of three major areas of disease impact in ankylosing spondylitis (disease activity, structural damage and functioning), and discusses which measures are relevant for use in clinical practice.     

Rehabilitation in ankylosing spondylitis

PURPOSE OF REVIEW: Medical therapy of ankylosing spondylitis has improved dramatically with the advent of anti-tumor necrosis factor therapy, but nonpharmacologic therapies have long been employed to treat the condition. The purpose of this review is to summarize the most recent data to assess the role of exercise and nonpharmacologic therapies in ankylosing spondylitis. RECENT FINDINGS: We review six articles published since 2005. The most common outcome measures (validated scores from Bath group) were only formally utilized in two studies. Four of the six studies were randomized controlled trials. One study using balneotherapy did not reveal any significant improvement in the medium term. One study used a multimodal exercise program, which revealed some benefit. Two studies assessed short and long-term efficacy of an experimental exercise protocol and suggested a prolonged benefit. Two small studies looking at biologic markers suggested that exercise may impact cytokine production. SUMMARY: All studies we reviewed had small numbers of participants without a standardized control group and each study used different outcome measures. This review demonstrates the importance of continued emphasis on exercise therapy, the need for a standardized approach to exercise therapy, and a potential biologic effect. Exercise therapy should remain a mainstay of ankylosing spondylitis treatment complementing medical therapy.     

Glomerulonephropathy in ankylosing spondylitis

Aim: Renal abnormalities have been reported in ankylosing spondylitis (AS). The purpose of this study was to elucidate the nature of glomerulonephropathy in AS. Methods: Two hundred and sixty‐six patients with definite AS diagnosed at Taipei Veterans General Hospital, Taiwan, were enrolled. Urinary analysis and renal biopsy were performed in this study. The nature of glomerulonephropathy in AS was analyzed. Results: Twelve out of 266 (4.5%) patients had AS‐associated nephropathy manifesting as haematuria alone (11 patients) or haematuria and proteinuria (1 patient). Renal biopsy in seven patients showed IgA nephropathy in two cases, mesangial nephropathy with isolated C3 deposits in three cases, and IgM nephropathy in two cases, one of which had accompanied infectious endocarditis. Conclusion: AS‐associated nephropathy is not uncommon and mesangial nephropathy is the most common form. Microscopic haematuria and proteinuria are the most common manifestations of renal involvement.     

Assessments in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease requiring regular medical care and monitoring to alleviate symptoms, maintain function, identify disease progression and initiate appropriate, timely therapies. Monitoring of the AS patient in clinical daily practice should not only include general history taking and physical examination, but also incorporate specific concepts, pertaining to the disease, which will aid in the detection of disease progression, the requirement of therapeutic intervention and the response to therapy. The Assessments in AS (ASAS) international working group has defined a core set of disease concepts that should be a part of everyday clinical record-keeping in AS, and has identified and validated measurement instruments corresponding to these health concepts, which can easily be incorporated into clinical practice. The group has also developed recommendations for management and a consensus statement for the use of biological therapies in AS, which includes recommendations for the monitoring of AS patients receiving these therapies. This chapter reviews the recommendations for monitoring AS patients in daily clinical practice, with particular regard to those receiving biological treatments.