Intra-articular glucocorticoid injection site: best practice guidelines

The article presents modern recommendations for the use of systemic administration of glucocorticoids. It is indicated that there is a clear tendency to minimize the doses and timing of the appointment of systemic glucocorticoids in rheumatoid arthritis, and in seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis), in accordance with both foreign and domestic recommendations, systemic therapy with glucocorticoids is not carried out. It is emphasized that at the present stage, the role of local administration of glucocorticoids will increase as an effective way to reduce the activity of arthritis in any nosologically form. The mechanisms of action of locally administered glucocorticoids leading to anti-inflammatory and analgesic effects are described. The comparative characteristics of locally administered glucocorticoids with different duration of action according to their effectiveness and safety are presented. Predictors of the effectiveness of local therapy with glucocorticoids are described. The data on the evaluation of the duration of the anti-inflammatory and analgesic effects of various local glucocorticoids, including in comparison with the intra-articular administration of hyaluronic acid preparations, which showed the advantages of betamethasone over triamcinolone acetate, are presented. The differences in the crystal structure of betamethasone and triamcinolone acetate are described. It is indicated that the 2.5-fold smaller size of betamethasone crystals compared to triamcinolone acetate crystals and the absence of betamethasone crystals makes it possible to use betamethasone in the treatment of inflammatory processes in periarticular tissues, as well as in crystalline arthritis (gout, pseudogout). The data on the safety of the use of intra-articular injection of glucocorticoids are presented. It is indicated that the registration in the Russian Federation of a new form of betamethasone in pre-filled syringes makes it even more possible to avoid infectious complications of this type of therapy. Rare cases of complications of local therapy with glucocorticoids are described.

Rates of spondyloarthropathies vary with age and ethnicity in HLAB27 uveitis

Background/AimsTo determine associations between HLAB27-positive uveitis, ethnicity and seronegative spondyloarthropathies (SpAs) in a New Zealand population.MethodsRetrospective observational cohort study. Medical records of all subjects with uveitis at Auckland District Health Board from 2008 to 2018 were reviewed for HLAB27 status, age of presentation, ethnicity and SpA.ResultsIn 10 years, 2567 subjects with uveitis were seen and 492 (19.2%) were HLAB27-positive. Of the HLAB27-positive subjects, 301 were male (60.3%) and median age was 37.8 years (IQR 29.7–50.0). Ethnicities were Caucasian (n=298, 60.6%), Asian (n=111, 22.6%), Maori (n=41, 8.2%) and Pacific Islander (n=38, 7.7%). Uveitis classification was anterior (n=478, 97.2%), intermediate (n=40, 8.1%), panuveitis (n=9, 1.8%) and scleritis (n=2, 0.4%). Maori or Pacific Islander ethnicity was associated with intermediate or panuveitis (p=0.003). Ankylosing spondylitis occurred in 163 subjects (33.1%); 29 (17.8%) were Maori or Pacific Islander. Subjects were younger (OR 0.982, p=0.009) and male (OR 1.980, p=0.001). There was no association with ethnicity or uveitis classification. Psoriatic arthritis (PsA) occurred in 11 subjects (2.2%). Chronic anterior uveitis was more common with PsA (27.3% vs 7.1%, p=0.023). There was no association with gender or ethnicity. Inflammatory bowel disease occurred in 19 subjects (3.8%) and reactive arthritis occurred in 14 subjects (2.8%). None developed chronic anterior uveitis (p=0.246 and p=0.227, respectively). There was no association with age at presentation, gender, ethnicity or uveitis classification.ConclusionThis cohort of New Zealand-based subjects with HLAB27-positive uveitis showed a difference in age and ethnicity in uveitis subtypes and SpAs.

Imaging of diffuse idiopathic skeletal hyperostosis (DISH)

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterised by calcification and ossification of ligaments and entheses. The condition usually affects the axial skeleton, in particular, at the thoracic segment, though also other portions of the spine are often involved. DISH often involves also peripheral tendinous and/or entheseal sites either alone, or in association with the involvement of peripheral joints. At times, new bone formation involves the bone itself, but sometimes it involves joints not usually affected by osteoarthritis (OA) which result in bony enlargement of the epiphysis, joints space narrowing and a reduced range of motion. Because of the entheseal involvement, DISH can be mistaken for seronegative spondyloarthropathies or for a "simple" OA. Furthermore, other implications for the recognition of DISH include spinal fractures, difficult intubation and upper endoscopies, decreased response rates in DISH with concomitant spondyloarthritides, and increased likelihood to be affected by metabolic syndrome and cardiovascular diseases. This Atlas is intended to show the imaging finding in DISH in patients diagnosed with the condition by the Resnick classification criteria.

Association between secretor status and Lewis phenotype with seronegative spondyloarthritis as indicator of autoimmunity

The classical paradigm of autoimmune pathogenesis involving specific genetic makeup and exposure to environmental triggers has been challenged recently by the addition of a third element, the loss of intestinal barrier function. Regardless of HLA B27 phenotype or gastrointestinal symptoms, evidence of ileitis, ileocolitis or colitis exists in patients with spondyloarthropathy. The FUT2 secretory gene is a strong candidate for Crohn's susceptibility by shaping the functional states of mucosal microbiota and may thus have influence on the release of zonulin, the main regulator of gut permeability. Gram negative bacteria precipitate and may be involved in the pathogenesis of spondyloarthropathies. Susceptibility to many infectious agents is associated with ABO blood group or secretor state. Patients who cannot secrete ABO and Lewis blood group antigens into body fluids, an ability controlled by a single gene on chromosome 19, are known to be at increased risk of certain autoimmune diseases associated with human leukocyte antigen (HLA) markers. Lewis (Le) blood group phenotype can be used to infer secretor status. The objective of this study was to determine the distribution of secretor state and Lewis blood group phenotype in patients with seronegative spondyloarthropathies and healthy control subjects. Hundred and ten (110) patients with seronegative spondyloarthropathies (58 females and 52 males) and 103 control (74 males and 29 females) subjects participated in this study. Samples of saliva and blood were subjected to haemagglutination inhibition tests for determination of secretor status and Lewis phenotype. A total of 92(84%) patients and 92 (89%) control subjects were secretors while 18 (16%) patients and 11 (11%) control subjects were non-secretors. There was no statistically significant difference (?2 1,461 p<0,05 and degrees of freedom 1) in distribution of secretor status in comparison to seronegative spondyloarthropathies by comparing two observed populations. Seven patients had modified (reduced) expression of Lewis b antigen on their erythrocytes. Reduction of Lewis b antigen expression was not observed on erythrocytes of healthy subjects. Reduced expression of Lewis b antigen could be a consequence of the inflammatory process within the gut and it also suggests several pathogenic mechanisms which may be relevant to the synthesis of Lewis antigens inside the gut or its absorption on erythrocytes in patients with spondyloarthropathy.