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Rheumatoid arthritis (RA) is a chronic disease, the etiology of which has yet to be clarified, which causes activation of proinflammatory pathways that bring about joint and systemic inflammation. Although peripheral nervous system anomalies are observed widely in RA, very few case reports on changes in the central nervous system (CNS) have been published. In recent years, the pathophysiology of CNS involvement that can occur in RA has attracted a great deal of attention. Emphasis has focused on the possibility that CNS involvement occurs due to blood–brain barrier (BBB) damage associated with chronic inflammation. The present study was performed to investigate the possible effects of BBB dysfunction and tumor necrosis factor (TNF) blocker therapy on BBB function, which may cause CNS damage in patients with RA. 58 RA patients [47 (81.0%) females, 11 (19.0%) males] and 34 healthy controls [24 (70.6%) females, 10 (29.4%) males] were included in the study. All RA patients were on synthetic DMARD therapy at the beginning. Thirty patients continued DMARD therapy, and 28 patients with high disease activity were started on TNF blocker therapy. All demographic characteristics of the patients were recorded. Disease activity was evaluated using the Disease Activity Score 28-joint count C reactive protein. The Mini-Mental State Examination was used to evaluate cognitive function, and the Fazekas scale was used to assess cranial lesions visualized by magnetic resonance imaging (MRI). Patients’ peripheral blood S100β, glial fibrillary acidic protein (GFAP), claudin, interleukin (IL)-17, and IL-1β levels were measured at the beginning of the study and after 6 months. Demographic characteristics (including sex, age, and body mass index) were similar in the RA and control groups. S100β and GFAP levels were significantly higher in the patient group than in the control group. In the group that was started on TNF blocker therapy, S100β and GFAP levels were significantly decreased 6 months after commencement of treatment. No difference was observed between the RA and control groups in terms of hyperintense lesions seen on cranial MRI. The S100β levels increased with lesions in the deep white matter seen on cranial MRI in patients with RA. In conclusion, next to decreasing disease activity and joint erosions by suppressing inflammation, anti-TNF therapy in RA can also suppress potential CNS involvement linked to BBB (blood–brain barrier) dysfunction. Further studies with broader participation and longer patient follow-up are needed to reinforce this hypothesis.

We aimed at investigating the ultrasonographic (US) and clinical prevalence of enthesopathy in patients with rheumatoid arthritis (RA), and axial spondyloarthropathy (SpA), as well as the correlation between this condition and disease activity, along with the quality of life. Included in the study were 30 axial SpA, 21 patients with RA, and 25 healthy cases. Bath Anklylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Quality of Life (ASQoL), Disease activity index  28 (DAS28), and Health Assessment Questionnaire (HAQ) were used for clinical evaluation, and enthesal pain was evaluated by VAS, whereas enthesitis US evaluation was performed by using the MAdrid Sonographic Enthesitis Index (MASEI). A total of 152 knees, ankles, and elbow regions of all patients and controls were examined by US. Total scores of physical examination of enthesitis were 1.97 ± 2.68 in axial SpA, 2.43 ± 1.80 in RA, and 0.23 ± 0.12 in the control groups. No statistically significant difference was identified in the enthesitis examination between axial SpA and RA groups (p= 0.123). According to the MASEI, no significant difference was observed in quadriceps tendon enthesitis or in distal patellar ligament enthesitis between axial SpA and RA groups (MASEI 3, 4, 5: p= 0.993, p= 0.124, p= 0.652). Aside from those points, axial SpA patients had statistically higher enthesitis scores at all MASEI enthesitis points (p< 0.05). In the axial SpA group, a significant and positive correlation was identified between BASDAI scores and total scores of enthesitis physical examination and MASEI total scores (r = 0.739, p= 0.0001, r = 0.516, p= 0.002). A moderately significant correlation was identified between ASQoL total scores and MASEI total scores (r = 0.466, p= 0.006), but not between the HAQ total scores and MASEI total scores (r = 0.213, p= 0.065). Compared to RA, US and clinical examination of enthesitis in patients with axial SpA should focus on the calcaneal enthesitis region. In axial SpA, ultrasonographic enthesitis is associated with impaired quality of life. Ermittelt werden sollten die sonographische (US) wie die klinische Prävalenz der Enthesopathie bei Patienten mit rheumatoider Arthritis (RA) und Patienten mit axialer Spondyloarthropathie (SpA) sowie die Korrelationen mit der Krankheitsaktivität und der Lebensqualität. In die Studie aufgenommen waren 30 Patienten mit axialer SpA, 21 mit RA und 25 gesunde Kontrollpersonen. Zur klinischen Evaluation dienten „Bath Anklylosing Spondylitis Disease Activity Index“ (BASDAI), „Ankylosing Spondylitis Quality of Life“ (ASQoL), „Disease activity index 28“ (DAS28) und „Health Assessment Questionnaire“ (HAQ), Schmerzen im Bereich von Sehnen wurde mittels einer VAS (visuelle Analogskala) dokumentiert, die sonographische Evaluation dagegen erfolgte unter Verwendung des MASEI (MAdrid Sonographic Enthesitis Index). Insgesamt 152 Knie‑, Sprunggelenk- und Ellenbogenregionen aller Patienten und Kontrollen wurden sonographiert. Die Summenscores der körperlichen Untersuchung betrugen bei axialer SpA 1,97 ± 2,68 in axial SpA, bei RA 2,43 ± 1,80 und bei den Kontrollpersonen 0,23 ± 0,12. Kein statistisch signifikanter Unterschied ließ sich bei der Untersuchung auf Enthesitis zwischen den beiden Patientengruppen ausmachen (p= 0,123). Gemäß dem MASEI wurde zwischen diesen Gruppen ebenfalls kein signifikanter Unterschied beobachtet hinsichtlich einer Enthesitis der Quadrizeps- oder der distalen Patellarsehne (MASEI 3, 4, 5: p= 0,993, p= 0,124, p= 0,652). Neben diesen Aspekten hatten die SpA-Patienten statistisch signifikant höhere Scores an allen MASEI-Enthesitispunkten (p< 0,05). In der Patientengruppe mit axialer SpA zeigte sich eine signifikante, positive Korrelation zwischen BASDAI-Scores und Summenscores der körperlichen Untersuchung auf Enthesitiden und den MASEI-Summenscores (r = 0,739, p= 0,0001, r = 0,516, p= 0,002). Eine mäßig signifikante Korrelation bestand zwischen den ASQoL- und den MASEI-Summenscores (r = 0,466, p= 0,006), keine statistisch signifikante Korrelation dagegen zwischen den HAQ- und den MASEI-Summenscores (r = 0,213, p= 0,065). Anders als bei RA sollten bei axialer SpA die sonographische und die klinische Untersuchung auf Enthesitis auf mögliche entsprechende Befunde in der kalkanearen Region fokussiert sein. Bei Patienten mit axialer SpA ist eine sonographisch dargestellte Enthesitis mit einer beeinträchtigten Lebensqualität verbunden.

AbstractObjective: Low back pain [LBP] is an important health issue due the diagnosis and treatment expenses and loss of workforce it leads to. Biomechanical changes in the vertebral column caused by changes in the lumbosacral angles [LSAs] may lead to LBP. The purpose of this study was to assess body mass index [BMI] and LSAs in patients with LBP and investigate the association between LBP, LSAs and BMI.Methods: Lumbar lordotic angle [LLA], LSA, sacro-horizontal angle [SHA] and sacral inclination angle [SIA] were measured in 117 patients with chronic LBP and 85 healthy normal controls [HNCs] by means of lumbosacral radiography. In addition, association between LSAs, BMI and LBP was investigated.Results: There were no significant differences between patients and HNCs regarding LSAs and BMI. LLA was lower in male patients with LBP compared to male HNCs without LBP [p  0.013]. In addition, SIA [p  0.002] and BMI [p  0.006] were higher in female patients with LBP compared to male patients with LBP. It was found that an increase in LLA increased the risk of having LPB by approximately 1.04-folds [ranging from 1.01 to 1.08; p  0.045]. On the other hand, no association was found between LSAs and BMI.Conclusion: Changes in LSAs may cause LBP. An increase in LLA may be influential in increasing the risk of LBP. Therefore, measurement of LSAs may guide the physician who is to make clinical decisions in examination of patients with LBP.

Background Calprotectin is one of the major leukocyte S100 proteins showing both calcium binding and antimicrobial characteristics. The serum level of calprotectin is markedly elevated in patients with inflammatory bowel disease, rheumatoid arthritis, as well as systemic lupus erythematosus and has been suggested to play a prominent role in both progression and pathogenesis of these diseases.Aim The purpose of this study was to investigate the serum level of calprotectin in patients with ankylosing spondylitis (AS) and its association with disease activity and other clinical characteristics of AS.Materials and Methods Thirty-one patients who met the modified New York criteria for AS and 45 healthy controls were included in this study. Both Bath AS disease activity index and AS disease activity score were applied on the patients with AS for the assessment of disease activity; Bath AS functional index, for the assessment of functional activity; Bath AS radiology index, for the assessment of radiological damage; and the AS quality of life questionnaire for the assessment of disease-related life status. Spinal and hip measurements were performed using Bath AS metrology index. The serum level of calprotectin was determined using enzyme-linked immunosorbent assay kit.Results Mean serum level of calprotectin was significantly higher in the patients with AS compared with healthy controls (P= 0.003). Serum levels of calprotectin did not correlate with Bath AS disease activity index, AS disease activity score, Bath AS functional index, Bath AS radiology index, Bath AS metrology index, modified Schober, chest expansion, AS quality of life questionnaire, erythrocyte sedimentation rate, and C-reactive protein values (P> 0.05).Conclusions Our results suggest that calprotectin might play an important role in the pathogenetic mechanisms of AS; however, the calprotectin levels did not correlate with the measurements of disease activity, functional abilities, radiological damage, and the quality of life in these patients. Further insight into this area of research might provide opportunities to develop novel treatment strategies, which take into account the role of these peptides in the pathogenetic mechanisms of AS.

AbstractObjectives: To evaluate the 25-hydroxy vitamin D3[25OHD3] levels and the associated factors in patients with chronic nonspecific low back pain [LBP] in our region.Methods: Sixty patients diagnosed with chronic nonspecific LBP and a control group of 30 healthy subjects were enrolled. The demographic characteristics were recorded and the serum 25OHD3level was measured. The severity of the LBP was measured with a visual analog scale. Milk and dairy product consumption, fish consumption, dressing style, exposure to the sunlight, and physical activity levels of the individuals in each group were recorded. The quality of life was evaluated with the Short Form 36. Depression status was evaluated through the Beck Depression Inventory. The Oswestry Disability Scale was used for the functional assessment of the patient group.Results: The mean age of the patients was 30.58 ± 7.78 years and control group was 30.97 ± 6.70 years. The sun exposure and fish consumption were significantly higher in the control group. The scores from all the dimensions of the Short Form 36 [except for the mental health parameter] and Beck Depression Inventory were significantly lower in the patient group. The 25OHD3level was also significantly lower in the patient group. According to the Oswestry Disability Scale, the daily life of the patients was observed to be limited due to LBP.Conclusions: In the patients with chronic LBP [CLBP], 25OHD3level is lower than the healthy controls. In CLBP, increasing incidence of depression, deterioration in the quality of life, and serious functional impairment are observed. Vitamin D levels should be evaluated and any deficiency should be treated in patients with CLBP.

AbstractObjectives: The aim of this study was to determine the relationship between serum coenzyme Q10 [CoQ10] levels and symptoms of fatigue associated with fibromyalgia syndrome [FMS].Methods: Patients diagnosed with primary FMS and domographically matching healthy normal controls [HNCs] were sought to participate in the study. The total antioxidant status, total oxidative status, and CoQ10 levels were measured in blood samples from the patients and the controls.Results: A total of 40 patients with FMS and 30 HNCs were recruited. There were no statistically significant differences between the two groups in regard to C-reactive protein, mean erythrocyte sedimentation rate, mean age, and mean body mass index [p > 0.05]. The mean time from symptom onset to diagnosis for the FMS patients was 2.88 years, and the average number of tender points was 14. The serum CoQ10 levels were significantly lower in the FMS patients compared with the HNC group [p  0.000]. The serum total oxidative status and oxidative stress index levels were higher, and the serum total antioxidant status levels were lower in the FMS patients compared with those of the HNC group [p < 0.05]. The visual analog scale [VAS] pain scores and the VAS fatigue scores were significantly higher in the FMS group than in the HNC group [p  0.000]. The serum CoQ10 levels were negatively correlated with the mean Modified Fatigue Impact Scale scores [p  0.02, r  0.30], VAS pain scores [p  0.00, r  0.38], and VAS fatigue scores [p  0.03, r  0.28].Conclusions: The CoQ10 deficiency may contribute to the etiopathogenesis of FMS fatigue.

OBJECTIVE: To assess the frequency of juvenile onset ankylosing spondylitis (JOAS) in Turkish patients with AS and to compare with adult onset AS (AOAS) in a cross-sectional study design. METHODS: A total of 322 patients were recruited from the joint database of 5 university hospitals in eastern Turkey. RESULTS: Patients with JOAS (n = 43, 13.4%) had significantly longer diagnostic delay (9.21 vs 5.08 yrs), less severe axial involvement and more prevalent uveitis (OR 2.92, 95% CI 1.25–6.79), and peripheral involvement at onset (OR 3.25, 95% CI 1.51–6.98, adjusted for current age; and OR 2.26, 95% CI 1.07–4.76, adjusted for disease duration). Patients with AOAS had higher radiographic scores and more restricted clinimetrics but similar functional limitations and quality of life. CONCLUSION: JOAS and AOAS had distinctive courses and Turkish patients with AS had similar features compared to other Caucasian patient populations.

The purpose of this study was to determine the demographic and epidemiological characteristics of traumatic spinal cord-injured patients.

The objectives of this study were to assess the relationship between physical impairment and disability during stroke rehabilitation and to determine the effect of cognitive functions on physical impairment during rehabilitation. Prospectively collected data from stroke patients admitted for rehabilitation were compared at admission and at discharge by the Chedoke–McMaster Stroke Assessment (the Chedoke Assessment) impairment inventory and subscores of the Functional Independence Measure (FIM). The Chedoke Assessment was used to measure physical impairment in the lower extremities and the FIM was used to measure physical disability; motor and cognitive subscales of the FIM instrument were also evaluated. Although stroke-related impairment and motor FIM were significantly correlated with each other, cognitive measures on the FIM at discharge were not correlated with motor impairment, although cognitive disability was slightly improved. It is possible that dependency in physical activities of daily living and walking after stroke are mostly affected by degree of motor impairment.

Abstract:  As data on the relationship between parity and bone mineral density often seem to be controversial, ultimately, a comprehensive research study was thought to be necessary. This study focused on examining the influence of the number of pregnancies on bone mineral density and investigating the relationship between pregnancy and bone mineral density at four sites in postmenopausal women of different age groups. A total of 509 postmenopausal women, varying from 45 to 86 years of age (mean age of 60.85 � 7.53 years) were considered for the study. A standardized interview was employed to obtain information on demographics, lifestyle, and, reproductive and menstrual histories. Patients were separated into four groups according to the number of pregnancies, i.e., nulliparae (52 patients), one to two parity (66 patients), three to five parity (178 patients), and more than five parity (213 patients). The patients were further classified into two age groups, 40–59 years (233 patients) and 60–80 years (276 patients), respectively. The number of pregnancies was found to range from 0 to 17 (with an overall mean of 5.42 � 3.68), with 4.29 � 2.74 (range, 0–16) accounting for live births, while 1.02 � 1.53 (range, 0–14) were abortions. There were no significant differences among the groups with respect to parameters such as, age, body mass index (BMI), age at menarche, age at menopause, and years since menopause (P > 0.05) in all of the 509 women and in the 40- to 59- and 60- to 80-year groups. When all the patients were considered, the bone mineral density (BMD) values of the spine and the trochanter for the more-than-five-parity group, were found to be significantly lower than those of the other groups (P < 0.05), while the BMD values of the spine and the femur (neck, trochanter) appeared to decrease with increasing parity. In the 40- to 59-year group, the BMD of the spine in both the nulliparae and one-to-two-parity groups was significantly higher than that of the more-than-five-parity group (P < 0.05). No significant differences were found among the groups with respect to the BMD values at any femur sites. The nulliparae patients in the 60- to 80-year group exhibited significantly higher trochanter and Ward's BMD values than those of the more-than-five-parity group (P < 0.05), whereas in the one-to-two-parity group, spine BMD values appeared to be significantly higher than those of the more-than-five-parity group (p < 0.05). Significant correlations were found between the number of pregnancies and BMD values for the spine (r = −0.23; P < 0.01), trochanter (r = −0.16; P < 0.01), and Ward's triangle (r = −0.14; P < 0.05), with no significant correlation for femur neck BMD (r = −0.08; P > 0.05) values. In conclusion, the present study suggests that the number of pregnancies has an effect on the BMD values and that this situation shows a variation in different age groups. In addition, our study indicates that there is a significant correlation between the number of pregnancies and the spine, trochanter, and Ward's triangle BMD, but there is no correlation for the femur neck BMD.

Abstract.:  The purpose of this study was to investigate the associations of tooth loss with skeletal bone mass, years since menopause, educational level, current smoking status, dietary calcium intake, and number of pregnancies in postmenopausal osteoporotic women in Turkey. The study population consisted of 1171 postmenopausal women aged 40–86 years (mean age, 61.19 ± 7.28 years). A detailed history was obtained from all women, including relevant lifestyle parameters, risk factors, and measurements of weight and height. Women were separated into three groups according to the number of teeth remaining as group 1 (edentulous, 457 women), group 2 (10 or fewer teeth, 232 women), and group 3 (more than 10 teeth remaining, 482 women). There was no significant difference among the three groups in mean age and menopausal age (P < 0.05). Body mass index of group 1 was significantly higher than that of group 2 (P < 0.01). Educational level was significantly different between three groups: groups 1 and 2 (P < 0.001), groups 1 and 3 (P < 0.0001), and groups 2 and 3 (P < 0.001). Educational level was lowest in group 1 and highest in group 3. Despite a low ratio of cigarette smoking in general, a smoking habit was most prevalent in group 3 and least in group 2. The ratio of women receiving adequate calcium was significantly lower in group 1 than in other groups (P < 0.001); mean calcium intake was similar in all groups. The number of pregnancies was significantly higher in group 1 than in other groups (P < 0.001). Lumbar bone mineral density (BMD) of group 1 was significantly lower than that of groups 2 and 3 (P < 0.001). Although no significant difference was found between groups 1 and 3, femoral neck BMD of group 2 was less than in others, and differences between groups 1 and 2 and between groups 2 and 3 (P < 0.001) were significant. Lumbar bone mineral content (BMC) of group 1 was significantly lower than that of groups 2 and 3 (P < 0.001), and lumbar BMC in group 2 was significantly higher than in group 3 (P < 0.05). Femoral neck BMC in group 1 was significantly higher than in groups 2 and 3 (P < 0.001). In conclusion, lumbar BMD and BMC in the edentulous group were significantly lower, whereas femoral neck BMD and BMC were significantly higher in edentulous group compared with the others. Our findings indicated that improvement in lifestyle factors and nutritional strategies for the treatment and prevention of osteoporosis may have additional benefit in reducing tooth loss.

OBJECTIVE: Fibromyalgia (FM) is a chronic, painful musculoskeletal disorder characterized by widespread pain, pressure, hyperalgesia, morning stiffness, and an increased incidence of depressive symptoms. The etiology, however, has remained elusive. The aim of the present study was to examine the inflammatory response system in FM and to investigate the effect of depression level on serum cytokines. METHODS: Serum interleukin-1 (IL-I), IL-2 receptor (IL-2r), IL-6, and IL-8 and the Hamilton Depression Rating Scale (HDRS) score were determined in 32 healthy volunteers and in 81 patients with FM, classified according to the American College of Rheumatology criteria. RESULTS: In our study, serum IL-1 and IL-6 were not statistically significant, but serum IL-8, IL2r, and HDRS score were significantly higher in patients with FM than the control group (p < 0.01). In addition, in patients with FM, IL-8 was found to be related to pain intensity (r = 0.35; p < 0.01). CONCLUSION: IL-8 may play an important role in the occurrence of pain in FM.

Abstract.: The physiologic role of calcitonin in mineral and bone homeostasis is not very well understood. Very few longitudinal studies have reported the effects of calcitonin therapy on trace minerals in postmenopausal osteoporosis despite the documented involvement of trace minerals in normal skeletal metabolism. Several trace minerals, particularly magnesium (Mg) and zinc (Zn), essential for organic bone matrix synthesis have been known for at least three decades. The present study was designed to determine whether the mineral profile was different between 70 osteoporotic and 30 nonosteoporotic postmenopausal women and to evaluate the efficacy of calcitonin therapy for 6 months on these trace minerals in postmenopausal osteoporotic women. In our study, the serum values of Mg, copper (Cu), and Zn (P < 0.05) were significantly lower in the patient group than those in the control group. After 3 months of treatment, serum Cu, Zn, and Mg levels did not differ between the patients and controls, and this situation has continued after the end of 6 months of therapy. Serum Cu, Zn, and Mg levels increased consistently during the 6-month treatment period. The higher levels of serum Mg in the 3rd and 6th months of therapy were found to be statistically significant compared to those before treatment (P < 0.05). Serum Cu and Zn levels were found to be significantly higher at all measurements during the treatment period as well as at the end of therapy (P < 0.05). These results suggest that (1) calcitonin therapy regulates Mg, Cu, and Zn levels in postmenopausal osteoporosis; (2) when serum calcium and phosphorus were normal in postmenopausal osteoporosis, serum Mg, Cu, and Zn were more useful for evaluation; and (3) further studies are essential to evaluate the role of dietary composition on the manifestations of osteoporosis.

Background: C-reactive protein (CRP) is often normal in patients with psoriatic disease. Herein, we aimed to define markers of systemic inflammation in patients with monomorphic and polymorphic psoriatic skin, entheseal, and joint disease. Methods: Three-step approach: (i) selection of serum markers elevated in psoriatic arthritis compared healthy controls from a panel of 10 different markers reflecting the pathophysiology of psoriatic disease; (ii) testing of these selected markers as well as C-reactive protein (CRP) in a larger cohort of 210 individuals- 105 healthy controls and 105 patients with psoriatic disease with either monomorphic skin (S), entheseal (E) or joint (A) involvement or polymorphic disease with various combinations of skin, entheseal and joint disease (SE, SA, EA, SEA); (iii) testing whether tumor necrosis factor (TNF) and interleukin (IL)-17 inhibitor therapy normalizes these markers. Results: CRP was not elevated or was rarely elevated in the subgroups (S 0%, E 0%, A 20%, SE 7%, SA 33%, EA 27%, SEA 33%) despite active psoriatic disease. In sharp contrast, beta-defensin 2 and lipocalin-2 levels were elevated in the majority of patients with monomorphic skin (93% and 73%) and entheseal (both 53%), but not joint disease (27% and 20%). Conversely, elevations of calprotectin and IL-8 were found in the majority of patients with monomorphic joint disease (both 73%). IL-22 was elevated in all three monomorphic disease manifestations (S 60%, E 46%; A 60%). Furthermore, the vast majority of patients with polymorphic psoriatic disease (SE, SA, EA, SEA) showed widespread marker elevation. IL-17- and TNF inhibitor treatment significantly lowered all 5 markers of inflammation in PsA patients. Conclusions: Systemic inflammation is detectable in the majority of patients with psoriatic disease, even if CRP is normal. The respective marker pattern depends on the manifestation of psoriatic disease with respect to skin, entheseal, and joint involvement.

We investigated abnormalities of the hypothalamic–pituitary–gonadal axis and cortisol concentrations in women with fibromyalgia and chronic fatigue syndrome (CFS) who were in the follicular phase of their menstrual cycle, and whether their scores for depressive symptoms were related to levels of these hormones. A total of 176 subjects participated – 46 healthy volunteers, 68 patients with fibromyalgia, and 62 patients with CFS. We examined concentrations of follicle-stimulating hormone, luteinizing hormone (LH), estradiol, progesterone, prolactin, and cortisol. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). Cortisol levels were significantly lower in patients with fibromyalgia or CFS than in healthy controls (P< 0.05); there were no significant differences in other hormone levels between the three groups.