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Objectives: To investigate the risk of flare-ups after COVID-19 vaccination in patients with rheumatic disease. Methods: A total of 1,617 patients with rheumatic diseases were identified from three rheumatology clinics. Patients were interviewed for demographic data, disease activity, and vaccination status. Disease flare-up was determined clinically by independent rheumatologists. Change of serum markers and medications were retrieved from medical records. The risk of exacerbation of rheumatic disease, change in serum markers, and escalation of rheumatic medications between vaccinated and nonvaccinated patients were determined using Cox, linear, and logistic regression models, respectively. Possible confounding factors were also taken into consideration. Results: Among 562 (34.76%) patients who received COVID-19 vaccination, rheumatic disease (HR = 2.10, [Formula: see text] 0.001), inflammatory arthritis (HR = 2.71, [Formula: see text] 0.001), rheumatoid arthritis (RA) (HR = 2.03, [Formula: see text] = 0.002), spondyloarthritis (SpA) (HR = 4.78, [Formula: see text] 0.001), autoimmune disease (HR = 1.77, [Formula: see text] = 0.01), and systemic lupus erythematosus (SLE) (HR = 1.99, [Formula: see text] = 0.02) were associated with postvaccination clinical flare-up. Adult Still’s disease (B = 12.76, [Formula: see text] = 0.03) was associated with increased serum C-reactive protein (CRP). No association was found between vaccination and escalation of rheumatic medication. Subgroup analyses showed that only the mRNA vaccine was associated with flare-ups. Conclusion: COVID-19 vaccination was associated with minor disease flare-up but not escalation of rheumatic medications. In the absence of absolute contraindications, COVID-19 vaccination is recommended in patients with rheumatic disease. KEY MESSAGES 1. Vaccination is effective in the prevention of morbidity due to COVID-19 in patients with autoimmune diseases. 2. The mRNA vaccine was associated with mild rheumatic disease flare-up. 3. Inactivated virus vaccine is preferable to mRNA vaccine in patients with active autoimmune disease.

Axial spondyloarthritis (SpA) is a spectrum of inflammatory conditions predominantly involving the spine and sacroiliac (SI) joints. The development of biological therapies has revolutionized the treatment paradigm in SpA. This has led to a great improvement in clinical outcomes, including inflammation suppression, symptom alleviation, and functional improvement. Despite its usefulness, the question regarding the optimal duration of therapy remains unanswered. This is particularly important given the cost associated with biological therapies, and the potential side effects related to immune suppression. Currently, guideline and data regarding dose reduction of biologics treatment in axial SpA has not been well established. This randomized controlled trial aims to study the possibility of biologic dose reduction in patients with axial SpA. The primary measure will be the occurrence of disease flare up in participants undergoing biologics tapering compared with participants on standard dose of treatment. The study also aims to evaluate the role of anti-drug antibodies in disease flare, the effect of biologics dose reduction on structural changes, and the cost effectiveness of biologics dose reduction. The results of this study will be crucial for clinical decisions and establishing future guidelines regarding dose reduction of biologics in SpA.

Introduction: To investigate the relationship between spondyloarthritis (SpA) and osteoporosis including any association or prediction, and hence suggesting a plan of screening and management for osteoporosis in SpA. Methods: 168 and 538 research articles with keywords “osteoporosis” and “spondyloarthritis” or “ankylosing spondylitis” conducted between 1990 and 2021 were collected in Medline and PubMed, respectively. Focused review was conducted in 34 articles. Results: Osteoporosis is a common comorbidity in both ankylosing spondylitis and spondyloarthropathy as suggested by multiple studies across different countries, with a reduction in bone mineral density (BMD) and altered bone microarchitecture in vertebrae and cortical bone of proximal femur, leading to an increased risk of vertebral fractures and sarcopenia. Associated factors include male sex, advanced age, long disease duration, high serum erythrocyte sedimentation rate (ESR), decreased femoral and lateral lumbar BMD, and high radiological indices. It is likely to be related to chronic systemic inflammation and immobility. Serum uric acid level, certain genes and antibodies may also contribute to the pathology. The likelihood of osteoporosis in SpA can be evaluated by trabecular bone score, which are negatively correlated with serum levels of ESR and C-reactive protein (CRP). Alendronate with adequate dietary intake of calcium and vitamin D is the recommended management. Conclusion: The prevalence of osteoporosis is higher in patients with SpA due to the chronic presence of pro-inflammatory cytokines, functional impairment, and steroid therapy. With the help of inflammatory markers, imaging and radiological indices, the risk of osteoporosis, and vertebral fractures can be predicted. The management plan should be modified to include prevention and treatment of osteoporosis.

The Hong Kong Society of Rheumatology (HKSR) has developed evidence-based position statements on the use of magnetic resonance imaging (MRI) in axial spondyloarthritis (axSpA). A special interest group (SIG) developed the statements based on the literature review of the following research questions: 1) In whom should SI joint MRI be done to diagnose axSpA? 2) Should spine MRI be performed for diagnosis of axSpA? 3) Should spine and SI joint MRI be used in the assessment and monitoring of disease activity? 4) Which MRI sequence(s) should be used in axSpA? These statements have at least 75% agreement from voting rheumatology fellows of HKSR, and are developed to serve as local practice guidelines for rheumatologists and musculoskeletal radiologists in the management of axSpA.

Objectives To assess the associations of hepatic injury and fibrosis in patients with psoriasis (PsO) and rheumatoid arthritis (RA). Methods A total of 318 patients attending dermatology and/or rheumatology out-patient clinics in Queen Mary Hospital, with clinical diagnosis of PsO, psoriatic arthritis (PsA) or RA were consecutively recruited from July 2020 to August 2022. Demographic data, comorbidities, and medications were recorded. Body mass index (BMI) was measured. Serum biomarkers for hepatic injury including autotaxin, matrix metalloproteinase (MMP) 3, MMP 8, and MMP 9 were determined. Transient elastography (TE) was performed to determine liver stiffness measure (LSM) and controlled attenuation parameter (CAP). Regression models were built to determine the association between methotrexate and leflunomide cumulative dosage, serum biomarkers and TE scores. Results A total of 67 (20.4%) patients had LSM>7.1 kPa. Multivariate linear regression showed methotrexate cumulative dosage was associated with autotaxin level (B=4.77, 95% CI 1.39; 8.15, p=0.001). There was no association between methotrexate cumulative dosage and MMP 3, MMP 8, MMP 9, LSM, CAP. There was also no association between leflunomide cumulative dosage and autotaxin, MMP 3, MMP 8, MMP 9, LSM, CAP. BMI (B=6.18, 95% CI 4.95; 7.41, p

Magnetic resonance imaging (MRI) of the spine is a frequent investigation for low back pain (LBP). Applications in axial spondyloarthritis (SpA) include diagnosis and assessment of disease activity. Sacroiliitis on MRI is a known diagnostic criterion. Other MRI lesions such as corner inflammatory lesions (CIL) and fatty corner lesions (FCL) may have potential roles in aiding diagnosis1,2 and in predicting the formation of syndesmophytes. Facet joint and costovertebral lesions are associated with limited spinal mobility and functional impairment3. Other lesions described include discovertebral lesions (DVL), Modic type I and II lesions. Identification of individual lesions helps rheumatologists to understand disease progression and guide treatment.

Objective To develop a deep learning algorithm for grading sacroiliitis based on SPARCC in magnetic resonance imaging (MRI). Method A total of 996 images with inflammatory lesions from 210 participants with MRI sacroiliitis were used for training and validation. The testing cohort consisted of 18 participants with and 19 without MRI sacroiliitis. One hundred and fifty four images from the testing cohort had inflammatory lesions identified by a pre-trained algorithm from our previous study[1]. The ground truth was defined by manually outlined regions of interests (ROIs) consisting of bone marrow edema (BME) at the sacroiliac joint. The performance of the deep learning pipeline in predicting the SPARCC score was compared to manual interpretation by two experienced readers. Result The intra-observer reliability and the Pearson coefficient between the SPARCC scores from two experienced readers and the deep learning pipeline were 0.83 and 0.86, respectively. The sensitivities in identifying all inflammatory lesions, deep lesions, and intense lesions were 0.83, 0.79 and 0.81, respectively. The Dice coefficients of the sacrum and ilium segmentation were 0.82 and 0.80, respectively. The accuracies of identifying the SI joint and reference vessel were 0.90 and 0.88, respectively. Conclusion The performance of AI algorithms in SPARCC scoring was compatible with manual scoring by experienced readers. This proposed deep learning pipeline could be the first demonstration of a complete and SPARCC-informed deep-learning approach in scoring STIR images in SpA.

Uveitis is the most common ophthalmological disorder in the field of rheumatology, accounting for a significant proportion of visual morbidity, both locally and internationally. Causative factors can be divided into infectious and noninfectious etiologies. The diagnosis of uveitis is a major challenge due to heterogeneity in presentation. The disease course may be acute monophasic, recurrent, or chronic relapsing. Complications include posterior synechiae, secondary cataract, ocular hypertension or glaucoma, macular edema, retinal vascular occlusion, epiretinal membrane, and so on, and ultimately visual loss. Antimicrobial therapy is indicated for infection, whereas noninfectious uveitis warrants a combination of steroids, immunosuppressives, and anti-inflammatory agents. With the advancement of biologics, treatment strategies in chronic, noninfectious uveitis have had multiple breakthroughs, particularly in treatment-resistant cases. This article provides a review of the diagnostic approach to uveitis based on symptomatology and ophthalmological findings, and discussion of relevant treatment modalities and strategies.

Recombinant human granulocyte colony-stimulating factor (G-CSF) is commonly used to accelerate recovery of neutropenia in patients with marrow suppression. We hereby report a patient with systemic lupus erythematosus (SLE) who developed diffuse lupus nephritis and impending cytokine storm after G-CSF therapy. The exact mechanisms by which G-CSF leads to lupus flares remains enigmatic. Increased neutrophil apoptosis and release of cytokines have been postulated. The use of G-CSF in patients with autoimmune disease should be cautious.

Abstract Objectives To compare the risk of five nonpulmonary infections leading to hospitalization between spondyloarthritis (SpA) and nonspecific back pain (NSBP), and to identify the risk factors. Methods A total of 3018 patients with SpA and 2527 patients with NSBP were identified. Data from December 1995 to June 2019 was retrieved from a centralized electronic medical record system. The date of onset of five types of nonpulmonary infections including: urinary tract infection (UTI), skin infection, gastroenteritis (GE), septic arthritis, and pancreato‐hepatobiliary tract infection were identified. Demographic data, comorbidities, and medications used were also retrieved. Comparative risk of each type of infection between SpA and NSBP was determined using propensity score adjustment method. Cox regression model was used to identified risk factors. Results Patients with SpA were younger in age, predominantly male, with fewer comorbid diabetes mellitus (DM), renal impairment, and depression. Compared with NSBP, patients with SpA had higher risk of UTI (hazard ratio [HR] 1.91; p 6 months (HR 2.22; p

Immune checkpoint inhibitors (ICIs) have forged a new direction for the treatment of cancer. However, ICIs – programmed cell death protein 1 (PD-1), programmed death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors – are also known to cause immune-related adverse events (irAEs). Rheumatological adverse events are uncommon and often low grade, but flares of underlying rheumatological diseases may be triggered. Guidelines are available for the effective management of the rheumatological adverse events that more frequently arise from the use of ICIs, such as inflammatory arthritis, inflammatory myopathies, Sjogren syndrome, scleroderma, and polymyalgia rheumatica and eosinophilic fasciitis.

Abstract Introduction To investigate the vaccination rate, reported side effects, and patient concerns for COVID‐19 vaccination in patients with rheumatic diseases. Methods A multicentre cross‐sectional study from rheumatology clinics in two major hospitals in Hong Kong was conducted between June 3, 2021 and October 8, 2021. Patient interviews for demographics, clinical characteristics, vaccination status, reported side effects, and factors influencing decisions about vaccination were supplemented with structured questionnaires. Results Out of 1367 patients, 413 (30.2%) had received COVID‐19 vaccination. Side effects were reported in 335 (81.1%) of patients, of which the most common were injection site pain or swelling (66.3%), fatigue (57.1%), fever (19.9%), and headache (19.6%). Multivariate logistic regression models showed that males (odds ratio [OR] = 1.80; p

Introduction: To study the dose-response relationship between smoking and axial Spondyloarthritis (axSpA) disease outcome. Method: One hundred and sixty participants with axSpA were recruited from a single rheumatology center. All of them fulfilled the classification criteria for axSpA by the Assessment of SpondyloArthritis International Society (ASAS). Clinical, demographic and biochemical data was collected. Participants were asked for detailed smoking histories including past and current smoking, smoking duration and quantity. Radiographs of cervical and lumbar spine were performed for modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and modified New York (MNY) criteria for radiological sacroiliitis. Ankylosing Spondylitis Disease Activity Score (ASDAS) was calculated based on C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Univariate and multivariate regression models were performed to determine the associations between pack-year smoking and different disease outcomes. Results: Among the participants, 62 (38.7%) were either current (N = 39) or former smokers (N = 23). Ex-smokers quit smoking by 18.8 ± 12.4 years. The mean pack-year for patients who had ever smoked was 19.4 ± 23.1. In univariate analyses, pack-year smoking was associated with BASFI (p

Objective: To investigate the associations between age and clinical and radiological disease activities in axial SpA. Methods: One hundred and twenty-one patients fulfilling the Assessment of SpondyloArthritis International Society Classification Criteria for axial SpA were included in analyses. Patient demographics, disease activity and radiographic scores, as well as magnetic resonance imaging (MRI) with diffusion weighted imaging derived apparent diffusion coefficient values (DWI(ADC)), were compared between patients aged > 40 and ≤ 40 years at a cross-sectional level. Variables with significant differences in univariate analyses were used as dependent variables in multivariate linear regression models adjusted for potential confounding/contributing factors. Results: Multivariate analysis showed that increasing age was significantly associated with higher Bath Ankylosing Spondylitis Functional Index (B = 0.04, p < 0.01) and Bath Ankylosing Spondylitis Metrology Index scores (B = 0.04, p < 0.01); as well as higher modified Stoke Ankylosing Spondylitis Spine Score (B = 0.41, p < 0.01). On MRI, increasing age was associated with a lower DWI(ADC) (B = (-0.01), p < 0.01) of the SI joints, but higher DWI(ADC) values of the axial spine (B = 0.01, p = 0.01). Conclusion: Increasing age in SpA was associated with greater functional impairment and structural damage, more inflammation of the axial spine, but less inflammation of the SI joints. Our findings are consistent with the traditional belief that SpA is an “ascending disease” and highlights the importance of different modalities of MRI in the diagnosis and disease monitoring of SpA.

We report a 49-year-old lady with ulcerative colitis (UC) who subsequently developed systemic lupus erythematosus (SLE) ten years later. By reviewing the drug history and serum autoimmune panel, we hypothesize that systemic lupus erythematosus may occur in a patient with a history of inflammatory bowel disease as a coexisting disease, or triggered by drugs used in inflammatory bowel disease, such as disease-modifying anti-rheumatic drugs (DMARDs). This case raises the discussion that patients with Inflammatory bowel disease (IBD) may have a genetic predisposition for developing other autoimmune diseases, and explores the possibility of drugs used in the treatment of IBD as a trigger for SLE development. Being able to differentiate the two has important implications in management and prognosis.

Background This analysis aimed to evaluate the extent of treat-to-target (T2T) achievement after 1-year intensive treatment in patients enrolled to the APLAR SpA registry. Methods Patients who fulfilled the CASPAR2006 for psoriatic arthritis (PsA), and 2009ASAS criteria for axial spondylitis (AxSpA) were recruited. Current analysis included the first 143 patients reaching the 1-year timepoint across 7 Asia-Pacific regions (Hong Kong, Singapore, Korea, India, Pakistan, Qatar and Thailand). Results 79 patients with PsA(age: 52±13 years, 43(55%) male, disease duration: 8.0±8.3 years) and 64 patients with AxSpA (age:41±16 years, 48(75%) male, disease duration: 4.8±7.2 years) were included. There were significant improvement in Disease Activity in Psoriatic Arthritis (DAPSA) (22.1±14.4 at baseline vs 11.5±10.0 at 1-year, p

Background: Studies have reported that female patients with spondyloarthritis have different disease courses and treatment responses compared to male patients. Whether patients’ sex is associated with a different outcome after receiving one-year of tight control, treat-to-target (T2T) strategy remains uncertain. Thus, this study aimed to evaluate the differences in the clinical response between male and female patients from the APLAR SpA Registry. Methods: Patients who fulfilled the CASPAR 2006 classification criteria for PsA and 2009 ASAS classification for axSpA were recruited. They received 1 year of protocolized treatment aiming at 1) MDA or DAPSA-LDA for PsA patients, and 2) ASDAS-LDA for axSpA patients. Patients were assessed every 3-monthly and treatment was escalated if target was not reached. Results: Ninety-one male (age: 45.6±16.1, 43 PsA, 48 axSpA) and 52 female (age: 49.2±13.4, 36 PsA, 16 axSpA) patients were included. There was no significant difference between the 2 sexes at baseline, except a higher ESR and more severe enthesitis in female patients. During the study period, the use of csDMARDs and NSAIDs decreased slightly, whilst the use of bDMARDs significantly increased across both sexes (Fig. 1a). Considering the whole cohort, there were significant improvement in disease activity in PsA after 1-year and disease activity in axSpA remained low. Despite similar bDMARDs use at 1-year, female PsA patients had a lower MDA achievement rate (36% in female vs 51% in male). Female patients also remained to have a higher physician global assessment score (2.61±1.76 in female vs 1.98±1.57 in male, p=0.03), greater functional impairment (HAQ: 0.54±0.57 in female vs 0.32±0.46 in male, p=0.01) and more severe enthesitis (SPARCC: 0.83±1.67 in female vs 0.16±1.09 in male, p=0.005) at 1-year. There was also a trend of higher perceived disease burden and peripheral involvement in female (Fig. 1b). Conclusion: There may be differential treat-to-target responses between male and female SpA patients. The causes of such differential characteristics should be further explored to potentially implement a sex-specific treat-to-target strategy for spondyloarthritis.