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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.

Background/ objectiveTuberculosis (TB) is one of the most infectious comorbidities in spondyloarthritis (SpA). Our goals were to determine the crude incidence rate of and risk factors for TB in SpA.MethodClinical data of 2984 patients with SpA from 11 rheumatology centres were reviewed. This included demographics, duration of follow-up, comorbidities including diabetes, chronic kidney disease, chronic heart disease, chronic lung disease, stroke and malignancies, date of diagnosis of tuberculosis, use of non-steroidal anti-inflammatory drugs, duration of glucocorticoid therapy for more than 6 months, conventional (cDMARD) and biological (bDMARD) disease modifying anti-rheumatic drug therapies. Crude incidence rates were reported. Cox regression models were used to determine the risk factors for TB in patients with SpA.ResultsForty-three patients had TB, of which 4 (9.3%) were extra-pulmonary. The crude incidence rate of TB was 1.57 in patients with SpA, compared with 0.58 in the general population in Hong Kong. Independent risk factors identified from the multivariate Cox regression model were: alcohol use (HR 2.62;p = 0.03), previous TB (HR 13.62;p p = 0.004), duration of glucocorticoid therapy greater than 6 months (HR 3.25;p = 0.01) and infliximab therapy (HR 5.06;p p ConclusionIncidence of TB was higher in patients with SpA. Glucocorticoid therapy beyond 6 months and infliximab therapy increased the risk of TB. Rheumatologists should avoid prolonged use of glucocorticoids and consider DMARDs other than infliximab in the treatment of at-risk patients.

Background: Cardiovascular (CVS) diseases are the leading cause of death worldwide and patients with rheumatic diseases have an increased CVS. CVS risk factors and CVS events are common in spondyloarthritis (SpA). Delineating the CVS risk in patients with SpA and identifying modifiable risk factors would be useful. Methods: Patients with SpA and patients with non-specific back pain (NSBP) were identified in rheumatology and orthopedics clinics, respectively. Clinical information and CVS events were retrieved. Baseline characteristics and incidence rates of CVS events were compared between two groups of patients using an age- and sex-matched cohort. Propensity score adjustment and Cox regression analysis were performed to determine the CVS risk associated with SpA. Results: A total of 5046 patients (SpA 2616 and NSBP 2430) were included from eight centers. Over 56,484 person-years of follow up, 160 strokes, 84 myocardial infarction (MI) and 262 major adverse cardiovascular events (MACE) were identified. Hypercholesterolemia was more prevalent in SpA (SpA 34.2%, NSBP 28.7%, p Conclusion: SpA is an independent CVS risk factor. Anti-tumor necrosis factor (TNF) drugs were associated with a reduced CVS risk in these patients.

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 [Formula: see text] 39) or former smokers (N [Formula: see text] 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 Conclusion: In Chinese axSpA patients, pack-year smoking was independently associated with poorer functional status, worsened spinal mobility and more radiological damages. Smoking cessation should be encouraged in patients with axSpA.

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 [Formula: see text] 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.

Aims: To compare the risk of community-acquired pneumonia (CAP) requiring hospitalization in spondyloarthritis (SpA) and non-specific back pain (NSBP), and to identify the risk factors for CAP in SpA. Methods: A total of 2984 patients with SpA from 11 rheumatology centers and 2526 patients with NSBP from orthopedic units were reviewed from the centralized electronic database in Hong Kong. Incidence of CAP requiring hospitalization and demographic data including age, gender, smoking and drinking status, use of sulfasalazine, individual biological-disease modifying anti-rheumatic drugs (DMARDs) used, micro-organisms, other immunosuppressants or immunosuppressive states, use of steroid for more than ½ year, and co-morbidities were identified. Risks of CAP in SpA were compared with those in NSBP using propensity score regression method. Multivariate Cox regression model was used to identify the risk factors in SpA. Results: CAP requiring hospitalization was found in 183 patients with SpA and 138 patients with NSBP. Increased risk for CAP was found in the following groups with SpA: all subgroups (hazard ratio (HR) 2.14, p Conclusion: Risk of CAP is increased in patients with SpA. Our data favor universal influenza and pneumococcal vaccination programs in the population. Rheumatologists should also advise smoking cessation and avoid long term steroid therapy.

Background Spondyloarthritis (SpA) has a significant impact on patients’ quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for cost-utility analysis of health care interventions and calculation of quality-adjusted life-years. It has been validated in patients with SpA. However, its responsiveness property is unclear. Hence, the aim of study is to test the responsiveness properties of the EQ-5D health measure for Chinese patients with SpA. Methods Prospective and consecutive recruitment of 151 Chinese patients with SpA was conducted with follow-up assessments 6 months later. Demographic data including smoking and drinking habits, education level, income and occupation was collected. Disease-associated data including disease duration, presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS), mental health (HADS) and the EQ-5D scores were recorded. Responsiveness was tested against the global rating of change scale (GRC) and changes in disease activity using BASDAI and ASDAS-CRP. Results A total of 113 (74.8%) patients completed the follow-up assessments. Most patients (61.6%) had low disease activity level with BASDAI Conclusions EQ-5D demonstrates satisfactory responsiveness property for assessment of changes in SpA disease activity. Level of evidence II

Objective The aim was to investigate the relationship between the intensity of spinal inflammation using the apparent diffusion coefficient (ADC) and radiographic progression in axial SpA. Methods This is a cross-sectional study of participants with axial SpA and back pain. Clinical, biochemical and radiological parameters were collected. The ankylosing spondylitis disease activity score (ASDAS)-CRP was determined. Radiographic progression was represented by the modified Stoke ankylosing spondylitis spine score (mSASSS). MRI with short tau inversion recovery (STIR) and diffusion-weighted imaging sequences were performed simultaneously. Inflammatory lesions on STIR were used for the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI indexes and as references in outlining regions of interest in ADC maps to produce mean (ADCmean) and maximal (ADCmax) ADC values. Univariate and multivariate linear regression analyses were used to determine independent associations between ADC and radiographic progression. Results The 84 participants with identifiable lesions on spinal ADC maps recruited were characterized by a mean (s.d.) age of 45.01 (13.68) years, long disease duration [13.40 (11.01) years] and moderate clinical disease activity [ASDAS-CRP 2.07 (0.83)]. Multivariate regression analysis using ADCmean as the independent variable showed that age (regression coefficient [B] = 0.34; P = 0.01), male sex (B = 0.25; P = 0.04) and ADCmean (B = 0.30; P = 0.01) were positively associated with mSASSS. Multivariate regression analysis using ADCmax as the independent variable showed a tendency for ADCmax to be associated with mSASSS (B = 0.21; P = 0.07). Conclusion The intensity of spinal inflammation as determined by ADC is associated with radiographic progression in participants with active axial SpA.

ObjectiveTo investigate the relationship between Ankylosing Spondylitis Disease Activity Score (ASDAS) and intensity of spinal inflammation measured by apparent diffusion coefficient (ADC) in MRI in participants with active axial spondyloarthritis (SpA).MethodsParticipants with axial SpA and back pain were recruited. Clinical, demographic, biochemical and imaging data were collected. ASDAS was calculated based on C reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Inflammatory lesions were identified in short tau inversion recovery images and the corresponding ADC maps to determine the maximum apparent diffusion coefficient (ADCmax), normalised maximum ADC, mean apparent diffusion coefficient (ADCmean) and normalised mean ADC by two independent readers. Spondyloarthritis Research Consortium of Canada (SPARCC) spine and sacroiliac (SI) joint MRI indexes were determined. Univariate and multivariate linear regression models were used to determine the associations between of ASDAS with ADC values, SPARCC spine and SI MRI scores.ResultsEighty-two participants had identifiable ADC lesions. Multivariate analyses using ADCmax and SPARCC spine MRI as independent variables showed associations with ASDAS-CRP (ADCmax: B=0.27, p=0.02; SPARCC: B=0.32, p=0.01) and ASDAS-ESR (ADCmax: B=0.24, p=0.03; SPARCC: B=0.36, pConclusionASDAS is associated with both the extent and the intensity of spinal inflammation in patients with detectable inflammatory lesions. Our results showed that ASDAS is an objective disease assessment tool.Trial registration numberHKUCTR-2087.

Background Spondyloarthritis (SpA) has a significant impact on patients’ quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for the cost-utility analysis of health care interventions and calculation of quality-adjusted life years. However, the applicability of the EQ-5D health measure in Chinese patients with SpA is currently unknown. Hence, the aim of the study is to test the psychometric properties and to validate the use of the EQ-5D health measure for utility analyses in Chinese patients with SpA. Methods Prospective and consecutive recruitment of 220 Chinese patients with SpA was conducted. Demographic data including smoking and drinking habits, education level, income, and occupation was collected. Disease-associated data including disease duration, the presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS, ODI), mental health (HADS depression and anxiety), and the EQ-5D scores were recorded. SF-36 scores were used to verify the findings. Baseline correlations were performed along with test-retest reliability, validity, and internal consistency tests. Specifically, the relationship between EQ-5D and disease activity and functional scores was studied. Results EQ-5D scores achieved acceptable internal consistency and reliability. A ceiling effect was observed for all domains of the EQ-5D except for pain/discomfort. No floor effect was observed. Significant negative correlations were observed between ODI, HADS, BASFI, BASMI, BASDAI, and ASDAS-CRP and with EQ-5D. A higher disease activity was well-differentiated by EQ-5D, as with the disability and mental health scores. Conclusions The EQ-5D demonstrates satisfactory psychometric properties for assessment of SpA patients. It has high utility for demonstrating changes in disease activity and disability.

Objectives To describe the clinical characteristics and the relations with disease activity, functional status, and syndesmophytes formation in patients with axial spondyloarthritis (AxSpA) by categorizing them into different groups. Methods One hundred and sixty three patients with AxSpA were recruited. Clinical and blood parameters were collected. Patients were asked to complete the self-assessment questionnaires, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Bath Ankylosing Spondylitis Functional Index (BASFI). Spinal mobility was measured according to Bath Ankylosing Spondylitis Metrology Index (BASMI). Radiographs of cervical and lumbosacral spine were performed for modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Radiological sacroiliitis was scored for ankylosing spondylitis (AS). Magnetic resonance imaging (MRI) of the sacroiliac (SI) joints was performed for spondyloarthritis research consortium of Canada (SPARCC) MRI inflammation score. Two-way cluster analyses were performed to determine the relationships between the parameters. Results Two cluster models were built using SPARCC scores of different scorers. Results were similar. The group of patients with highest mSASSS (20.33 vs 20.33) and prevalence radiological AS (85% vs 86%) were male patients (75% vs 75%), positive for HLA-B27 (70.0% vs 66.7%), smokers (87.5% vs 97.2%), and higher SPARCC SI joints score (5.32 vs 3.17). Higher BASDAI was observed among female sex. BASMI varies little but the group with highest BASMI (3.60 vs 3.62) also had highest mSASSS (20.33 vs 20.33). Conclusion Our data showed that male smokers with HLA-B27 positivity and SI joints inflammation have more radiological damage and higher prevalence of AS, consistent with known poor prognosis factors.

Background: The presence of ⩾3 corner inflammatory lesions has been proposed as the definition of a positive spinal magnetic resonance imaging (MRI) for axial spondyloarthritis (axSpA), but subsequent studies showed inconclusive findings. Our objective was to evaluate whether locations of corner inflammatory lesions (CILs) would affect the diagnostic utility of MRI in axSpA. Method: Two groups were consecutively recruited from eight rheumatology centers in Hong Kong. The ‘axSpA’ group included 369 participants with a known diagnosis of axSpA. The ‘non-specific back pain’ (NSBP) control group consisted of 117 participants. Clinical, biochemical, and radiological parameters were collected and all patients underwent MRI of the spine and sacroiliac joints. CILs were assessed based on their locations (cervical, thoracic or lumbar) to determine the optimal cutoff for diagnosis. Results: The cutoff of ⩾5 whole spine CILs (W-CILs) and ⩾3 thoracic spine CILs (T-CILs) had comparable specificity to MRI sacroiliitis. Of 85/369 axSpA patients without sacroiliitis on conventional radiograph or MRI, 7 had ⩾5 W-CILs and 11 had ⩾3 T-CILs. Incorporating the proposed cutoffs into Assessment of SpondyloArthritis international Society axSpA criteria, ⩾5 W-CILs and ⩾3 T-CILs had similar performance when added to the imaging criteria for sacroiliitis (sensitivity 0.79 versus 0.80, specificity 0.92 versus 0.91). Conclusion: Spinal MRI provided little incremental diagnostic value in unselected axSpA patients. However, in patients without sacroiliitis on MRI or radiographs, 8–13% might be diagnosed by spinal MRI. Thoracic and whole spine MRI had similar diagnostic performance using the proposed cutoff of ⩾5 W-CILs and ⩾3 T-CILs.