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LetterCorrespondence

Dr. Solmaz, et al reply

Dilek Solmaz, Sibel Bakirci, Lihi Eder, Johannes Roth and Sibel Zehra Aydin
The Journal of Rheumatology April 2021, 48 (4) 619-620; DOI: https://doi.org/10.3899/jrheum.201431
Dilek Solmaz
1Faculty of Medicine, Division of Rheumatology, University of Ottawa, Ottawa;
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Sibel Bakirci
1Faculty of Medicine, Division of Rheumatology, University of Ottawa, Ottawa;
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Lihi Eder
2Women’s College Research Institute, Women’s College Hospital and the Department of Medicine, University of Toronto, Toronto;
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Johannes Roth
3University of Ottawa, Chief, Division of Pediatric Dermatology and Rheumatology, Children’s Hospital of Eastern Ontario, Ottawa;
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Sibel Zehra Aydin
4Faculty of Medicine, Division of Rheumatology, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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  • For correspondence: saydin@toh.ca
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To the Editor:

We sincerely thank Dr. Masi, et al for their comments in response to our manuscript, “Entheseal Changes in Response to Age, Body Mass Index and Physical Activity: An Ultrasound (US) Study in Healthy People”1,2. Our study had demonstrated that US changes within the enthesis are associated with older age, higher BMI, physical activity, and male sex. As seen in Figure 1 of the original manuscript, the slope of the US scores are different for patients younger and older than 50 years old; therefore, Masi, et al suggested looking at these subgroups separately in detail2.

In Table 1, we have provided the multiple regression analysis for US scores of patients who are < and ≥ 50 years old. While we acknowledge that the sample sizes for these subgroups are rather small (48 and 27, respectively), with correspondingly low power to detect statistical significance, we do believe that they lend support to Masi, et al’s hypothesis2 that the effect of biomechanical factors contributing to enthesitis may change with age. In particular, all 3 models found the effects of BMI to be higher in the older group than in the younger (Table 1). Looking in further detail, in the younger population, the entheseal changes were mostly seen as signs of damage, that was linked to high physical activity and male sex, with borderline significance for the latter. In the elderly, both inflammatory changes were observed within the entheses as well as features of damage being linked to some of the investigated factors. More specifically, age and BMI were found to increase the inflammatory changes on US in the elderly, and damage was again increased with BMI, although to a lesser degree.

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Table 1

Multivariate regression results of factors affecting ultrasound scores, according to subgroups of younger (< 50 yrs) and older (≥ 50 yrs) age.

Our group has previously shown that patients with osteoarthritis (OA) may have similar features of enthesitis as patients with spondyloarthritis (SpA), which may explain the remarkable increase in the US scores after the age of 50 years3. Only 8 patients in our sample had clinically detectable OA. Upon repeating our analysis excluding these participants, we observed the same pattern of effects with the same factors achieving statistical significance. Degeneration is likely to increase after the age of 50, which may not always lead to clinical symptoms of OA. Standard screening with radiographs in the elderly may therefore lead to a higher prevalence of OA than clinical tools. In our study, radiographs were not performed to diagnose OA and therefore it is possible that there may have been some subclinical OA in the participants.

We appreciate the guidance that Masi, et al2 had provided regarding the potential use of multivariate adaptive regression spline (MARS) modeling to explore complex interactions in this setting, but this approach will require a larger sample size. We plan to collect more data and hope to present a more robust and nuanced analysis in a future manuscript.

In conclusion, our results indicate that age, BMI, physical activity, and sex affect the inflammation and damage scores on entheseal US, but the relationship is likely complex and changes with advanced age. Further work is clearly required to gain a full understanding of the biology of healthy entheses with a larger sample size and how it responds to biomechanical stress, and how this relates to the pathogenesis of SpA.

ACKNOWLEDGMENT

We appreciate the further statistical guidance provided by Tim Ramsay and Dr. Al Masi.

  • Copyright © 2021 by the Journal of Rheumatology

REFERENCES

  1. 1.↵
    1. Bakirci S,
    2. Solmaz D,
    3. Stephenson W,
    4. Eder L,
    5. Roth J,
    6. Aydin SZ
    . Entheseal changes in response to age, body mass index, and physical activity: an ultrasound study in healthy people. J Rheumatol 2020;47:968-72.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Masi A,
    2. Andonian B,
    3. van der Heijde D
    . Biomechanical factors may be the main contributor to entheseal changes in normal adults. J Rheumatol 2021;48:618-19.
    OpenUrlFREE Full Text
  3. 3.↵
    1. Yumusakhuylu Y,
    2. Kasapoglu-Gunal E,
    3. Murat S,
    4. Kurum E,
    5. Keskin H,
    6. Icagasioglu A,
    7. McGonagle D, et al.
    A preliminary study showing that ultrasonography cannot differentiate between psoriatic arthritis and nodal osteoarthritis based on enthesopathy scores. Rheumatology 2016;55:1703-4.
    OpenUrlCrossRefPubMed
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Dr. Solmaz, et al reply
Dilek Solmaz, Sibel Bakirci, Lihi Eder, Johannes Roth, Sibel Zehra Aydin
The Journal of Rheumatology Apr 2021, 48 (4) 619-620; DOI: 10.3899/jrheum.201431

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Dr. Solmaz, et al reply
Dilek Solmaz, Sibel Bakirci, Lihi Eder, Johannes Roth, Sibel Zehra Aydin
The Journal of Rheumatology Apr 2021, 48 (4) 619-620; DOI: 10.3899/jrheum.201431
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