SAT0371 ARE ENGLISH-LANGUAGE VIDEOS ON YOUTUBE A USEFUL SOURCE OF INFORMATION FOR SPONDYLOARTHRITIS?

Background:

Spondyloarthritis (SpA) is a family of chronic inflammatory disorders. Social media, such as YouTube, is a popular online platform where patients often visit for information. However, the validity of the content uploaded onto YouTube is not known.

Objectives:

This study aimed to evaluate the content, reliability and quality of the most viewed English-language YouTube videos on SpA.

Methods:

Keywords “spondyloarthritis”, “spondyloarthropathy” and “ankylosing spondylitis” were searched on YouTube on October 7th, 2019. The top 270 videos were screened. Videos were excluded if they were irrelevant, in non-English language or if they had no audio. Total number of views, duration on YouTube (days), video length, upload date, number of likes, dislikes, subscribers and comments were recorded for videos. A modified 5-point DISCERN tool1and the 5-point Global Quality Scale (GQS) score2were used to assess the reliability and quality of the videos, with higher scores indicating greater reliability and quality respectively.

Results:

Two hundred of 270 videos were included in the final analysis [61.5% from healthcare professionals, 37.0% from patients, 1.5% from news channels]. Of the 200 videos, 15 were uploaded within the last year and 112 in the last five years. 120 (60%) were categorized as useful information (Group 1), 6 (3%) as misleading information (Group 2), 52 (26%) as useful patient opinion (Group 3) and 22 (11%) as misleading patient opinion (Group 4). Useful videos were mainly from healthcare professionals or patients (86%). Useful videos (Group 1 and 3) had higher median (IQR) number of subscribers [2700 (14700) vs 211 (457), p < 0.01], reliability scores [3 (1) vs 2 (1), p < 0.01] and GQS scores [3 (1) vs. 2 (1), p < 0.001] compared to misleading videos (Group 2 and 4), respectively.

Videos uploaded by healthcare professionals tended to have more useful information [94% (116 of 123) vs. 66% (49 of 74), p < 0.001] and had higher median (IQR) reliability scores [3 (1) vs 2 (1), p < 0.001] and GQS scores [3 (2) vs 2 (1), p < 0.001] compared to patient uploaded videos respectively. Of the 5 (out of 123) videos from healthcare professionals that had misleading information, it was because of outdated information on diagnosis (3 videos) and treatment (5 videos) of SpA. Of the 22 videos that had misleading patient opinion, 9 (41%) wrongly described the clinical features for SpA and 14 (64%) portrayed the current evidence based treatment options as ineffective and described alternative treatment plans (i.e. diet restrictions, complementary and alternative medicine).

Conclusion:

The majority of English language YouTube videos have useful information on the topic of SpA, however, 31% of patient opinions have inaccurate information on the clinical features and treatment options, and viewers need to be cognisant of these “fake news”.

References:

[1]Charnock D, Shepperd S, Needham G, Gann R (1999) DISCERN: an instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 53(2): 105-111

[2]Bernard A, Langille M, Hughes S, Rose C, Leddin D, Veldhuyzen van Zanten S (2007) A systematic review of patient inflammatory bowel disease information resources on the World Wide Web. Am J Gastroenterol 102(9):2070-2077

Disclosure of Interests:

Sakktivel Elangovan: None declared, Yu Heng Kwan: None declared, Warren Fong Consultant of: Abbvie, Janssen, Novartis, Speakers bureau: Abbvie, Janssen, Novartis

THU0569 PHYSICAL ACTIVITY IN AXIAL SPONDYLOARTHRITIS AND RHEUMATOID ARTHRITIS: A CROSS-SECTIONAL STUDY IN A SOUTH-EAST ASIAN COHORT

Background:

Axial spondyloarthritis (AxSpA) and rheumatoid arthritis (RA) are two common rheumatic diseases that can result in joint damage and deformities, leading to reduced physical function and quality of life. Physical activity (PA) and exercise have been shown to improve general well-being and reduce cardiovascular risk in patients with AxSpA and RA, and are part of the non-pharmacological management in the EULAR guidelines. Despite this, PA levels are reduced in AxSpA and RA patients1,2. In addition, it has also been reported that Asians have lower levels of PA3.

Objectives:

This study aims to examine the patterns of PA in a multi-ethnic Asian cohort.

Methods:

This was a cross-sectional study conducted between May 2016 and Jan 2017. Consecutive patients with AxSpA and RA were recruited at an outpatient rheumatology clinic at Singapore General Hospital, the largest tertiary hospital in Singapore. Controls were based on a previous cross-sectional study4. PA was assessed using the Global Physical Activity Questionnaires (GPAQ) developed by the world health organization (WHO)5.

Results:

74 AxSpA and 69 RA patients were recruited and compared to 886 controls. AxSpA patients were younger (median age [IQR], 37.0 [26.3] years) and predominantly male (75.7%), while RA patients were the oldest (median age [IQR], 59.0 [16.5] years) and predominantly female (81.2%). BMI was similar between all three groups. RA patients had more comorbidities (such as hypertension, hyperlipidemia, diabetes mellitus) compared to AxSpA patients and controls.

All three groups had similar proportion of participants meeting WHO recommendations for PA (AxSpA = 77.0%, RA = 79.7%, controls = 83.1%, p=0.35) and median (IQR) time (95% CI) of PA per day [60 (107.1) vs 57.9 (122.9) vs 51.4 (94.3), p=0.93). More AxSpA patients had a high level of sedentary activity compared to RA or controls (AxSpA = 56.8%, RA = 23.2%, controls = 7.2%, p < 0.01). When comparing AxSpA and RA patients with inactive disease or in remission versus active disease, levels of PA did not differ between the 2 groups (p=0.33).

Conclusion:

Levels of PA did not differ significant between AxSpA and RA patients compared to the general population, and disease activity levels did not affect the level of PA in patients with AxSpA and RA. Of note was that patients with AxSpA and RA demonstrated higher levels of sedentary activity compared to the general population. Improving PA and decreasing sedentary activity could reduce the cardiovascular risk, especially in patients with RA.

References:

[1]Summers G, Booth A, Brooke-Wavell K, Barami T, Clemes S. <p>Physical activity and sedentary behavior in women with rheumatoid arthritis: a comparison of patients with low and high disease activity and healthy controls</p>.Open Access Rheumatol Res Rev. 2019;Volume 11:133-142. doi:10.2147/oarrr.s203511

[2]Sundstrom B, Ekergård H, Sundelin G. Exercise habits among patients with ankylosing spondylitis.Scand J Rheumatol. 2002;31(3):163-167. doi:10.1080/rhe.31.3.163.167

[3]Lip GY, Luscombe C, McCarry M, Malik I, Beevers G. Ethnic differences in public health awareness, health perceptions and physical exercise: implications for heart disease prevention.Ethn Health. 1996;1(1):47-53. doi:10.1080/13557858.1996.9961769

[4]Win AM, Yen LW, Tan KH, Lim RBT, Chia KS, Mueller-Riemenschneider F. Patterns of physical activity and sedentary behavior in a representative sample of a multi-ethnic South-East Asian population: A cross-sectional study.BMC Public Health. 2015;15(1):1-11. doi:10.1186/s12889-015-1668-7

[5]Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): Nine country reliability and validity study.J Phys Act Heal. 2009;6(6):790-804. doi:10.1123/jpah.6.6.790

Disclosure of Interests:

Andrew Khor: None declared, Chin Teck Ng: None declared, Warren Fong Consultant of: Abbvie, Janssen, Novartis, Speakers bureau: Abbvie, Janssen, Novartis

FRI0328 PROFILING OF THE IMMUNE COMPARTMENT IN THE TISSUE ENVIRONMENT OF PSORIATIC ARTHRITIS USING RNASEQ

Background:

Psoriasis is a chronic inflammatory disease of the skin with a reported prevalence of 0.09-11.4% of the population (1). 1 in 4 psoriasis patients also have psoriatic arthritis (PsA) (2), with additional joint involvement that can be associated with significant morbidity. Despite its relative commonness, the aetiology of psoriasis is not well understood, and there is no cure for this disease. Additionally, up to 30% of PsA patients with active disease are recalcitrant to treatment. Thus it remains a prerogative to understand the immune mechanisms contributing to the development of the disease in order to inform strategies for novel therapies.

Objectives:

Our aim was to identify perturbations in local tissue immune networks that could contribute to the pathology of psoriasis and psoriatic arthritis. We hypothesise that psoriasis is driven by a disrupted tissue microenvironment, which then provides cues to a susceptible peripheral immune system to drive pathology. Thus as the first part of our study, we investigated the transcriptional profiles of normal and lesional skin.

Methods:

Skin punch biopsies were obtained from both lesional and morphologically normal skin of 4 PsA patients with active disease. CD45+ cells were isolated using magnetic enrichment for RNA purification and subsequent RNAseq. Differently expressed genes (DEG) were identified and pathway analysis performed using the integrated Differential Expression and Pathway (iDEP) analysis tool. Gene set enrichment analysis was performed using GSEA.

Results:

Transcriptomic analyses of skin revealed that lesional skin, compared to non-lesional sites, was enhanced for expression of genes associated with immune processes (including genes such as such asIL17A,FCN1, andCTLA4) anti-microbial responses (such asDEF4BAandS100A8) and immune cell chemotaxis (notablyCXCL13andSELPLG), suggesting a possible inflammatory response to skin microbiota. Interestingly, lesional skin showed a deficiency in expression of genes associated with tRNA metabolic processes (includingAARS,YARS, and other aminoacyl tRNA synthetases), suggesting a possible defect in protein translation. Similarly, pathway analysis revealed an enrichment in humoral immune response pathways in PsA lesional skin, and a comparative deficiency in RNA metabolic pathways.

Conclusion:

Our transcriptional approach provides a comprehensive overview of localised immunity in psoriasis and predicts intimate interactions with the peripheral immune system. Further studies are ongoing to uncover cell types involved, as well as parallels at other disease sites (joints). These findings will facilitate the identification of novel targets for treatment of PsA.

References:

[1]World Health Organization (2016).Global report on psoriasis. [Online] (https://apps.who.int/iris/bitstream/handle/10665/204417/9789241565189_eng.pdf.psoriasis;jsessionid=54912784D28C9F36ECCD45471AC5775B?sequence=1,accessed 24 January 2020)

[2]Alinaghi F., Calov M., Kristensen L.E., Gladman D.D, Coates L.C., Julien D., Gottlieb A.B., Gisondi P., Wu J.J., Thyssen J.P., Egeberg A. (2019) Prevalence of psoriatic arthritis in patients with psoriasis: A systemic review and meta-analysis of observational and clinical studies.Journal of the American Academy of Dermatology.,80(1), 251-265.

Disclosure of Interests:

Gladys Ang: None declared, Pavanish Kumar: None declared, Dianyan Guo: None declared, Ahmad Lajam: None declared, Warren Fong Consultant of: Abbvie, Janssen, Novartis, Speakers bureau: Abbvie, Janssen, Novartis, Ying Ying Leung Speakers bureau: Novartis, Janssen, Eli Lilly, Salvatore Albani: None declared

AB0836 PREVALENCE AND DETERMINANTS OF FATIGUE IN PSORIATIC ARTHRITIS IN AN ASIAN POPULATION

Background:

Fatigue is one of the core domains to be measured in all clinical trials for psoriatic arthritis (PsA). Studies of fatigue in PsA in Asia are scarce.

Objectives:

To describe the prevalence and evaluate the factors associated with fatigue in PsA patients within a multi-ethnic Asian population.

Methods:

We used data from the PRESPOND registry for PsA patients attending an outpatient clinic of a tertiary institution in Singapore. Demographics data and disease characteristics were evaluated. Fatigue was assessed by question 1 of BASDAI (BASDAI-F) and the vitality domain of SF-36 (SF-36 VT).

Results:

131 patients (50.4% men, 63.4% Chinese, median PsA duration 1.78 years) with completed data for fatigue were included. The median (IQR) tender and swollen joint count was 2 (5) and 1 (3) respectively. 45 patients (34%) experienced high fatigue (defined by BASDAI-F ≥ 6/101,2). 5 clusters of factors were identified using principal component analysis that explained 66.2% of the variance of all factors, which mapped to disease activity, disease chronicity, demographics (ethnicity and gender), and BMI (Figure 1). Of these, disease activity and chronicity were significantly associated with BASDAI-F and SF-36 VT. In a multivariate analysis, back pain, peripheral joint pain and patient global assessment were associated with BASDAI-F, whereas peripheral joint pain, HAQ-DI, age and BMI were associated with SF-36 VT (Table 1).

Table 1.

Multivariable analysis for variables associated with fatigue

BASDAI-FSF-36 VTb95% CIβpb95% CIβpBack pain (0-10)0.335(0.180, 0.490)0.356<0.001----Peripheral joint pain (0-10)0.027(0.012, 0.042)0.2680.001-2.296(-3.410, -1.182)-0.320<0.001PGA (0-100)0.211(0.061, 0.361)0.2360.006----HAQ-DI (0-3)-----12.74(-17.97, -7.51)-0.386<0.001Age, y----0.260(0.065, 0.456)0.1790.009BMI, kg/m2-----0.644(-1.183, -0.105)-0.1650.020Figure 1.

Principal component analysis with 5 components and residuals (in dotted lines). Only factor loadings with magnitudes greater than 0.40 are shown.

Conclusion:

PsA-associated fatigue is prevalent in this Asian PsA cohort and is associated with disease activity and chronicity.

References:

[1]Gudu T, Etcheto A, de Wit M, Heiberg T, Maccarone M, Balanescu A, et al. Fatigue in psoriatic arthritis - a cross-sectional study of 246 patients from 13 countries. Joint Bone Spine. 2016;83(4):439-43.

[2]Walsh JA, McFadden ML, Morgan MD, Sawitzke AD, Duffin KC, Krueger GG, et al. Work productivity loss and fatigue in psoriatic arthritis. J Rheumatol. 2014;41(8):1670-4.

Disclosure of Interests:

Joel Shi Quan Tan: None declared, Warren Fong Consultant of: Abbvie, Janssen, Novartis, Speakers bureau: Abbvie, Janssen, Novartis, Yu Heng Kwan: None declared, Ying Ying Leung Speakers bureau: Novartis, Janssen, Eli Lilly

Risk of malignancies in patients with spondyloarthritis treated with biologics compared with those treated with non-biologics: a systematic review and meta-analysis

Background:

The aim of our study was to synthesize evidence on the occurrence of malignancy in spondyloarthritis (SpA), from randomized controlled trials (RCTs) comparing biologics with non-biologics and biologics to each other.

Methods:

We systematically searched Medline, Cochrane Library, EMBASE, Scopus and ClinicalTrials.gov from inception until 31 October 2018. RCTs with ⩾24-week follow-up were included. We extracted data using standardized forms and assessed the risk of bias using the Cochrane Risk of Bias Tool. We performed pair-wise meta-analyses and network meta-analyses to compare the risk of malignancy for each biologics class and SpA type. We reported the Peto odds ratio (OR) of any malignancy along with 95% confidence intervals (95% CI). Bayesian posterior probabilities comparing risk of malignancy of each biologic class with non-biologics were computed as supplementary measures.

Results:

Fifty-four trials were included; most (44/54) had follow-up <1 year. Among 14,245 patients, 63 developed a malignancy. While most Peto ORs were >1, they had wide 95% CI and p >0.05. The overall Peto OR comparing biologics with non-biologics was 1.42 (95% CI 0.80–2.53). Only interleukin-17 inhibitors in peripheral SpA had p <0.05 (Peto OR 2.77, 95% CI 1.07–7.13); the posterior probability that the risk was higher than non-biologics was 98%. Stratified analyses revealed no consistent trend by prior exposure to biologics, duration of follow-up, study quality, study-arm crossover, analytical approaches and type of malignancy.

Conclusions:

Our findings indicate no overall elevated risk of malignancy with biologics in SpA. As our meta-analyses are unable to conclude on the long-term risk, long-term pharmacovigilance of biologics in SpA may still be warranted.

Association between beta-blocker use and obesity in Hong Kong Chinese elders: a post-hoc analysis

INTRODUCTION

Studies of Caucasian populations have shown that beta-blockers may exacerbate weight gain, a risk factor for many chronic diseases. Still, beta-blockers are the most prescribed antihypertensives in the Chinese population in Hong Kong. We aimed to explore the association between beta-blocker use, hypertension, and weight status of this population.

METHODS

A post-hoc analysis regarding body mass index (BMI) and the use of beta-blockers was performed based on the medication profile of community-dwelling older adults. Participants' BMI, hypertension diagnosis, name, dose, frequency, route of administration of beta-blockers, and other drugs that may alter body weight were recorded.

RESULTS

Of 1053 Chinese individuals aged ≥65 years (mean age 76.9±7.2 years, 80% female) from 32 elderly centres in Hong Kong, 18% (185/1053) of them consumed beta-blockers. That group also had a significantly larger proportion of obese individuals (45.9% vs 32.1%, P=0.002). After adjusting for other weight-altering drugs, beta-blockers remained a significant predictor of overweight and obesity (P=0.001). As the hypertensive population had significantly higher BMI than the normotensive population (24.3±3.6 vs 22.9±3.5, P<0.001), a sub-analysis on those with hypertension diagnosis confirmed that only the hypertensive population taking atenolol had a significantly larger population of obese individuals (BMI ≥25) compared with those who took metoprolol (58.9% vs 38.5%, P=0.03) and those who did not take any beta-blockers (58.9% vs 38.4%, P=0.007).

CONCLUSIONS

Our findings taken together with other guideline reservations cast doubt on whether beta-blockers, particularly atenolol, should be the major drug prescribed to older adults with hypertension.

Validity and reliability of Work Productivity and Activity Impairment among patients with axial spondyloarthritis in Singapore

OBJECTIVES

To assess the validity and reliability of the Work Productivity and Activity Impairment (WPAI) questionnaire in patients with axSpA.

METHODS

English-speaking patients seen at a dedicated axSpA clinic in a Singapore tertiary referral hospital were recruited from 2017 to 2019. Content validity of the WPAI was assessed through cognitive debriefing interviews (CDIs). Construct validity was assessed by a priori hypotheses regarding the correlations of the WPAI outcomes (absenteeism, presenteeism, overall work productivity loss, and activity impairment) with Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Patient Global Score (BAS-G), patient global assessment (PGA) and pain scores. Known group validity was assessed relative to disease activity. Test-retest reliability was assessed by intraclass correlation coefficients (ICC) in patients without treatment change 2 weeks apart.

RESULTS

Cognitive debriefing interviews conducted with 10 patients (22-46 years old, 50% male) supported the content validity of the WPAI. We analyzed cross-sectional data from 168 patients (mean [SD] age 41.0 [14.4], 79.8% male). Construct validity was established by meeting 100% of the hypotheses. Presenteeism, overall work productivity loss, and activity impairment demonstrated strong correlations with BASFI, BAS-G, PGA, and pain (r_s  > .6). The WPAI was able to distinguish patients grouped by disease activity. Test-retest reliability conducted with 50 patients ranged from moderate to good for all the four outcomes (absenteeism: ICC = 0.54; presenteeism: ICC = 0.76; activity impairment: ICC = 0.79; overall work productivity loss: ICC = 0.83; all P < .01).

CONCLUSIONS

This study supports the content validity, construct validity, and test-retest reliability of the WPAI in patients with axSpA.

Assessment of medical professionalism: preliminary results of a qualitative study

BACKGROUND

The importance of medical professionalism has been well documented in the literature. Cultural background affects the constituents of professionalism. However, few studies have explored the domains of medical professionalism in an Asian context. We aim to describe the views and experiences of both patients and faculty on medical professionalism in an urban Asian city state.

METHODS

Data for this qualitative study were collected through focus group discussions (FGDs) with patients and in-depth interviews (IDIs) with faculty members. The IDIs and FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using a priori framework derived from Professionalism Mini Evaluation Exercise (P-MEX). Sociodemographic data of faculty members and patients were obtained through brief questionnaires.

RESULTS

A total of 31 patients (58.1% male, all had visited healthcare facilities within the past year) and 26 faculty members (42.3% male, 38.5% from medical disciplines, median years as faculty is 11) participated in this study. The results supported the four domains of medical professionalism - Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills. Two new sub-domains which emerged from data were (1) communicated effectively with patient and (2) demonstrated collegiality.

CONCLUSIONS

The domains of professionalism in Singapore were similar to previous studies. This study allows a better understanding of medical professionalism to enhance the assessment and ultimately, the teaching of medical professionalism in an urban multi-ethnic Asian city.

The direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore

OBJECTIVE

To estimate the economic annual direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore, and to identify factors associated with these costs.

METHODS

A retrospective, cross-sectional, Institutional Review Board-approved study was conducted. A questionnaire was administered to the patients between 2013 and 2016 from the Singapore General Hospital (SGH) spondyloarthritis registry. Direct medical costs and indirect costs were estimated using the SGH database and the human capital approach respectively. Multivariate analyses using generalized linear model with gamma distribution and a log-linked function was conducted to identify factors associated with these total, direct and indirect costs. All costs were adjusted to 2017 using the Singapore Consumer Price Index and converted to 2017 US dollars (USD) by purchasing power parity.

RESULTS

A total of 135 consecutive patients were included in the study, with a mean age of 40.4 ± 13.2 years. The overall annual total economic cost to society was around USD 74 790 820, with annual direct cost being the main component of total cost (90.8%). Annual direct cost was around USD 67 931 457, while annual indirect cost was around USD 6 855 951. Presence of extra-spinal symptoms (ever) was associated with an increase in total and direct costs. Higher education level and Patient Global Assessment were associated with an increase in indirect costs. Lack of employment was associated with a decrease in indirect costs.

CONCLUSION

The disease burden of axSpA in Singapore is not trivial given that the disease is relatively common. This highlights the need for measures to accommodate patients with axSpA economically in Singapore.

Assessing Professionalism in Medicine - A Scoping Review of Assessment Tools from 1990 to 2018

BACKGROUND

Medical professionalism enhances doctor-patient relationships and advances patient-centric care. However, despite its pivotal role, the concept of medical professionalism remains diversely understood, taught and thus poorly assessed with Singapore lacking a linguistically sensitive, context specific and culturally appropriate assessment tool. A scoping review of assessments of professionalism in medicine was thus carried out to better guide its understanding.

METHODS

Arksey and O'Malley's (2005) approach to scoping reviews was used to identify appropriate publications featured in four databases published between 1 January 1990 and 31 December 2018. Seven members of the research team employed thematic analysis to evaluate the selected articles.

RESULTS

3799 abstracts were identified, 138 full-text articles reviewed and 74 studies included. The two themes identified were the context-specific nature of assessments and competency-based stages in medical professionalism.

CONCLUSIONS

Prevailing assessments of professionalism in medicine must contend with differences in setting, context and levels of professional development as these explicate variances found in existing assessment criteria and approaches. However, acknowledging the significance of context-specific competency-based stages in medical professionalism will allow the forwarding of guiding principles to aid the design of a culturally-sensitive and practical approach to assessing professionalism.

Validity and reliability of the Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in patients with axial spondyloarthritis (axSpA) in Singapore

INTRODUCTION

The Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) are commonly used instruments for measuring disease activity. However, few studies have assessed their psychometric properties in patients with axial spondyloarthritis (axSpA). We aimed to assess the validity and reliability of ASDAS-CRP and BASDAI in patients with axSpA in Singapore.

METHODS

Cross-sectional data from 280 patients with axSpA from a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2011 to 2019 were used. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed through 12 a priori hypotheses by correlation of overall ASDAS-CRP and BASDAI score with other patient-reported outcomes measures (PROMs). Structural validity was evaluated via confirmatory factor analysis using maximum-likelihood method, where Comparative Fit Index (CFI) >0.95, Tucker-Lewis Index (TLI) >0.95, Root Mean Square Error of Approximation (RMSEA) <0.06 and Standardized Root Mean Residuals (SRMR) <0.08 were indicative of good fit.

RESULTS

Among 280 patients (78.2% Male; 92.5% Chinese), ASDAS-CRP showed poor internal consistency of 0.33, while BASDAI showed high internal consistency of 0.87. Convergent and divergent construct validity were demonstrated by fulfillment of 11 out of 12 a priori hypotheses when ASDAS-CRP and BASDAI were compared with other PROMs. Our proposed ASDAS-CRP and BASDAI model showed good fit for a 1-factor structure respectively (CFI = 0.993, TLI = 0.984, RMSEA = 0.036, SRMR = 0.026 for ASDAS-CRP; CFI = 0.993, TLI = 0.985, RMSEA = 0.057, SRMR = 0.022 for BASDAI), demonstrating structural validity.

CONCLUSION

This study supports the use of both ASDAS-CRP and BASDAI in measuring disease activity in patients with axSpA in Singapore.

Evaluation of Mobile Apps Targeted at Patients With Spondyloarthritis for Disease Monitoring: Systematic App Search

Background

There are many apps developed for patients with spondyloarthritis in the market, but their purpose and quality are not objectively evaluated.

Objective

The objective of this study was to identify and evaluate existing publicly available, high-quality apps that use validated measurement instruments for monitoring spondyloarthritis disease activity.

Methods

We conducted a review of apps available on the Apple App Store and the Google Play Store based on a combination of keywords and inclusion and exclusion criteria. Validated disease activity measurement instruments were identified. Data regarding app characteristics, including the presence of validated disease activity measurement, were extracted. The Mobile App Rating Scale (MARS) was used to review the apps for user experience.

Results

A total of 1253 apps were identified in the app stores, and 5 apps met the criteria and were further analyzed. Moreover, 2 apps (MySpA and Group for Research and Assessment of Psoriasis and Psoriatic Arthritis App) contained some of the validated disease activity monitoring instruments for specific spondyloarthritis subtypes. These 2 apps were also rated good on the MARS (with total mean scores ≥4 out of 5), whereas the other apps scored poorly in comparison.

Conclusions

There are 2 high-quality spondyloarthritis disease activity monitoring apps publicly available, but they only target 2 spondyloarthritis subtypes—ankylosing spondylitis and psoriatic arthritis. There is a lack of high-quality apps that can measure disease activity for other spondyloarthritis subtypes, and no app that consolidates all validated disease activity instruments across subtypes was available.

Association between access to health-promoting facilities and participation in cardiovascular disease (CVD) risk screening among populations with low socioeconomic status (SES) in Singapore

BACKGROUND

Low socioeconomic status (SES) is a barrier for cardiovascular disease (CVD) risk screening and a determinant of poor CVD outcomes. This study examined the associations between access to health-promoting facilities and participation in a CVD risk screening program among populations with low SES residing in public rental flats in Singapore.

METHODS

Data from Health Mapping Exercises conducted from 2013 to 2015 were obtained, and screening participation rates of 66 blocks were calculated. Negative binomial regression was used to test for associations between distances to four nearest facilities (i.e., subsidized private clinics, healthy eateries, public polyclinics, and parks) and block participation rate in CVD screening. We also investigated potential heterogeneity in the association across regions with an interaction term between distance to each facility and region.

RESULTS

The analysis consisted of 2069 participants. The associations were only evident in the North/North-East region for subsidized private clinic and park. Specifically, increasing distance to the nearest subsidized private clinic and park was significantly associated with lower [incidence rate ratio (IRR) = 0.88, 95% confidence interval (CI): 0.80-0.98] and higher (IRR = 1.93, 95%CI: 1.15-3.25) screening participation rates respectively.

CONCLUSIONS

Our findings could potentially inform the planning of future door-to-door screenings in urban settings for optimal prioritization of resources. To increase participation rates in low SES populations, accessibility to subsidized private clinics and parks in a high population density region should be considered.

Validity and reliability of the Assessment of Spondyloarthritis International Society Health Index in English-speaking patients with axial spondyloarthritis in Singapore

OBJECTIVES

To assess the validity and reliability of the Assessment of Spondyloarthritis International Society Health Index (ASAS HI) among patients with axial spondyloarthritis (axSpA) in Singapore.

METHODS

We collected data from English-speaking patients with axSpA seen at a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2017 to 2018. Face validity of the English version of ASAS HI was assessed through cognitive debriefing interviews (CDIs). Structural validity was assessed with confirmatory factor analysis. Convergent construct validity was assessed with 12 a priori hypotheses about the magnitude and direction of correlations between the ASAS HI summary score and other patient-reported outcome measures. Internal consistency was assessed using Cronbach's alpha. Test-retest reliability was assessed by intraclass correlation coefficient (ICC). Measurement error was assessed by analyzing smallest detectable change (SDC).

RESULTS

Ten patients (age range 22-46 years, 50% male) participated in CDIs and face validity was supported. Among 108 patients (median age: 37 [21-77], 80.6% males), unidimensionality was confirmed (comparative fit index = 0.960, Tucker-Lewis Index = 0.952, root mean square error of approximation = 0.038, standardized root mean residuals = 0.068, model Chi-square test P = 0.1251) in the 17-item ASAS HI. The ASAS HI showed good internal consistency of 0.83 and excellent test-retest reliability (ICC = 0.95; 95% CI 0.91-0.98) when baseline was compared with week 2. SDC was 1.02. Convergent validity was supported as hypotheses were confirmed in 100% of the results.

CONCLUSIONS

This study supports the ASAS HI as a valid and reliable measure of health status for use in patients with axSpA in Singapore.

A systematic review of the association of obesity with the outcomes of inflammatory rheumatic diseases

This was a systematic review of the literature on the association between obesity and the outcome of inflammatory rheumatic diseases. We conducted a literature search using PubMed®, Embase and PsycINFO®. Articles were classified into three categories based on the effects of obesity on the outcomes of inflammatory rheumatic diseases. The subject population, country, type of studies, number of patients, measurement of obesity and outcomes assessed were presented. Quality was appraised using Kmet et al's criteria. 4,331 articles were screened and 60 were relevant to the objective. Obesity had a negative, positive and neutral association with outcomes of inflammatory rheumatic diseases in 38 (63.3%) studies with 57,612 subjects, 11 (18.3%) studies with 3,866 subjects, and 11 (18.3%) studies with 3,834 subjects, respectively. In most studies, the disease population had been diagnosed with rheumatoid arthritis (RA). Tumour necrosis factor-α inhibitors were mostly associated with negative outcomes. More studies examining subjects outside Europe and North America and diseases other than RA are warranted.

Comparison of ankylosing spondylitis and non-radiographic axial spondyloarthritis in a multi-ethnic Asian population of Singapore

OBJECTIVES

To compare clinical characteristics, disease activity, patient-reported outcomes and associated comorbidities between patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthitis (nr-axSpA) in a multi-ethnic Asian population of Singapore.

METHODS

We used data from the PREcision medicine in SPONdyloarthritis for Better Outcomes and Disease Remission (PRESPOND) registry in Singapore General Hospital. All patients fulfilled 2009 Assessment in AS International Working Group classification criteria for axial SpA (axSpA). Of these, all AS patients fulfilled the 1984 modified New York criteria. Baseline characteristics, medications, disease activity, patient-reported outcomes and inflammatory markers were recorded using standardized questionnaires.

RESULTS

Two hundred and sixty-two axSpA patients (82% Chinese, 79% male) were included. Mean age (SD) at diagnosis was 32.4 (13.1) years, which was similar between AS and nr-axSpA patients. AS patients were older (mean age 42.7 [13.5] vs 37.4 [13.8] years, P = 0.02), had longer disease duration (mean disease duration 10.9 [8.7] vs 6.4 [4.8] years, P < 0.01), higher Bath Ankylosing Spondylitis Metrology Index (BASMI) (mean BASMI 3.1 [2.3] vs 1.5 [1.5], P < 0.01), more frequently human leukocyte antigen (HLA)-B27 positive (82% vs 68%, P = 0.03), associated with uveitis (33% vs 17%, P = 0.03), and hypertensive (17% vs 0%, P < 0.01) compared to nr-axSpA, respectively. Nr-axSpA patients had higher Bath Ankylosing Spondylitis Global Score (BAS-G) (mean BAS-G 46.9 [16.8] vs 38.6 [20.6], P < 0.01), Bath Ankylosing Spondylitis Disease Activity Index (mean [SD] 4.2 [1.6] vs 3.5 [1.9], P = 0.02) and AS quality of life (ASQoL) (mean ASQoL 4.9 [4.8] vs 3.5 [4.1], P = 0.04) scores compared to AS patients respectively at baseline. Patient global assessment, Bath Ankylosing Spondylitis Functional Index, AS Disease Activity Score - C-reactive protein (CRP), Health Assessment Questionnaire, Short-Form 36 physical component summary and mental component summary were similar in both groups at baseline, as were medications used and mean erythrocyte sedimentation rate and CRP.

CONCLUSIONS

In our multi-ethnic Asian cohort, patients with AS are more likely to be HLA-B27 positive, have uveitis, hypertensive, and have poorer spinal mobility, while nr-axSpA patients tend to experience poorer well-being and quality of life.

Factors associated with patient-physician discordance in a prospective cohort of patients with psoriatic arthritis: An Asian perspective

Objectives

To evaluate factors associated with patient‐physician discordance in a multiethnic Asian cohort of psoriatic arthritis (PsA) patients.

Methods

We used data from a prospective cohort of consecutive patients with PsA fulfilling the Classification Criteria for Psoriatic Arthritis, recruited from a single center in Singapore. Sociodemographic, clinical data and patient‐reported outcomes were collected using a standardized protocol at baseline, 4 months, 8 months, 1 year, 2 years and 5 years. patient‐physician discordance was defined as patient global assessment minus physician global assessment (PGA‐PhGA). We evaluated variables associated with patient‐physician discordance using generalized linear regression to control for within‐subject effect.

Results

One hundred and fortytwo patients (51.4% male, 66.2% Chinese, mean [SD] age and duration of illness 51.1 [13.8] years and 27.5 [98.3] months) were recruited at baseline. Paired results for PGA and PhGA were available for 291 visits with median (interquartile range) follow‐up time of 11.6 (17) months. In univariable analysis, duration of illness, fatigue, pain, tender and swollen joint count, dactylitis count, and health‐related quality of life (Short Form‐36) domains were significantly correlated with patient‐physician discordance. In multivariable analysis, age, fatigue level, pain score were positively associated with patient‐physician discordance, while swollen joint count and mental health were negatively associated with patient physician discordance.

Conclusions

Increased age, higher fatigue levels, higher pain score  and poorer mental health may explain underestimation of disease activity by physicians. Physicians’ overestimation of disease activity may be explained by higher swollen joint counts.

Traditional Chinese medicine (TCM) collaborative care for patients with axial spondyloarthritis (AcuSpA): protocol for a pragmatic randomized controlled trial

Background

Axial spondyloarthritis (AxSpA) is a chronic disease which results in fatigue, pain, and reduced quality of life (QoL). Traditional Chinese medicine (TCM), especially acupuncture, has shown promise in managing pain. Although a TCM collaborative model of care (TCMCMC) has been studied in cancer, there are no randomized controlled trials investigating TCM in AxSpA. Therefore, we will conduct a pragmatic trial to determine the clinical effectiveness, safety, and cost-effectiveness of TCMCMC for patients with AxSpA. We define TCMCMC as standard TCM history taking and physical examination, acupuncture, and TCM non-pharmacological advice and communications with rheumatologists in addition to usual rheumatologic care. The purpose of this paper is to describe the rationale for and methodology of this trial.

Methods/design

This pragmatic randomized controlled trial will recruit 160 patients who are diagnosed with AxSpA and have inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). Simple randomization to usual rheumatologic care or the intervention (TCMCMC) with a 1:1 allocation ratio will be used. Ten 30-min acupuncture sessions will be provided to patients assigned to the TCMCMC arm. All participants will continue to receive usual rheumatologic care. The primary endpoint — spinal pain — will be evaluated at week 6. Secondary endpoints include clinical, quality of life, and economic outcome measures. Patients will be followed up for up to 52 weeks, and adverse events will be documented.

Discussion

This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of a TCMCMC for patients with AxSpA.

Trial registration

ClinicalTrials.gov, NCT03420404. Registered on 14 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3117-2) contains supplementary material, which is available to authorized users.

Validity and reliability of the ten-item Connor-Davidson Resilience Scale (CD-RISC10) instrument in patients with axial spondyloarthritis (axSpA) in Singapore

We aimed to assess the validity and reliability of the ten-item Connor-Davidson Resilience Scale (CD-RISC10) in patients with axial spondyloarthritis (axSpA) in Singapore. We used cross-sectional data from 108 patients with axSpA recruited from a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2017 to 2018. Analyses were guided by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) framework. Face validity was assessed through cognitive debriefing interviews (CDIs). Internal consistency was assessed through Cronbach's alpha. Test-retest reliability was assessed through intraclass correlation (ICC). Measurement error was assessed through smallest detectable change (SDC). Construct validity was assessed through six a priori hypotheses through correlation of the CD-RISC10 score with other patient-reported outcome measures. Structural validity was assessed using confirmatory factor analysis (CFA). Fit indices evaluated were root-mean-square error of approximation (RMSEA), comparative fit index (CFI), Tucker-Lewis index (TFI), and standardized root-mean-squared residual (SRMR). Ten patients completed the CDIs and face validity was supported. Among 108 patients (median age: 37(21-77), 81.5% males, 93.5% Chinese), the CD-RISC10 demonstrated good internal consistency (Cronbach's alpha = 0.94), and excellent test-retest reliability [ICC = 0.964 (95% CI 0.937-0.980)]. SDC was calculated as 1.88. Construct validity was established by meeting five out of the six a priori hypotheses. Structural validity was supported as CFA confirmed a one-factor model, with adequate fit statistics after adding three covariances (RMSEA = 0.077; CFI = 0.975; TLI = 0.964; SRMR = 0.036). This study supports the CD-RISC10 as a valid and reliable measure of resilience for use in patients with axSpA.

A systematic review of factors affecting medication adherence among patients with osteoporosis

The aim of this review was to identify factors that influence patients' adherence to anti-osteoporotic therapy. Factors identified that were associated with poorer medication adherence included polypharmacy, older age, and misconceptions about osteoporosis. Physicians need to be aware of these factors so as to optimize therapeutic outcomes for patients.

INTRODUCTION

To identify factors that influence patients' adherence to anti-osteoporotic therapy.

METHODS

A systematic review of literature was performed for articles published up till January 2018 using PubMed®, PsychINFO®, Embase®, and CINAHL®. Peer-reviewed articles which examined factors associated with anti-osteoporotic medication adherence were included. Classes of anti-osteoporotic therapy included bisphosphonates, parathyroid hormone-related analogue, denosumab, selective estrogen receptor modulators, estrogen/progestin therapy, calcitonin, and strontium ranelate. Meta-analyses, case reports/series, and other systematic reviews were excluded. Identified factors were classified using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of 2404 articles reviewed, 124 relevant articles were identified. The prevalence of medication adherence ranged from 12.9 to 95.4%. Twenty-four factors with 139 sub-factors were identified. Bisphosphonates were the most well-studied class of medication (n = 59, 48%). Condition-related factors that were associated with poorer medication adherence included polypharmacy, and history of falls was associated with higher medication adherence. Patient-related factors which were associated with poorer medication adherence included older age and misconceptions about osteoporosis while therapy-related factors included higher dosing frequency and medication side effects. Health system-based factors associated with poorer medication adherence included care under different medical specialties and lack of patient education. Socio-economic-related factors associated with poorer medication adherence included current smoker and lack of medical insurance coverage.

CONCLUSION

This review identified factors associated with poor medication adherence among osteoporotic patients. To optimize therapeutic outcomes for patients, clinicians need to be aware of the complexity of factors affecting medication adherence.

A Systematic Review of the Quality and Utility of Observer-Based Instruments for Assessing Medical Professionalism

BACKGROUND

Professionalism, which encompasses behavioral, ethical, and related domains, is a core competency of medical practice. While observer-based instruments to assess medical professionalism are available, information on their psychometric properties and utility is limited.

OBJECTIVE

We systematically reviewed the psychometric properties and utility of existing observer-based instruments for assessing professionalism in medical trainees.

METHODS

After selecting eligible studies, we employed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria to score study methodological quality. We identified eligible instruments and performed quality assessment of psychometric properties for each selected instrument. We scored the utility of each instrument based on the ability to distinguish performance levels over time, availability of objective scoring criteria, validity evidence in medical students and residents, and instrument length.

RESULTS

Ten instruments from 16 studies met criteria for consideration, with studies having acceptable methodological quality. Psychometric properties were variably assessed. Among 10 instruments, the Education Outcomes Service (EOS) group questionnaire and Professionalism Mini-Evaluation Exercise (P-MEX) possessed the best psychometric properties, with the P-MEX scoring higher on utility than the EOS group questionnaire.

CONCLUSIONS

We identified 2 instruments with best psychometric properties, with 1 also showing acceptable utility for assessing professionalism in trainees. The P-MEX may be an option for program directors to adopt as an observer-based instrument for formative assessment of medical professionalism. Further studies of the 2 instruments to aggregate additional validity evidence is recommended, particularly in the domain of content validity before they are used in specific cultural settings and in summative assessments.

A qualitative study of quality of life domains and subdomains relevant to patients with spondyloarthritis

AIMS

To identify quality of life (QoL) domains and subdomains relevant to patients with different spondyloarthritis (SpA) subtypes in Singapore, and to assess how identified QoL domains and subdomains map onto currently used patient-reported outcome measures (PROMs).

METHODS

Nine focus group discussions (FGDs), including two previously conducted FGDs from the Updating the Psoriatic Arthritis Core Domain Set Study, were conducted with patients with SpA in Singapore. The FGDs were organized by SpA subtype and language spoken. All FGDs were audio-taped, transcribed verbatim. After thematic analysis through open and axial coding, the domains were organized using the World Health Organization Quality of Life (WHOQOL) framework. Identified QoL domains and subdomains were mapped to currently used PROMs.

RESULTS

The nine FGDs included 51 patients. In total, 27 domains and 92 subdomains were identified and then organized within the 7 broad categories of the WHOQOL framework. Patients in Singapore were more concerned about "financial resources, " "work satisfaction" and "positive feelings" while less concerned about "freedom, physical safety and security" than patients in Western countries. "Home environment" and "work satisfaction" emerged as unique QoL domains relevant to patients with axial SpA (axSpA). PROMs for psoriatic arthritis (PsA) can capture both identified domains of PsA and axSpA.

CONCLUSIONS

A wide range of QoL domains and subdomains are relevant to SpA patients in Singapore, and there appears to be minimal differences in their relative importance between SpA subtypes. This study supports the development and validation of common QoL-specific PROMs for usage in SpA.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study

Background

This study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status.

Methods

Using data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant.

Results

The mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49–19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23–12.19; p = 0.02). Sensitivity analyses generated consistent findings.

Conclusion

Both ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0871-7) contains supplementary material, which is available to authorized users.

The impact of axial spondyloarthritis on quality of life (QoL): a comparison with the impact of moderate to end-stage chronic kidney disease on QoL

PURPOSE

The purpose of the study was to assess the impact of axial spondyloarthritis (axSpA) on patients' quality of life (QoL) compared to patients with moderate to end-stage chronic kidney disease (CKD).

METHODS

We conducted secondary analysis of QoL data obtained from patients with axSpA and CKD from 2011 to 2014. QoL was assessed using the SF-36 version 2 and KDQoL-SF for patients with axSpA and CKD, respectively. Patients with CKD were subcategorized to CKD-pre-dialysis, hemodialysis (CKD-HD) and peritoneal dialysis (CKD-PD). Linear regression was used to compare QoL between patients with axSpA and CKD after adjusting for age, gender, ethnicity, education level, and marital status.

RESULTS

A total of 765 patients (mean age 54.6, 63.0% males, 69.0% Chinese) were analyzed, of which 188 (24.5%) had axSpA. Patients with axSpA had poorer SF-36 bodily pain (BP) scores (axSpA: reference; CKD-pre-dialysis β: 11.04, p < 0.001; CKD-HD β: 9.52, p < 0.001; CKD-PD β: 10.35, p < 0.001) and higher general health scores (axSpA: reference; CKD-pre-dialysis β: - 7.87, p < 0.001; CKD-HD β: - 7.14, p < 0.001, CKD-PD β: - 7.25, p < 0.001) as compared to patients with CKD. Generally, patients with axSpA had poorer SF-36 scores than patients with CKD-pre-dialysis and similar SF-36 scores compared to patients with CKD-HD or CKD-PD.

CONCLUSIONS

The burden of axSpA on QoL is not trivial and is comparable to patients with CKD-HD or CKD-PD.

A systematic review of the factors associated with the initiation of biologicals in patients with rheumatological conditions

Objectives

Biologicals play a crucial role in managing some of the rheumatological diseases, thus it is important for clinicians, healthcare institutions and policy-makers to understand why biologicals are initiated or refused so as to make better decisions to improve patients' disease outcomes. Although there have been many studies investigating factors associated with the initiation of biologicals for patients with rheumatological conditions, there have been no systematic reviews that provide a comprehensive summary. We aim to provide a summary of factors associated with biologicals' initiation for patients with rheumatological conditions.

Methods

We performed a literature search in PubMed, Embase and PsycINFO. We identified and screened studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Factors were presented according to patient, disease-related, therapy-related, healthcare team-related and system in-place factors.

Results

A total 1755 articles were reviewed and 24 articles were found to be relevant to our objective. Forty four factors reviewed were placed into five main categories: patient factors (n=13); disease-related factors (n=11); therapy-related factors (n=7); healthcare team-related factors (n=4) and system in-place-related factors (n=9). The factors studied by the published papers found to be associated with decisions to initiate biologicals varied widely.

Conclusion

Forty two factors of five different categories were found to be associated with biologicals' initiation for patients with rheumatological conditions. Clinicians need to be mindful of the complex nature of these factors to optimise therapy of patients with rheumatological conditions. Healthcare institutions and policy- makers ought to be aware of any potential barriers to successful biologicals' treatment and address them accordingly.

IgG4-related disease: features and treatment response in a multi-ethnic cohort in Singapore

OBJECTIVES

To describe the features and treatment outcomes of IgG4-RD in multi-ethnic patients in Singapore.

METHODS

Retrospective study was performed on IgG4-RD patients identified from patient databases in a tertiary hospital.

RESULTS

Fourty-two patients (76% male) were included; 79% fulfilled the 2011 comprehensive diagnostic criteria for IgG4-RD for definite IgG4-RD. 81% were Chinese and 19% were Malays. Common initial manifestations included jaundice (52%), abdominal pain (36%) and swollen salivary glands (26%). Only 36% had a history of allergy. 83% had ≥ 1 organ involvement. Erythrocyte sedimentation rate, immunoglobulin E, IgG2 and IgG4 levels were elevated in 84%, 100%, 70% and 44% of patients, respectively. The most common histopathological feature was >10 IgG4+ cells per high power field (66%). 94% (34/36) of patients were treated with moderate to high doses of glucocorticoids, including 17 patients with combination immunosuppressants. Of these, all patients responded to therapy by 3 months. With a median (range) follow-up of 4.1 (0.4-13.8) years, 69% (25/36) needed low dose of glucocorticoids to maintain disease remission. Twenty-six per cent had relapse of disease, of which 82% had disease recurrence in the same organs.

CONCLUSIONS

Pancreatitis, lymphoadenopathy and cholangitis were the commonest manifestations in Asians with IgG4-RD. All patients responded to glucocorticoid therapy by 3 months, two-thirds required maintenance therapy with glucocorticoids, and one-quarter developed relapse of disease.

Measurement properties of patient reported outcome measures for spondyloarthritis: A systematic review

OBJECTIVES

This systematic review aimed to identify studies investigating measurement properties of patient reported outcome measures (PROMs) for spondyloarthritis (SpA), and to evaluate their methodological quality and level of evidence relating to the measurement properties of PROMs.

METHODS

This systematic review was guided by the preferred reporting items for systematic review and meta-analysis (PRISMA). Articles published before 30 June 2017 were retrieved from PubMed^®, Embase^®, and PsychINFO^® (Ovid). Methodological quality and level of evidence were evaluated according to recommendations from the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

RESULTS

We identified 60 unique PROMs from 125 studies in 39 countries. Twenty-one PROMs were validated for two or more SpA subtypes. The literature examined hypothesis testing (82.4%) most frequently followed by reliability (60.0%). A percentage of 77.7% and 42.7% of studies that assessed PROMs for hypothesis testing and reliability, respectively had "fair" or better methodological quality. Among the PROMs identified, 41.7% were studied in ankylosing spondylitis (AS) only and 23.3% were studied in psoriatic arthritis (PsA) only. The more extensively assessed PROMs included the ankylosing spondylitis quality of life (ASQoL) and bath ankylosing spondylitis functional index (BASFI) for ankylosing spondylitis, and the psoriatic arthritis quality of life questionnaire (VITACORA-19) for psoriatic arthritis.

CONCLUSION

This study identified 60 unique PROMs through a systematic review and synthesized evidence of the measurement properties of the PROMs. There is a lack of validation of PROMs for use across SpA subtypes. Future studies may consider validating PROMs for use across different SpA subtypes.

Patient preferences for types of community-based cardiac rehabilitation programme

Introduction

Cardiac rehabilitation (CR) improves mortality, morbidity and quality of life of cardiovascular patients. However, its uptake is poor especially in the hospitals due to long travel distances and office hours constraints. Community-based CR is a possible solution.

Objectives

To understand the type of community-based CR preferred and identify patient characteristics associated with certain programme combinations.

Methods

A cross-sectional survey was administered to a randomised list of patients at risk for or with cardiovascular diseases at two community-based CR centres. Participants were presented with nine hypothetical choice sets and asked to choose only one of the two alternative programme combinations in each choice set. Attributes include support group presence, cash incentives, upfront deposit and out-of-pocket cost. The counts for each combination were tallied and corrected for repeats. Chi-square test and logistic regression were performed to understand the characteristics associated with the preferred CR combination.

Results

After correcting for repeats, patients most (85.2%) prefer CR programmes with new group activities, support group, cash rewards, deposit and out-of-pocket cost, and few exercise equipment with physiotherapist presence without the need for monitoring equipment. Patients with more than three bedrooms in their house are less likely (OR 0.367; CI 0.17 to 0.80; P=0.011) to choose the choice with no physiotherapist and few equipment available.

Conclusion

This is the first study to explore patients' preferences for different types of community CR. Higher income patients prefer physiotherapist presence and are willing to settle for less equipment. Our study serves as a guide for designing future community-based CR programmes.

Disseminated tuberculosis masquerading as a presentation of systemic lupus erythematosus

Tuberculosis (TB) infection is the endemic in Asia-Pacific region. Miliary TB is a disseminated form which may present similarly as autoimmune conditions. Here we describe a 17-year-old girl who had miliary TB with manifestations mimicking new-onset systemic lupus erythematosus (SLE) including oral ulcers, serositis, cytopenia, proteinuria and raised autoantibody titers. Complex associations between SLE and TB are highlighted. High index of clinical suspicion for TB infection is needed upon presentations resembling immune diseases like SLE.

The Utility of FDG PET/CT in IgG4-Related Disease with a Focus on Coronary Artery Involvement

Purpose

Our case series aims to study the growing use of FDG PET/CT in diagnostic evaluation and follow up of IgG4-RD with emphasis on patients presenting with coronary artery involvement.

Methods

We conducted a search on the nuclear medicine and rheumatology service databases and identified patients with histologically proven IgG4-RD with FDG PET/CT performed at the Singapore General Hospital. The radiological, clinical, and laboratory findings of these patients were analyzed retrospectively.

Results

The series included ten male and two female patients. The commonest organ involved (five patients) was the pancreas. In three patients, coronary artery involvement manifested as soft tissue masses surrounding the arterial lumens. In these patients, histological diagnosis was established from alternative biopsy sites with abnormal metabolic activity on FDG PET/CT.Correlation between laboratory and metabolic imaging findings was not statistically significant in our series.Four patients had follow-up FDG PET/CT; three showed interval reduction in metabolic activity to baseline. One showed persistent abnormal metabolic activity before a rise in IgG4 levels. The metabolic imaging response was used to guide steroid dose.

Conclusions

FDG PET/CT is a useful tool in evaluation and follow-up of IgG4-RD, particularly in identifying alternative biopsy sites in patients who present with coronary artery involvement. Hypermetabolic coronary artery masses on FDG PET/CT should raise clinical suspicion of IgG4-RD. As the coronary artery masses may not show decrease in size after treatment, FDG PET/CT is also useful for metabolic response assessment.

An audit on technical quality of root fillings performed by undergraduate students

AIM

To evaluate radiographically the technical quality of root fillings performed by undergraduate dental students and to assess whether students were exposed to an appropriate endodontic case mix during their clinical training.

METHODOLOGY

A retrospective audit was undertaken evaluating the clinical records of patients who underwent endodontic procedures during the period from September 2015 to June 2016 in the Dental School at Queen's University Belfast, UK. Two final-year dental students were trained and calibrated to evaluate postoperative intra-oral periapical radiographs of completed root canal treatments using specific assessment criteria. Data were presented as frequencies, percentage and mean ± standard deviation (SD). Comparisons of treatment outcomes between groups (posterior and anterior teeth) were calculated using Fisher's exact test, and the level of significance was set at P < 0.05. Intra- and interexaminer reproducibility was assessed by Kappa statistics.

RESULTS

A total of 222 teeth and 381 canals were assessed, and of those, 253 (66%) of the root fillings were found to be acceptable in all the assessment parameters, namely taper, length and lateral adaptation of the root filling. Subanalysis of individual root filling parameters revealed that 372 canals (97%) exhibited good taper, and 275 canals (72%) were considered to be of an appropriate length, with 89 canals (23%) found to be underfilled and 17 canals (5%) overfilled. Overall 346 (91%) of canals had good lateral condensation. Students treated both single and multirooted teeth, and there was no significant association between tooth type and the quality of root filling provided (P > 0.05).

CONCLUSIONS

In the majority of the teeth treated by undergraduate students at Queen's University Belfast, the technical quality of the root filling was acceptable and students were exposed to an appropriate case mix for endodontic training.

A systematic review of the barriers affecting medication adherence in patients with rheumatic diseases

Medication adherence is a crucial part in the management of rheumatic diseases, especially with many such patients requiring long-term medications. In this paper, we aim to systematically review the literature for the factors associated with medication adherence in the rheumatic patient population. We carried out a systematic literature search using PubMed^®, PsychInfo^® and Embase ^® with relevant keywords and employed the PRISMA^® criteria. We included English peer-reviewed articles that studied the factors affecting medication adherence in patients with rheumatic diseases, which were assessed by two independent reviewers. Hand searches were conducted and relevant factors were extracted and classified using the World Health Organization (WHO)'s five dimensions of medication adherence. A simple diagram was drawn to summarise the factors extracted. 1977 articles were identified and reviewed and 90 articles were found to be relevant. A total of 17 factors and 38 sub-factors were identified and categorized based on the WHO's five dimensions of medication adherence. A hand model for medication adherence was developed to succinctly summarise these dimension to remind clinicians the importance of medication adherence in daily practice. We conducted a systematic review on the various factors including patient, therapy, condition, health system and socioeconomic-related factors that affected medication adherence in rheumatic patients. We found 17 factors and 38 sub-factors that affected medication adherence in this population. This systematic review can facilitate future focused research in unexplored dimensions.

Association of obesity with patient-reported outcomes in patients with axial spondyloarthritis: a cross-sectional study in an urban Asian population

To determine if obesity is associated with poorer patient-reported outcomes (PROs) in patients with axial spondyloarthritis (axSpA), we conducted a cross-sectional study using data of the PRESPOND registry from a tertiary referral center in Singapore between 2011 and 2015. Demographics, clinical, and PRO variables were collected. Patients were divided into three categories: normal (BMI < 23 kg/m²), overweight (23 kg/m² ≤ BMI < 27.5 kg/m²) and obese (BMI ≥ 27.5 kg/m²), using Asian BMI classification. The dependent variables are Pain score, Bath Ankylosing Spondylitis Patient Global Score (BAS-G), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), and Medical Outcomes Study Short Form 36 version 2 (SF-36). Multivariate regression analyses were performed with these dependent variables and obesity categories, adjusting for confounders. Among 194 patients with axSpA, 32% are overweight while 22% are obese. We found that obese patients had significant poorer pain (β: 11.87, 95%CI 2.13, 21.60) and BAS-G scores (β: 10.18, 95%CI 1.59, 18.76) when compared to normal BMI patients. However, obesity was not associated with BASDAI (β 0.50, 95%CI -0.22, 1.22), BASFI (β 0.08, 95%CI -0.66, 0.81), HAQ (β -0.07, 95%CI -0.21, 0.06), physical component summary (β -0.02, 95%CI -4.47, 4.44), and mental component summary (β -2.85, 95%CI -7.57, 1.88) of SF-36. Obesity was associated with pain score and BAS-G but not with BASDAI, BASFI, HAQ, and SF-36. Further study is needed to examine the causal relationship between obesity and poorer PROs.

Ejection of the Massive Hydrogen-rich Envelope Timed with the Collapse of the Stripped SN 2014C

We present multi-wavelength observations of SN 2014C during the first 500 days. These observations represent the first solid detection of a young extragalactic stripped-envelope SN out to high-energy X-rays ~40 keV. SN 2014C shows ordinary explosion parameters (Ek ~ 1.8 × 1051 erg and Mej ~ 1.7 M⊙). However, over an ~1 year timescale, SN 2014C evolved from an ordinary hydrogen-poor supernova into a strongly interacting, hydrogen-rich supernova, violating the traditional classification scheme of type-I versus type-II SNe. Signatures of the SN shock interaction with a dense medium are observed across the spectrum, from radio to hard X-rays, and revealed the presence of a massive shell of ~1 M⊙of hydrogen-rich material at ~6 × 1016 cm. The shell was ejected by the progenitor star in the decades to centuries before collapse. This result challenges current theories of massive star evolution, as it requires a physical mechanism responsible for the ejection of the deepest hydrogen layer of H-poor SN progenitors synchronized with the onset of stellar collapse. Theoretical investigations point at binary interactions and/or instabilities during the last nuclear burning stages as potential triggers of the highly time-dependent mass loss. We constrain these scenarios utilizing the sample of 183 SNe Ib/c with public radio observations. Our analysis identifies SN 2014C-like signatures in ~10% of SNe. This fraction is reasonably consistent with the expectation from the theory of recent envelope ejection due to binary evolution if the ejected material can survive in the close environment for 103-104 years. Alternatively, nuclear burning instabilities extending to core C-burning might play a critical role.

Effect of ethnicity on disease activity and physical function in psoriatic arthritis in a multiethnic Asian population

Geographic differences in manifestation of psoriatic arthritis (PsA) could be related to differences in genetic or environmental factors. We aimed to compare the disease activity and functional status using validated outcome measures among patients with PsA of different ethnicities living in the same environment. We performed a cross-sectional study on consecutive patients with PsA classified by the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria from a single center. Sociodemographic data, clinical variables, and patient-reported outcomes were collected using a standardized protocol. Disease activities were assessed by validated composite scores: clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA), Composite Psoriatic Disease Activity Index (CPDAI), and minimal disease activity (MDA). Physical function was assessed with Health Assessment Questionnaire (HAQ) and the Medical Outcome Study Short-Form 36 (SF36) physical function subscales. Linear regression analyses were performed to identify variables associated with disease activities and physical function. Ninety-eight patients (51.5%, men) with mean (±SD) age and duration of PsA of 51.5 ± 13.8 and 5.5 ± 8.4 years were recruited. Indian was overrepresented compared with the national distribution of ethnicities. Compared to Chinese, Indian patients were more likely to be using biological therapies, have higher tender joint count, and worse enthesitis. Higher proportion of Indians had higher disease activity categories measured by cDAPSA, CPDAI, and MDA and had poorer physical function. In the multivariable analysis, ethnicity was significantly associated with HAQ and SF36-PF. Compared to Chinese, Indians with PsA living in the same environment had worse disease activity and physical function measured by validated outcomes.

The effectiveness of a real life dose reduction strategy for tumour necrosis factor inhibitors in ankylosing spondylitis and psoriatic arthritis

OBJECTIVE

To determine feasibility of TNF inhibitor (TNFi) dose reduction for severe AS and PsA patients.

METHODS

A retrospective study in a real-world setting. Criteria for dose reduction of TNFi included BASDAI < 4 for ⩾6 months in AS; or DAS28-ESR ⩽ 3.2 for ⩾6 months in PsA. TNFi dose was reduced by one-third. Patients who flared (BASDAI > 4 in AS or DAS28-ESR > 3.2 in PsA) were re-escalated to standard treatment dose.

RESULTS

Twenty-six per cent (33/125) of AS and 18% (15/83) of PsA patients fulfilled criteria and underwent TNFi dose reduction. Fifty-eight per cent (19/33) of AS and 60% (9/15) of PsA patients maintained TNFi dose reduction for mean (s.d) of 1.0 (0.8) years. Reinstating standard dose of TNFi recaptured low disease activity in all patients who failed dose reduction within 24 weeks, with no statistically significant difference in mean BASDAI compared with those maintaining TNFi dose reduction in AS at 24 weeks [mean (s.d) BASDAI 2.4 (1.1) vs 1.9 (1.5), respectively (P = 0.229)]; however in PsA, those who failed dose reduction had higher disease activity compared with patients maintained on TNFi dose reduction at 24 weeks [mean (s.d) DAS28-ESR 2.7 (0.6) vs 1.3 (0.5), respectively (P ⩽ 0.001)]. In PsA, a lower DAS28-ESR prior to dose reduction of TNFi was associated with more successful dose reduction.

CONCLUSIONS

In a real-world setting, 60% of individuals with severe AS and PsA who achieve low disease activity can successfully reduce the dose of TNFi therapy by a third for a mean of 1 year.

Carotid artery inflammation associated with gemcitabine-based therapy: a special report

Vasculitis is an inflammation that can present as acute or chronic in nature, which causes changes in the walls of blood vessels, including thickening, weakening, narrowing and scarring. Gemcitabine, an antimetabolite chemotherapeutic agent, is generally well tolerated with a favorable side effect profile. However, there is increasing evidence that it is associated with vasculitis, which can affect small and large vessels. In this case report, we report a patient who has experienced fever with severe tenderness over right carotid artery, which occurred on the fifth day after the administration of gemcitabine. The exact mechanism of gemcitabine-induced vasculitis is unknown but cessation of gemcitabine and initiation of anti-inflammatory treatment appears to aid in the resolution of the clinical syndrome.