Impact of ankylosing spondylitis on work and family life: comparisons with the US population

Sacroiliitis in inflammatory bowel disease

PURPOSE OF REVIEW

This review summarizes the recent evidence regarding the epidemiology of inflammatory bowel disease (IBD) associated sacroiliitis, including the prevalence, pathogenesis, role of imaging, and therapeutic challenges.

RECENT FINDINGS

Sacroiliitis is an underappreciated musculoskeletal manifestation of IBD, a chronic inflammatory condition of the gut affecting the younger population. Untreated sacroiliitis can lead to joint destruction and chronic pain, further adding to morbidity in IBD patients. Recent publications suggest sacroiliitis can be detected on abdominal imaging obtained in IBD patients to study bowel disease, but only a small fraction of these patients were seen by rheumatologists. Early detection of IBD-associated sacroiliitis could be achieved by utilization of clinical screening tools in IBD clinics, careful examination of existing computed tomography and MRI studies, and timely referral to rheumatologist for further evaluation and treatment. Current treatment approaches for IBD and sacroiliitis include several targeted biologic therapies, but IBD-associated sacroiliitis has limited options, as these therapies may not overlap in both conditions.

SUMMARY

With the advances in imaging, sacroiliitis is an increasingly recognized comorbidity in IBD patients. Future studies focusing on this unique patient population will expand our understanding of complex pathophysiology of IBD-associated sacroiliitis and lead to identification of novel targeted therapies for this condition.

Clinical and imaging findings in enteropathic spondyloarthritis with special emphasize in diagnostic delay: a cross-sectional study

Background

Enteropathic spondyloarthritides (eSpAs) are chronic inflammatory joint diseases associated with inflammatory bowel disease (IBD). Limited data are available on the prevalence since arthritis in IBD patients may be underestimated because medications may hide disease activity with a possible diagnostic delay.

Objectives

We aimed to evaluate diagnostic delay in eSpA and explore associated demographic, clinical, and radiographic characteristics.

Design

Single-centre cross-sectional study conducted on consecutive out-patients referred to the combined Gi-Rhe clinic (November 2018-October 2019).

Methods

We analysed eSpA patients for diagnostic delay, disease activity, inflammatory markers, conventional radiography (CR) and magnetic resonance images (MRI) of sacroiliac joints/spine.

Results

A total of 190 eSpA patients [118 peripheral SpA, 72 axial (Ax) SpA including 44 non-radiographic (nr)-axSpA] were enrolled. axSpA patients had a higher prevalence of men sex, HLA-B27 positivity, uveitis and pancolitis compared with peripheral eSpA. Median diagnostic delay in eSpA was 48 months (IQR 6-77) with no difference between axial and peripheral patients. Radiographic-axial SpA (r-axSpA) patients displayed a higher diagnostic delay compared with nr-axSpA (median/IQR 36/17-129 versus 31/10-57 months, p = 0.03) and were older, with longer disease duration, low education status and high rate of employment than patients with nr-axSpA. r-axSpA patients with sclerosis, syndesmophytes and bridge at CR had higher diagnostic delay than those without lesions. Men showed higher prevalence of spine damage lesions than women as sclerosis, squaring, syndesmophytes and bridges. Longer disease duration was detected in patients with radiographic damage as bridge and sacroiliitis grade 3. On MRI, sacroiliac bone oedema was associated with reduced diagnostic delay, whereas bone erosions were associated with higher diagnostic delay compared with that in patients without these lesions. Patients with psoriasis displayed a higher diagnostic delay compared to those without skin involvement.

Conclusion

Diagnostic delay was higher in r-axSpA compared with nr-axSpA despite the same treatment. Demographic, clinical features and radiological lesions were associated with diagnostic delay.

The impact of gender and sex on diagnosis, treatment outcomes and health-related quality of life in patients with axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic condition, historically considered a predominantly male disease. However, increasing evidence suggests a more equal prevalence between men and women. Of the limited research conducted to date, it is apparent that gender differences exist in terms of time to diagnosis, treatment outcomes and health-related quality of life (HRQoL). Despite this, women are underrepresented in clinical trials and most studies do not stratify by gender to identify potential differences in terms of disease manifestations and treatment response. In this perspectives article, we reflect on the potential biological and social factors contributing to these differences and propose three key areas of education and research that should be prioritised in order to address the unmet needs of female patients with axSpA, namely: (1) to identify ways to increase awareness of disease occurrence in female patients among healthcare professionals (HCPs), (2) to improve understanding of gender differences in disease manifestation and outcomes, and (3) to conduct gender-stratified clinical trials with a representative sample of female patients.

Age-stratified trends in the progression of spinal radiographic damage in patients with ankylosing spondylitis: a longitudinal study

Objective:

The objective of this study was to investigate spinal radiographic progression in specific age ranges of ankylosing spondylitis (AS) patients.

Methods:

Longitudinal data for 1125 AS patients at a single hospital from 2000 to 2018 were retrospectively reviewed. Radiographic intervals were obtained from patients with consecutive spinal radiographs. The radiographic progression rate was defined as the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) change per year within each interval. Using generalized estimating equations (GEEs), estimated marginal means were calculated for the mSASSS progression rate across age groups after adjusting for potential confounders.

Results:

We obtained 4016 radiographic intervals and stratified them into five groups based on patient age at the interval start: <20 (n = 122); 20–29 (n = 1124); 30–39 (n = 1690); 40–49 (n = 794); and ⩾50 years (n = 286). The mean (SD) mSASSS progression rate for all the intervals was 0.8 (1.9). The GEE-estimated mean mSASSS progression rate increased with age, peaking in the 30–39 age group with a value of 1.15 [95% confidence interval (CI) 1.03, 1.27], and decreased slightly thereafter. In the presence of risk factors, rapid progression occurred at earlier ages: the GEE-estimated mean mSASSS progression rate in those with elevated C-reactive protein levels and preexisting syndesmophytes was 2.82 (95% CI 1.93, 3.71) in the 20–29 age group.

Conclusion:

Spinal structural damage in AS seems to progress most rapidly when patients are age 30–39 years. An awareness of the trends in radiographic progression with advancing age could improve understanding of the natural course of AS.

The effect of Pulmonary Rehabilitation Programme on work productivity and clinical parameters in patients with ankylosing spondylitis

OBJECTIVE

The objective of the present study was to investigate the effect of the Pulmonary Rehabilitation Programme on work productivity, disease activity, functional status, quality of life, respiratory function tests (RFTs), physical capacity and depression in ankylosing spondylitis (AS) patients.

METHOD

Twenty-five patients diagnosed with AS were included in this study. The disease severity was evaluated with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), functional status was evaluated with Bath Ankylosing Spondylitis Functional Index (BASFI), quality of life was evaluated with AS-Related Quality of Life Scale (ASQOL), physical capacity was evaluated with the 6-min walking test (6MWT), depression level was evaluated with Beck Depression Scale (BDS) and work productivity was evaluated with Spondyloartropathy Work Productivity and Activity Impairment (WPAI-SpA) Survey. Finally, RFT was evaluated with spirometry measurement. The patients were included in the Pulmonary Rehabilitation Programme for 8 weeks.

RESULTS

A total of 30% of the patients who were included in this study were unemployed, 35% of them were on and below the hunger limit, 25% were on and below the poverty line, and 40% were on the normal income line. No significant changes were detected in the RFTs after the exercise programme in AS patients (P > .05), but significant improvements were detected in the BASDAI, BASFI, WPAI, 6MWT, ASQOL and BDS (P < .001).

CONCLUSION

Pulmonary Rehabilitation Programme was found to be an effective method of improving work productivity in AS patients. Also, the Pulmonary Rehabilitation Programme has positive effects on disease activity, functional status, physical capacity, depression level, and quality of life.

How do clinical and socioeconomic factors impact on work disability in early axial spondyloarthritis? Five-year data from the DESIR cohort

Objectives

To investigate the impact of clinical and socioeconomic factors on work disability (WD) in early axial spondyloarthritis (axSpA).

Methods

Patients from the DESIR cohort with a clinical diagnosis of axSpA were studied over 5 years. Time to WD and potential baseline and time-varying predictors were explored, with a focus on socioeconomic (including ethnicity, education, job-type, marital/parental status) and clinical (including disease activity, function, mobility) factors. Univariable analyses, collinearity and interaction tests guided subsequent multivariable time-varying Cox survival analyses.

Results

From 704 patients eligible for this study, the estimated incidence of WD among those identified as at risk (n = 663, 94%), and across the five years of DESIR, was 0.05 (95% CI 0.03, 0.06) per 1000 person-days. Significant differences in baseline socioeconomic factors, including lower educational status and clinical measures, including worse disease activity, were seen in patients developing WD over follow-up, compared with those who never did. In the main multivariable model, educational status was no longer predictive of WD, whereas the AS disease activity score (ASDAS) and the BASFI were significantly and independently associated with a higher hazard of WD [HR (95%CI) 1.79 (1.27, 2.54) and 1.42 (1.22, 1.65), respectively].

Conclusion

WD was an infrequent event in this early axSpA cohort. Nevertheless, clinical factors were among the strongest predictors of WD, over socioeconomic factors, with worse disease activity and function independently associated with a higher hazard of WD. Disease severity remains a strong predictor of adverse work outcome even in early disease, despite substantial advances in therapeutic strategies in axSpA.

Biologic use in psoriatic arthritis and ankylosing spondylitis patients: a descriptive epidemiological study using linked, routine data in Wales, UK

OBJECTIVES

PsA and AS are chronic diseases associated with significant morbidities. National and international management guidelines include treatment with biologic therapies to improve outcomes and quality of life. There are limited real-world data on the patients' journey from symptom onset to diagnosis and treatment in the UK. We use real-life, linked health data to explore patient pathways and the impact of biologics on patient outcomes.

METHODS

Data from the Secure Anonymised Information Linkage databank in Wales were used to assess diagnosis and treatment of patients ≥18 years of age with at least one International Classification of Diseases, Tenth Revision code present for PsA/AS in rheumatology clinic data and at least one Read code present in primary care records. We investigated the use of biologics while exploring demographics, comorbidities and surgical procedures of 641 AS patients and 1312 PsA patients.

RESULTS

AS patients were significantly younger at diagnosis and were predominantly male. The average time from presenting symptoms to diagnosis of AS and PsA was 7.9 (s.d. 5.5) and 9.3 (s.d. 5.5) years, respectively. The proportion of patients receiving biologic treatment was significantly higher in AS (46%) compared with PsA patients (28.8%); of these, 23.1% of AS and 22.2% of PsA patients stopped/switched a biologic. There was a significant reduction in primary care involvement, sick notes and disability living allowance for both AS and PsA patients following biologic initiation.

CONCLUSION

This real-world descriptive study confirms that patients treated with biologics have reduced disability and time off work despite being initiated ∼13 years after the first symptoms and 6 years after diagnosis.

Prevalence of axial spondyloarthritis in patients with inflammatory bowel disease using cross-sectional imaging: a systematic literature review

BACKGROUND

Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA), which, if left untreated, may significantly impact on clinical outcomes. We aimed to estimate the prevalence of axSpA, including previously undiagnosed cases, in IBD patients from studies involving cross-sectional imaging and identify the IBD features potentially associated with axSpA.

METHODS

PubMed, Embase and Cochrane databases were searched systematically between 1990 and 2018. Article reference lists and key conference abstract lists from 2012 to 2018 were also reviewed. All abstracts were reviewed by two authors to determine eligibility for inclusion. The study inclusion criteria were (a) adults aged 18 years or above, (b) a clinical diagnosis of IBD and (c) reporting identification of sacroiliitis using cross-sectional imaging.

RESULTS

A total of 20 observational studies were identified: 12 used CT, 6 used MR and 2 utilised both computed tomography (CT) and magnetic resonance (MR) imaging. Sample sizes ranged from 25 to 1247 (a total of 4096 patients); 31 studies were considered to have low selection bias, 13 included two or more radiology readers, and 3 included rheumatological assessments. The prevalence of sacroiliitis, the most commonly reported axSpA feature, ranged from 2.2% to 68.0% with a pooled prevalence of 21.0% [95% confidence interval (CI) 17-26%]. Associated IBD features include increasing IBD duration, increasing age, male sex, IBD location, inflammatory back pain and peripheral arthritis. No significant difference in the prevalence of sacroiliitis between Crohn's disease and ulcerative colitis was identified. Study limitations include variability in the individual study sample sizes and patient demographics.

CONCLUSION

This review highlights the need for larger, well-designed studies using more sensitive imaging modalities and multivariable modelling to better estimate the prevalence of axSpA in IBD. An improved knowledge of the IBD phenotype(s) associated with axSpA and use of cross-sectional imaging intended for IBD assessment to screen for axSpA may help clinicians identify those patients most at risk.

Lack of Associations between Endoplasmic Reticulum Aminopeptidase 2 Gene Polymorphisms and Ankylosing Spondylitis: A Meta-analysis with Trial Sequential Analysis

Background: Endoplasmic reticulum aminopeptidase 2 (ERAP2) gene is reported to be associated with inflammation-related diseases. Several studies have investigated the associations of ERAP2 gene polymorphisms and susceptibility to ankylosing spondylitis (AS). However, the findings of those studies were inconsistent. The aim of this study was to elucidate the associations by a meta-analysis with trial sequential analysis (TSA).Methods: Online databases of PubMed, Web of Science, EMBASE, Cochrane Library, Wanfang, and CNKI were searched to identify eligible studies on the associations of ERAP2 gene polymorphisms and AS. Study quality was judged based on the Newcastle-Ottawa scale (NOS). Strengths of associations were presented by P-value, odds ratios (ORs), and 95% confidence intervals (95%CIs). TSA was employed to evaluate the information size and statistical power.Results: A total of six studies encompassing 2774 AS patients and 4119 disease-free controls were eligible for this meta-analysis. Five studies reported rs2248374 polymorphism and three studies reported rs2549782 polymorphism. The pooled data suggested that the two polymorphisms were not significantly associated with AS susceptibility: rs2248374, A vs. G, OR = 0.94, 95%CI 0.86-1.02, P = .14; rs2549782, T vs. G, OR = 1.03, 95%CI 0.95-1.12, P = .45. TSA indicated that the sample sizes appeared to be inadequate to obtain a positive outcome.Conclusion: The present findings of this study do not support any evidence on the associations of rs2248374 and rs2549782 polymorphisms in the ERAP2 gene and susceptibility to AS. Additional well-designed and large-sample studies in diverse ethnicities are encouraged to validate the current findings.

Educational needs of patients with rheumatic and musculoskeletal diseases attending a large health facility in Austria

INTRODUCTION

Patient education is an important part of the management of rheumatic and musculoskeletal diseases. Given that patients with diverse diseases do not have the same needs, it is crucial to assess the educational requirements of targeted groups to provide tailored educational interventions. The aim of our study was to assess educational needs of a large cohort of patients with different rheumatic and musculoskeletal diseases attending a health facility in Austria.

METHODS

We assessed educational needs, via an online survey of patients with fibromyalgia (FMS), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) recruited from an Austrian health-care facility, using the Austrian version of the Educational Needs Assessment Tool (OENAT).

RESULTS

For our sample of 603 patients, AS (62%), RA (15%), and FMS (24%), there were no educational need differences for the domains of movements, disease process, and self-help measures. Patients with FMS had less need for pain management education and greater need for education about feelings, than other disease groups. Patients with RA had a greater need for education related to treatments than other groups, and patients with AS had a greater need for treatment education than patients with FMS. Patients with AS reported greater need for support system education than other patient groups.

CONCLUSION

Educational needs vary by disease groups, suggesting that health-care professionals should assess disease-specific needs for education to provide optimal assistance in disease management for patients.

Patient‐reported Impact of Axial Spondyloarthritis on Working Life: Results from the EMAS survey

Objective

To evaluate work‐related issues (WRIs) and their determinants in patients with axial spondyloarthritis (SpA) across Europe.

Methods

The European Map of Axial Spondyloarthritis is a cross‐sectional online survey (2017–2018) of unselected patients with self‐reported axial SpA from 13 European countries. Participants were classified as active or inactive members of the labor force according to the International Labor Organization standards. Those employed reported WRIs due to axial SpA in the past 12 months. Sociodemographic characteristics and patient‐reported outcomes were compared between patients with and without WRIs. Stepwise regression analysis was conducted to identify independent determinants of WRIs.

Results

The sample comprised 2,846 patients with axial SpA, 1,653 were active members of the labor force, 1,450 were employed, and of those employed, 67.7% reported at least 1 WRI. The most frequently reported WRIs were taking sick leave (56.3%), difficulty fulfilling working hours (44.6%), and missing work for doctor’s appointments (34.6%). Of the total sample, 74.1% declared that they had faced or would face difficulties finding a job due to axial SpA. Patients with WRIs were more often female, were less likely to be married or in a relationship, and had a higher educational level, poorer patient‐reported outcomes, and a greater prevalence of anxiety and depression. Multivariable regression showed that WRIs were associated with a higher Bath Ankylosing Spondylitis Disease Activity Index score (odds ratio [OR] 1.30 [95% confidence interval (95% CI) 1.16–1.45]) and the 12‐item General Health Questionnaire score (OR 1.15 [95% CI 1.09–1.22]), and were negatively associated with inflammatory bowel disease (OR 0.58 [95% CI 0.36–0.91]).

Conclusion

Approximately two‐thirds of employed patients experienced WRIs due to axial SpA. Association between disease activity and psychological distress with WRIs suggests the need to ensure that axial SpA patients receive the required support to cope with their working life.

Work Disability in Axial Spondyloarthritis

PURPOSE OF REVIEW

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that typically affects people of working age. Work-related outcomes are therefore important to study, both from an individual but also a societal perspective. Through this review of the literature, we explore the impact of axSpA on key work outcomes including work and productivity loss and predictors for these.

RECENT FINDINGS

Recent evidence confirms that axSpA is associated with substantial consequences on the ability to work. Reassuringly, early treatment and use of biologics have been associated with improved wok outcomes highlighting the importance of prompt diagnosis and management. High disease activity, labour-intensive jobs, poor physical function and impaired spinal mobility are among identified predictors of adverse work outcomes in axSpA. The impact of axSpA on work outcomes is considerable and necessitates optimal intervention, including suppression of disease activity, to enhance people's chances of remaining in work.

Insight into the Quality of Life of Patients with Ankylosing Spondylitis: Real-World Data from a US-Based Life Impact Survey

INTRODUCTION

We aim to assess the real-world, US patient-reported impact of ankylosing spondylitis (AS) on quality of life (QOL) across physical, discomfort, social, and emotional domains.

METHODS

Demographic and QOL data were collected from a random sample of patients associated with the Spondylitis Association of America (SAA) from July to December 2017. QOL measures were based on the Evaluation of Ankylosing Spondylitis Quality of Life (EASi-QoL) questionnaire. The survey evaluated AS impact on the physical domain on the day of survey participation and impact on the discomfort, social, and emotional domains within the week before participation. A 3:1 (male to female) weighting was performed to reflect the reported prevalence of AS in US adults.

RESULTS

Of 820 respondents who completed the survey, 716 self-reported receiving an AS diagnosis from their doctor and were included in this analysis (mean age, 55.5 years; 46.9% male). The mean total EASi-QoL score was 28.9 (weighted); overall, 33.7%, 31.7%, and 34.7% of respondents, respectively, reported a low (EASi-QoL score 0-17), a medium (18-35), and a high (≥ 36) impact of AS on QOL. The physical domain was most impacted; 41.9% of respondents had an EASi-QoL score ≥ 10 (weighted). Women were significantly more likely than men to report a high impact of AS on all QOL domains. Biologic users reported an impact on QOL comparable with the impact on QOL of nonsteroidal anti-inflammatory drug use. AS also impacted lifestyle characteristics, including career choice and sports participation.

CONCLUSION

AS negatively impacted all QOL domains analyzed. The incorporation of subjective measures of disease into disease evaluation should be considered.

FUNDING

Novartis Pharmaceuticals Corporation and UCB, Inc. Plain language summary available for this article.

Impact of biological therapy on work outcomes in patients with axial spondyloarthritis: results from the British Society for Rheumatology Biologics Register (BSRBR-AS) and meta-analysis

OBJECTIVES

To quantify, among patients with axial spondyloarthritis (axSpA), the benefit on work outcomes associated with commencing biologic therapy.

METHODS

The British Society for Rheumatology Biologics Register in Axial Spondyloarthritis (BSRBRAS) recruited patients meeting Assessment of SpondyloArthritis International Society criteria for axSpA naïve to biological therapy across 83 centres in Great Britain. Work outcomes (measured using the Work Productivity and Activity Impairment Index) were compared between those starting biological therapy at the time of recruitment and those not. Differences between treatment groups were adjusted using propensity score matching. Results from BSRBR-AS were combined with other studies in a meta-analysis to calculate pooled estimates.

RESULTS

Of the 577 participants in this analysis who were in employment, 27.9% were starting biological therapy at the time of recruitment. After propensity score adjustment, patients undergoing biological therapy, at 12-month follow-up, experienced significantly greater improvements (relative to non-biological therapy) in presenteeism (-9.4%, 95% CI -15.3% to -3.5%), overall work impairment (-13.9%, 95% CI -21.1% to -6.7%) and overall activity impairment (-19.2%, 95% CI -26.3% to -12.2%). There was no difference in absenteeism (-1.5%, 95% CI -8.0 to 4.9). Despite these improvements, impact on work was still greater in the biological treated cohort at follow-up. In the meta-analysis including 1109 subjects across observational studies and trials, treatment with biological therapy was associated with significantly greater improvements in presenteeism, work impairment and activity impairment, but there was no difference in absenteeism.

CONCLUSIONS

There is consistent evidence that treatment with biological therapy significantly improves work productivity and activity impairment in people with axSpA. However, there remain substantial unmet needs in relation to work.

Healthcare Utilization and Direct Costs in Patients with Ankylosing Spondylitis Using a Large US Administrative Claims Database

Introduction

In addition to the considerable patient and societal burdens, the financial burdens of ankylosing spondylitis (AS) are substantial. Understanding both all-cause and AS-specific direct costs in patients with AS is important if we are to understand the financial impact on patients with AS and payers in the United States. This study assessed both all-cause and AS-specific healthcare utilization and direct costs in US patients with AS using administrative claims data.

Methods

Adults aged ≥ 18 years enrolled in the MarketScan^® Commercial and Medicare databases with ≥ 1 inpatient or ≥ 2 non-rule-out outpatient diagnoses of AS between January 1, 2013, and December 31, 2013, were included. Patients had continuous enrollment with medical and pharmacy benefits for ≥ 12 months before and after the index date (first diagnosis). Non-AS controls were matched up to 5:1 to patients with AS on age, geographic region, index calendar year, and sex. All-cause and AS-specific healthcare utilization and direct costs were measured during the follow-up period and reported as per patient per year.

Results

Patients with AS (N = 6679) had significantly higher rates of total all-cause inpatient admission (12% vs 6%), emergency department visits (23% vs 15%), nonhospital-based outpatient visits (100% vs 84%), hospital-based outpatient visits (68% vs 46%), other outpatient services (97% vs 81%), and medication use (97% vs 82%) compared with matched controls (N = 19,951). Patients with AS had approximately tenfold higher median total healthcare costs than matched controls ($24,978 vs $2139 per patient per year), largely driven by increased outpatient and pharmacy costs; P < 0.05 for all comparisons. The median (IQR) total AS-specific healthcare costs were $10,250 ($774, $28,824).

Conclusion

In this analysis of claims data, increased outpatient and pharmacy costs were key contributors to higher all-cause total healthcare costs in US patients with AS.

Funding

Novartis Pharmaceuticals Corporation, East Hanover, NJ.

Electronic supplementary material

The online version of this article (10.1007/s40744-018-0124-4) contains supplementary material, which is available to authorized users.

Transcriptome analysis of ankylosing spondylitis patients before and after TNF-α inhibitor therapy reveals the pathways affected

Tumor necrosis factor-α (TNF-α) inhibitors are highly effective in suppressing inflammation in ankylosing spondylitis (AS) patients, and operate by suppression of TFN-α and downstream immunological pathways. To determine the mechanisms of action of TNF-α inhibitors in AS patients, we used transcriptomic and bioinformatic approaches on peripheral blood mononuclear cells from AS patients pre and post treatment. We found 656 differentially expressed genes, including the genome-wide significant AS-associated genes, IL6R, NOTCH1, IL10, CXCR2 and TNFRSF1A. A distinctive gene expression profile was found between male and female patients, mainly because of sex chromosome-linked genes and interleukin 17 receptor C, potentially accounting for the differences in clinical manifestation and treatment response between the genders. In addition to immune and inflammation regulatory pathways, like intestinal immune network for IgA production, cytokine-cytokine receptor interaction, Ras signaling pathway, allograft rejection and hematopoietic cell lineage, KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway analyses revealed that infection-associated pathways (influenza A and toxoplasmosis) and metabolism-associated pathways were involved in response to TNF-α inhibitor treatment, providing insight into the mechanism of TNF-α inhibitors.

Genetic association between TAP1 and TAP2 polymorphisms and ankylosing spondylitis: a systematic review and meta-analysis

OBJECTIVES

Ankylosing spondylitis (AS) is a chronic inflammatory joint disease. The transporter associated with antigen processing (TAP) has been identified to play an important role in immune response as well as the HLA-associated diseases. The aim of our meta-analysis was to investigate the contribution of TAP (TAP1 and TAP2) polymorphisms to the risk of AS.

METHODS

Meta-analyses were performed between 2 polymorphisms in TAP1 (TAP1-333, -637) and 3 polymorphisms in TAP2 (TAP2-379, -565, and -665) and AS.

RESULTS

The meta-analyses were involved with 6 studies with 415 cases and 659 controls. Significant association was found between TAP1-333Val, TAP1-637Gly, and TAP2-565Thr and AS compared with combined control group (TAP1-333Val: p = 0.009, OR = 1.40, 95% CI 1.09-1.80; TAP1-637Gly: p = 0.002, OR = 1.48, 95% CI 1.15-1.91; p = 0.03, OR = 1.38, 95% CI 1.04-1.84). Subgroup analysis shown that significant association was only found in AS when compared with HLA-B27-negative controls (TAP1-333Val: p = 0.004, OR = 1.53, 95% CI 1.14-2.06; TAP1-637Gly: p = 0.004, OR = 1.52, 95% CI 1.15-2.02; p = 0.02, OR = 1.56, 95% CI 1.09-2.24), but not in AS when compared with HLA-B27-positive controls (p > 0.05). Moreover, no significant associations were found between haplotypes in TAP1 and TAP2 in both the combined and the subgroup analyses (p > 0.05).

CONCLUSIONS

TAP1-333Val, TAP1-637Gly, and TAP2-565Thr were likely to be associated with AS.

Affective temperament profile in ankylosing spondylitis patients using TEMPS-A

[Purpose] This study aimed to compare the most common dominant affective temperaments in Ankylosing Spondylitis patients and investigate the relationship between the dominant affective temperaments and pain levels, disease activity, quality of life, current depression, and anxiety level in Ankylosing Spondylitis patients. [Subjects and Methods] Fifty-one patients diagnosed with axial spondiloartropathy and forty-two age- and gender-matched control subjects were included in this study. Disease duration, erythrocyte sedimentation rate, serum C-reactive protein, pain by the Visual Analog Scale, disease activity by the Bath Ankylosing Spondylitis Disease Activity Index, functional status by the Bath Ankylosing Spondylitis Functional Index; psychological status by the Beck Depression Inventory, Beck Anxiety Inventory and overall health assessment by the Ankylosing Spondylitis Quality of Life Scale were assessed in patients. The Turkish version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto Questionnaire was used to determine the dominant affective temperament. [Results] There was no statistical difference in the distribution of temperament subtypes between patients with Ankylosing Spondylitis and the controls. Depressive, anxious, and cyclothymic temperament scores were higher in patients with high values on the Bath Ankylosing Spondylitis Functional Index and Visual Analog Scale. There was a correlation between anxious subtypes of affective temperament scores and the value of Ankylosing Spondylitis Quality of Life Scale. Correlation analysis also found depressive, cyclothymic, irritable, and anxious temperament and psychiatric symptoms to be significantly related. [Conclusion] Affective temperament may contribute to symptoms of depression and anxiety in patients with Ankylosing Spondylitis and may increase disease activity and may reduce their quality of life.

Longitudinal Analyses of Presenteeism and Its Role as a Predictor of Sick Leave in Patients With Ankylosing Spondylitis

OBJECTIVE

To investigate, in a cohort of patients with ankylosing spondylitis (AS) adequately treated with infliximab, changes over time in presenteeism and the role of presenteeism relative to that of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) in predicting sick leave.

METHODS

Data were analyzed from 71 patients with paid work and taking a stable dose of infliximab participating in a 96-week study with 5 assessment points. Covariates included presenteeism, sick leave, time, sex, age, BASDAI, BASFI, Bath Ankylosing Spondylitis Metrology Index, and part- or full-time work. Presenteeism represented the AS impact on productivity (by visual analog scale, range 0-10, where 10 = completely unproductive). Sick leave represented the number of days absent from work due to AS in the last 6 months. A linear mixed-effects model for presenteeism, and hurdle and zero-inflated count models for sick leave were explored.

RESULTS

Mean ± SD presenteeism ranged from 2.2 ± 2.2 to 3.8 ± 7.8, and sick leave occurred in 8-17% of the patients during the 6-month period. Presenteeism positively correlated with BASDAI and BASFI, but was not significantly influenced by time. The chance of incurring sick leave was affected by presenteeism but not by BASDAI and BASFI. Conditional on being absent from work, the effect of presenteeism on the length of sick leave (in days) was much stronger than BASDAI and BASFI. For presenteeism ≥5, an increase of 1 unit in presenteeism yielded an increase by 36-40% (or 2-12 days) in the length of sick leave during the following 6 months.

CONCLUSION

Presenteeism, even measured by a simple visual analog scale, was an important factor to explain future sick leave.

Golimumab for the treatment of axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease of the axial skeleton that includes ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA). Patients with AS experience chronic pain due to sacroiliac joint and spinal inflammation, and may develop spinal ankylosing with syndesmophyte formation. Tumor necrosis factor α inhibitors (TNFi) have shown promise in the management of AS and axSpA by targeting the underlying inflammatory process, and providing symptomatic relief. Whether they alter the progression of the disease is uncertain. Golimumab is a fully human IgG1 monoclonal antibody that targets and downregulates the pro-inflammatory cytokine TNF-α. The use of golimumab has been shown to reduce the signs and symptoms of axSpA as well as improve patient function and quality reported outcomes. This review focuses on the biological rationale and the results of clinical trials with golimumab for the treatment of axSpA.

Axial spondyloarthritis

The term axial spondyloarthritis covers both non-radiographic disease and radiographic disease (also known as ankylosing spondylitis). Some studies have been performed to investigate the prevalence of axial spondyloarthritis, although most are limited to patients with radiographic disease. A strong genetic association has been shown between axial spondyloarthritis and human leukocyte antigen-B27 (HLA-B27), but the pathogenetic role of HLA-B27 has not yet been clarified. Tumour necrosis factor (TNF), IL-17, IL-23 and downstream pathways also seem to be important - based on the good results of therapies directed against these molecules - but their exact role in the inflammatory process is also not yet clear. Elucidating the interaction between osteoproliferation and inflammation will be crucial for the prevention of long-term structural damage of the bone. The development of new criteria for classification, diagnosis and screening of patients with axial spondyloarthritis will enable earlier intervention for this chronic inflammatory disease. MRI has become an important tool for the early detection of axial spondyloarthritis. NSAIDs and TNF blockers are effective therapies, including in the early non-radiographic stage. Therapeutic blockade of IL-17 or IL-23 seems to be a promising new treatment option. Tools for measuring quality of life in axial spondyloarthritis have become relevant to assess the impact that the disease has on patients. These diagnostic and therapeutic advances will continue to change the management of axial spondyloarthritis, and new insights into the disease pathogenesis will hopefully accelerate this process. For an illustrated summary of this Primer, visit: http://go.nature.com/51b1af.

Gender differences in axial spondyloarthritis

Within the concept of axial spondyloarthritis (axSpA), relevant differences between men and women have been described for patients with the radiographic disease form [ankylosing spondylitis (AS)]. The subjective perception of disease activity (spinal and peripheral pain, fatigue, morning stiffness) has been shown to be higher in female than in male patients. Moreover, women experience more functional limitations and a lower quality of life, despite lower degrees of radiographic spinal damage. Peripheral clinical involvement (arthritis and enthesitis) is, additionally, more predominant in women. On the other hand, a higher level of objective signs of inflammation (C-reactive protein, erythrocyte sedimentation rate, magnetic resonance imaging of sacroiliac joints and spine) has been reported in men. Whether these differences might explain the better response to treatment with anti-tumor necrosis factor agents observed in male patients remains unclear. The underlying causes of the discrepancies are still unknown and genetic, environmental, cultural and/or societal factors may be involved. While AS is still more prevalent in men in a ratio of 2-3:1, the prevalence of males and females in patients with axSpA without radiographic sacroiliac damage is similar. Gender differences in this subgroup of patients have not been adequately addressed, and are particularly needed to further validate the Assessment of SpondyloArthritis international Society classification criteria.

Health-related quality of life in patients with ankylosing spondylitis: a comprehensive review

Ankylosing spondylitis (AS) is a complex systemic rheumatological disease which often causes severe disability and impaired quality of life (QoL). We searched the PubMed/MEDLINE electronic database for available literature on QoL and its predictors in patients with AS. Recent evidence indicates that AS patients have poorer QoL compared to the general population, but similar to that of patients with other rheumatological disorders. Disease activity is one of the most powerful predictors of QoL, however latest advances in pharmacological treatment (namely, anti-TNF-α) along with physical exercise can minimize the effects of AS on QoL. Psychological distress symptoms contribute to impaired QoL both directly and indirectly by influencing disease activity. The impact of other psychosocial variables, however, is less studied and more prospective investigations are necessary, which could eventually lead to the development of psychosocial interventions that are personalized to this patient population.

Striking a balance: work-health-personal life conflict in women and men with arthritis and its association with work outcomes

PURPOSE

To examine men and women's perceptions of inter-role balance/imbalance in work, arthritis, and personal roles and its association with demographic, health and employment factors, including job stress, career satisfaction, job disruptions, absenteeism and perceived productivity losses.

METHODS

Participants were employed, aged ≥40 years and diagnosed with osteoarthritis or inflammatory arthritis. They were recruited through community advertising and rheumatology clinics in two Canadian provinces. Respondents completed a 35-45 min telephone interview and a 20-min self-administered questionnaire assessing role perceptions [(arthritis negatively impacts work (A → W); work/personal life negatively impact arthritis (W/P → A); work as a positive role (W +))], demographic, health and work context information. Analyses included exploratory factor analysis and multivariate regressions.

RESULTS

Findings revealed similarities between men (n = 104) and women (n = 248) in health, work and role perceptions, although women reported more benefits of working with arthritis (W+) than men. Some gender differences were found in factors associated with inter-role perceptions highlighting the importance of children, fatigue, unpredictable work hours, job control, and workplace activity limitations. Role perceptions were associated with work outcomes but only one perception, W/P → A, interacted with gender. Among men, greater perceptions that work and personal demands interfered with managing arthritis were associated with more job disruptions.

CONCLUSIONS

This study revealed negative and positive inter-role perceptions related to working with a chronic illness and associations with work outcomes. It highlights potentially modifiable factors that could assess risk and inform interventions to improve role balance and working experiences.

Association between KIR polymorphisms and ankylosing spondylitis in populations: a meta-analysis

OBJECTIVES

Published association studies of killer cell immunoglobulin-like receptors (KIRs) and ankylosing spondylitis (AS) in populations are inconsistent. The aim of this study is to determine whether the KIR polymorphisms confer susceptibility to AS in populations by conducting a meta-analysis.

METHODS

A computer search was carried out up to August 2013 for literature pertaining to AS and KIR polymorphisms. Publications addressing the association between the KIR polymorphisms and susceptibility to AS in populations were selected from the Pubmed, Elsevier Science Direct, China National Knowledge Infrastructure (CNKI) and Chinese Biomedical Literature Database (CBM) databases. The odds ratio (OR) with 95% confidence interval (95%CI) was calculated.

RESULTS

A total of 13 case-control studies in 9 articles were included in this meta-analysis. Meta-analysis results identified two positive associations of 2DS4 and 3DS1 with susceptibility to AS in populations. In subgroup analysis, there was a positive association between 2DS4 and susceptibility to AS in Asians, but not in Caucasians. And there were associations between 3DL1, 3DS1 and susceptibility to AS in Caucasians, but not in Asians. Results of subgroup analysis also showed that there were associations between 2DL5, 2DS4, 2DS5, 3DL1, 3DS1 and susceptibility to AS in HLA-B*27-positive patients and HLA-B*27-positive healthy controls.

CONCLUSIONS

This meta-analysis confirms that 2DS4 and 3DS1 might be potential risk factors for AS in populations.

Prevalence and associated risk factors for work disability in Egyptian patients with ankylosing spondylitis from one center

OBJECTIVE

To determine the prevalence of work disability (WD) in Egyptian patients with ankylosing spondylitis (AS) and to identify the main factors associated with this.

METHODS

A cross-sectional survey was conducted among all patients with AS during an extended outpatient visit in the period between July, 2011 and December, 2012. Demographic data were collected and a physical examination was performed. Multivariate modeling was applied to determine the factors associated with work disability.

RESULTS

The questionnaire was completed by 90 patients (85 males; 94.4%). The mean age of the participants was 37.8 (SD 9.7) years, mean disease duration was 12.1 (SD 8.9) years, and the mean symptom duration was 15 (SD 2.9) years. A total of 36 (40%) patients of working age were not working due to AS. The factors that associated with work disability, after completing logistic regression models, were older age (odds ratio [OR] = 1.8, 95%, confidence interval [CI] = 1.04-1.17), longer disease duration (OR = 1.60, 95% CI = 1.12-2.8), increasing diagnostic delay (OR = 2.1, 95% CI = 1.0-3.4), lower educational level (OR = 3.5, 95% CI = 1.6-6.4), manual profession (OR = 1.80, 95% CI = 1.10-2.6), living in a rural zone (OR = 3.14, 95% CI = 1.98-5.05), peripheral arthritis (OR = 2.04, 95% CI = 1.20-3.43) and psychological symptoms (OR = 2.3, 95% CI = 1.9-4.6).

CONCLUSION

The prevalence of WD among Egyptian patients with AS is considerably high. Clinical and psychosocial factors, in particular, appear to be associated with WD and should therefore be prioritized in clinical practice.

Juvenile Versus Adult-onset Ankylosing Spondylitis — Clinical, Radiographic, and Social Outcomes. A Systematic Review

Ankylosing spondylitis (AS) has 2 main modes of onset: juvenile-onset AS (JoAS) and adult-onset AS (AoAS). It is not known whether JoAS is a subtype of AS, or AS modulated by early age of onset and longer disease duration. We performed a systematic review of the literature, identifying 12 articles and 1 abstract directly comparing JoAS and AoAS cohorts, with observational study design. Patients with JoAS appear to have more peripheral joint involvement both clinically and radiographically (especially knees and ankles) and more root joint involvement (hips and shoulders); they are more likely to proceed to hip arthroplasty and often initially present with peripheral rather than axial symptoms. Patients with AoAS appear to have more axial symptoms and radiographic disease, particularly in the lumbar spine, and worse axial metrology. In terms of other characteristics, more evidence is needed to confidently state whether JoAS and AoAS are different.

Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force

BACKGROUND

Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA).

OBJECTIVE

To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy.

METHODS

Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail.

RESULTS

Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9-10 (10: maximum agreement) for all recommendations. A research agenda was formulated.

CONCLUSIONS

The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.

Management of work disability in rheumatic conditions: a review of non-pharmacological interventions

Because of its substantial personal social and economic costs, workforce participation among individuals with rheumatic diseases has received considerable research attention. This chapter reviews non-pharmacological employment interventions for people with rheumatic diseases, focussing on the comprehensiveness of interventions, whether they have been targeted to those groups identified as most at risk, and intervention outcomes and effectiveness. Findings highlight that early diagnosis and treatment of rheumatic diseases may not be enough to keep individuals employed and that comprehensive work interventions may have positive psychological effects, as well as result in increased work participation. However, we lack data addressing the optimum time to intervene and subgroup analyses to determine whether some groups are at increased risk for poor work outcomes. Consistent inclusion of behavioural and psychological outcomes to evaluate interventions and compare studies is also needed, along with cost-benefit studies, to determine the long-term feasibility of work interventions.

Improving the standard of care for people with ankylosing spondylitis and a new approach to developing specialist ESP-Led AS clinics

OBJECTIVES

In the UK, there is a wide variation in the quality of care that people with ankylosing spondylitis (AS) receive. People with AS require early diagnosis and referral to a specialist team to commence treatment and optimize outcome.

METHODS

At East Kent Hospitals University Foundation Trust, a specialist clinic led by an extended scope practitioner (ESP) physiotherapist has been set up for the assessment and monitoring of patients with AS. This report describes the service provided by the AS clinic.

RESULTS

Over eight years, the number of patients seen has risen from 62 to 352, and annual consultations from 186 to 986, with an average of 2.8 visits per patient per year. Ninety-seven patients have started treatment with a Tumour Necrosis Factor (TNF) blocker. The service has expanded by the addition of a support worker and biologic clinics.

CONCLUSION

For the Trust, the specialist service provides an improved quality of care and cost-effective use of staff resources. Evaluation has demonstrated that patients welcome the new service.

Etanercept in the treatment of ankylosing spondylitis: a meta-analysis of randomized, double-blind, placebo-controlled clinical trials, and the comparison of the Caucasian and Chinese population

BACKGROUND AND PURPOSE

Ankylosing spondylitis (AS) is a kind of rheumatic disease, leading to pain, fatigue, stiffness, and functional impairment, which seriously affects the quality of life. Etanercept, a fully human recombinant protein, has been applied for the treatment of AS. However, there has not been a systematic analysis for its efficacy and safety.

METHODS

This meta-analysis of fourteen randomized, double-blind, placebo-controlled clinical trials with 1,570 participants was performed to investigate the efficacy and safety of etanercept, by means of calculating the overall relative risk, and to compare the different responses between the Caucasian population and the Chinese population.

RESULTS

Generally, there was sufficient evidence to prove that etanercept has its advantages in both disease activity controlling and symptoms relieving, especially for axial joints compared with peripheric joints, without higher incidence of serious adverse events.

INTERPRETATION

Our preliminary analysis provided that the Caucasian population has better response to etanercept treatment, with more treatment-emergent adverse events. Further specially designed clinical trials need to be performed to investigate the different responses between axial and peripheric joints, also between different races.

Economic considerations of the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is associated with both significant direct and indirect costs, which vary by country, and have generally increased dramatically since the introduction of anti-tumor necrosis factor therapy. The cost-effectiveness of biologic agents is controversial, although cost-effectiveness studies need to consider the potential impact of anti-tumor necrosis factor treatments on work ability. Alternatives to reduce costs associated with biologics have been examined, including on-demand dosing and lower dose alternatives. Other treatment measures, such as total hip arthroplasty and physical therapy, are also effective in reducing pain and improving function in patients with AS, although the optimal type or combination of physical therapy treatment modalities, the optimal frequency and duration of treatment and whether therapy is equally effective in stable disease and uncontrolled AS need to be determined. No studies have examined differences in patient outcomes based on subspecialty care. Establishing an evidence base for these questions would help inform policy decisions to design the most cost-effective measures to treat AS.

Reduction of direct and indirect costs in patients with AS receiving etanercept: results from an open-label 36-week extension of the ASCEND study in four European countries

OBJECTIVE

To characterize the impact of etanercept (ETN) in AS on cost, work productivity and quality of life (QoL).

METHODS

A Phase 4, open-label, multi-centre (UK, Scandinavia) extension study in AS. Eligible subjects (n = 84) were treated for 36-52 weeks with ETN 50 mg s.c. once weekly. Analysis included direct costs (transformed out-patient and in-patient care elements), indirect costs (sick leave and lost working days), efficacy and QoL.

RESULTS

Annualized direct and indirect costs decreased (55.5%, P ≤ 0.008) during ETN treatment, as did out-patient and in-patient episodes (physiotherapist/physician visits, P = 0.012). Work productivity and QoL increased.

CONCLUSION

ETN therapy significantly reduces direct and indirect health-care costs and increases work ability and QoL in AS. Trial Registration. EUDRACT, https://eudract.ema.europa.eu/, 2006-001061-42.

Radiographic severity of ankylosing spondylitis is associated with polymorphism of the large multifunctional peptidase 2 gene in the Spondyloarthritis Research Consortium of Canada cohort

OBJECTIVE

There are limited data on genetic predictors of radiographic progression. The aim of this study was to examine polymorphisms in genes involved in antigen presentation and their effect on radiographic severity and progression.

METHODS

Caucasian patients with ankylosing spondylitis (AS) (diagnosed according to the modified New York criteria) from 2 Canadian centers were enrolled. Patients in the progression part of the study had at least 2 sets of radiographs obtained at a minimum gap of 1.5 years, with a modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Peripheral blood DNA was used for genotyping a panel of 13 coding-region single-nucleotide polymorphisms (SNPs) in ERAP1, LMP2, LMP7, TAP1, and TAP2. Linear regression analysis was performed to identify the predictors of the baseline mSASSS and logistic regression for predictors of progression. Progression was defined as an increase of 1 mSASSS unit per year.

RESULTS

A total of 241 AS patients (81% males; 82% HLA-B27-positive) were enrolled from the 2 centers for analysis of the predictors of baseline radiographic severity. In univariate analyses, the baseline mSASSS was associated with sex, disease duration, and SNPs rs30187 (ERAP1) and rs17587 (LMP2). In multivariate analyses, duration of disease (B = 0.74; P = 1 × 10(-11) ), sex (B = 12.1; P = 5 × 10(-5) ), and the LMP2 SNP rs17587 (B = 6.2; P = 0.01) were significantly associated with the baseline mSASSS. In multivariate analyses of progression, only the baseline mSASSS was a significant predictor (B = 0.03; P = 0.003).

CONCLUSION

This is the first study to demonstrate that LMP2 variants can affect radiographic severity in AS. The baseline mSASSS remains the strongest predictor of radiographic progression but explains only a fraction of the variability seen.

Determinants of work disability in patients with systemic sclerosis: a longitudinal study of the GENISOS cohort

OBJECTIVES

To determine the prevalence, correlates, and predictors of work disability (WD) in the Genetics versus ENvironment In Scleroderma Outcome Study (GENISOS). We hypothesized that WD in systemic sclerosis (SSc) is a function of demographic, clinical, and psychosocial factors.

METHODS

Patients enrolled in the GENISOS cohort were subdivided in 3 groups: work disabled, working, and retired or homemakers. The latter group (n = 29) was excluded from further analysis. We used logistic regression analysis with a forward hierarchical variable selection strategy to investigate the independent correlates of WD at enrollment. Cox regression proportional Hazard's model with a similar variable selection strategy was utilized to determine the predictors of WD in those working at enrollment.

RESULTS

Overall, 284 patients with a mean age of 48.7 years and disease duration of 2.5 (±1.6) years were enrolled into the GENISOS cohort, consisting of 83.5% female, 46.8% white, 28.9% Hispanic, and 20.4% African American. Patients were longitudinally followed in 1438 study visits. At enrollment, 124 patients (43.7%) were work disabled, whereas 131 (46.1%) were working. Lower level of education (P < 0.001), higher Medsger Lung Severity Index (P = 0.012), higher Fatigue Severity Score (P = 0.008), and less social support (P < 0.001) correlated independently with WD. Of those working at baseline, 35 (26.7%) eventually developed WD. Non-white ethnicity (P = 0.038), lower DLCO % predicted value (P = 0.038), and higher Fatigue Severity Score (P = 0.009) at enrollment independently predicted WD on follow-up visits.

CONCLUSIONS

WD is a major problem among SSc patients and its prevalence is substantially higher than other rheumatic conditions. Demographic, clinical, and psychosocial factors correlate with WD cross-sectionally and predict WD longitudinally in these patients.

Services for people with ankylosing spondylitis in the UK--a survey of rheumatologists and patients

OBJECTIVE

. To investigate the services offered to patients with AS in the UK in 2010.

METHODS

Two thousand non-health-care professional members of the National Ankylosing Spondylitis Society (NASS) were sent a questionnaire asking about their experiences surrounding diagnosis, treatment and access to therapies (response rate 40%). A separate questionnaire was sent to a consultant rheumatologist in every acute NHS trust in the UK, asking about services offered to patients with AS (response rate 68%).

RESULTS

Overall, there was a mean diagnostic delay of 8.57 years. Almost one-third (32.2%) of patients were not reviewed in secondary care. Non-attendance was associated with increasing age and longer disease duration. Twenty per cent of patients were taking anti-TNF drugs, but 18.8% of departments reported that their ability to give anti-TNF therapy was restricted (64% reported primary-care trust rationing and 14% lack of staff). Almost all rheumatology departments had access to MRI, but 70.9% still used X-ray radiographs as their first-line investigation. A minority (5.6%) of patients reported they had never seen a physiotherapist, but less than one-third could self-refer for treatment during a flare.

CONCLUSION

This is the first study to explore the services available to people with AS in the UK. Almost one-third of patients are not seen in rheumatology departments and therefore may be under-treated. For those who are seen, access to anti-TNF drugs and other therapies remains an issue.

Managing inflammatory arthritides: Role of the nurse practitioner and physician assistant

PURPOSE

To review the current management of the inflammatory arthritides, including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. This review examines the role of the nurse practitioner (NP) and physician assistant (PA) in the management of these chronic diseases.

DATA SOURCES

A review of the scientific literature and current guidelines regarding the management of inflammatory arthritides.

CONCLUSIONS

NPs and PAs play important roles in the interdisciplinary team involved in the treatment of patients with chronic inflammatory arthritic conditions. The management of inflammatory arthritides has evolved with the development of new treatment strategies and is focused on early intervention and minimizing progressive joint damage. NPs and PAs are ideally positioned to educate patients regarding treatment options and other important aspects of the disease process and to monitor disease activity using a number of validated instruments.

IMPLICATIONS FOR PRACTICE

Through active disease management, NPs and PAs can influence their patients to make better, more informed choices regarding treatment, which may optimize patient outcomes.

Work disability in patients with ankylosing spondylitis in Norway

OBJECTIVE

To report the prevalence of work disability (WD) in a cross-sectional study of a large population of patients with ankylosing spondylitis (AS) and the associated demographic and clinical characteristics, including extraspinal features, that contribute to WD.

METHODS

Patients with AS registered in a hospital database were invited to participate. A total of 360 patients took part. The survey period was 1998 to 2002. During an extended outpatient visit, data were collected according to a predefined data form. Demographic data were collected and a physical examination performed.

RESULTS

After 22.6 years of disease duration, the cumulative prevalence of WD reached 43.6%, and an additional 8.9% of patients were nonparticipants in the labor force. Significant odds ratios indicating an independent association with WD were found for history of polyarthritis (9.6), coronary heart disease (CHD; 7.8), female sex (3.4), having children with spondyloarthritis (2.9), changing profession (2.8), lower level of education (1.4), mean score of the Bath AS Functional Index (1.2), increasing age (1.05), and increasing finger-to-floor distance (1.02).

CONCLUSION

The longterm prevalence of WD among Norwegian patients with AS is considerably higher than in reports from other countries. Earlier polyarthritis and CHD were the strongest independent risk factors for WD.