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Phoka A, van den Bemt BJF, Lubrano E, Singh I, Fernández-Carballido C, Parow D, Webb D, Lacombe F, Harrington L, Baraliakos X. Elevating the Standard of Care for Patients with Axial Spondyloarthritis: 'Calls to Action' from Rheumacensus, a Multistakeholder Pan-European Initiative. Rheumatol Ther 2024; 11:773-794. [PMID: 38662146 PMCID: PMC11111622 DOI: 10.1007/s40744-024-00663-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/11/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Several barriers to optimal care in axial spondyloarthritis (axSpA) exist, which is detrimental to patient outcomes. The Rheumacensus programme aimed to identify how the standard of care (SoC) and treatment ambition for patients with axSpA could be elevated, from the unique perspective of three key stakeholders from across Europe: patients, healthcare professionals (HCPs) and payors. METHODS Rheumacensus followed three phases: an insights-gathering workshop to identify current unmet needs in axSpA and an area of focus, a modified Delphi process to gain consensus on improvements within the agreed area of focus, and a Consensus Council (CC) meeting to generate 'Calls to Action' (CTA) to highlight the changes needed to elevate the SoC for patients with axSpA. RESULTS The Rheumacensus CC consisted of four patient representatives, four HCPs and four payors. All 12 members completed all three Delphi e-consultations. The shared area of focus that informed the Delphi process was patient empowerment through education on the disease and treatment options available, to enable patient involvement in management and ultimately increase treatment adherence. Four key themes emerged from the Delphi process: patient empowerment, patient knowledge, patient-HCP consultations and optimal initial treatment. These themes informed 11 overarching CTA, which demonstrate the need for a multistakeholder approach to implement a paradigm shift towards patient-centred care to elevate health outcomes in patients with axSpA. CONCLUSION Rheumacensus identified CTA to help bridge the disparities observed in axSpA care. It is now imperative for all stakeholders to take practical steps towards addressing these CTA to elevate the SoC and treatment ambition in patients with axSpA.
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Affiliation(s)
- Andri Phoka
- Axial Spondyloarthritis International Federation, Nicosia, Cyprus
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud UMC, Nijmegen, The Netherlands
| | - Ennio Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze Della Salute "Vincenzo Tiberio", Università Degli Studi del Molise, Campobasso, Italy
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven University, Leuven, Belgium
| | | | | | - Detlev Parow
- Formerly Department of Medicines, Therapeutic Appliances and Remedies, DAK-Gesundheit, Hamburg, Germany
| | - Dale Webb
- National Axial Spondyloarthritis Society, London, UK
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Lindqvist E, Olofsson T, Jöud A, Geijer M, Wallman JK, Mogard E. How good is the agreement between clinical diagnoses and classification criteria fulfilment in axial spondyloarthritis? Results from the SPARTAKUS cohort. Scand J Rheumatol 2022:1-10. [PMID: 35695036 DOI: 10.1080/03009742.2022.2064183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To study the agreement between clinical axial spondyloarthritis (axSpA) diagnoses and fulfilment of the Assessment of SpondyloArthritis international Society (ASAS) axSpA and modified New York (mNY) classification criteria, and to compare disease/health status between axSpA subtypes. METHOD Patients with prevalent, clinical axSpA attending a rheumatology clinic were enrolled in a cross-sectional study. Assessments included physical evaluation, laboratory testing, questionnaires, and appropriate imaging, allowing classification. Standard axSpA outcome measures were compared between patients fulfilling mNY/radiographic versus non-radiographic axSpA (r-axSpA/nr-axSpA) criteria. RESULTS Of 239 consecutively included patients, 141 fulfilled ASAS r-axSpA and/or mNY criteria, while 57 fulfilled nr-axSpA criteria. The agreement between r-axSpA and mNY criteria fulfilment was 94%. The positive predictive value (PPV) of a clinical ankylosing spondylitis (AS) diagnosis for mNY criteria fulfilment was 71%; the PPV of an undifferentiated axSpA (u-axSpA) diagnosis for fulfilment of nr-axSpA criteria was 30% and 40% for mNY criteria. Patients with r-axSpA/AS were older, more often men, and had longer disease duration, more uveitis, and worse spinal mobility than nr-axSpA patients, who had more enthesitis and dactylitis. CONCLUSION We found an overall good concordance between clinical axSpA diagnoses and classification criteria fulfilment, with 83% fulfilling ASAS axSpA and/or mNY criteria. Regarding axSpA subtypes, the concordance was weaker, and although the ICD-10 code for AS correctly identified patients meeting mNY criteria in 71% of cases, one-third of mNY-positive patients lacked an AS diagnosis. Moreover, clinical u-axSpA diagnoses could not serve as a proxy to identify nr-axSpA, highlighting the importance of thorough classification in research on axSpA subtypes.
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Affiliation(s)
- Elisabet Lindqvist
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Tor Olofsson
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Anna Jöud
- Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Mats Geijer
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan K Wallman
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Elisabeth Mogard
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
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Perrotta FM, Scriffignano S, Ciccia F, Lubrano E. Therapeutic Targets for Ankylosing Spondylitis - Recent Insights and Future Prospects. Open Access Rheumatol 2022; 14:57-66. [PMID: 35469137 PMCID: PMC9034883 DOI: 10.2147/oarrr.s295033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/07/2022] [Indexed: 01/22/2023] Open
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease belonging to the axial spondyloarthritis (axSpA), a group of diseases that affects the axial skeleton and causes severe pain and disability. An early diagnosis and appropriate treatment can reduce the severity of the disease and the risk of progression. TNF-α inhibitors demonstrated efficacy and effectiveness in axSpA patients by reducing disease activity, minimizing inflammation and improving the quality of life. More recently, new insights in pathogenesis of axSpA, including the discovery of the role of IL-23/IL-17 axis and intracellular pathways, led to the development of new biologics and small molecules that improve our therapeutic armamentarium. New alternatives are also being soon available. The aim of this paper is to narratively review the recent insights and future prospects in the treatment of AS and, more in general, axSpA.
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Affiliation(s)
- Fabio Massimo Perrotta
- Academic Rheumatology Unit, Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Silvia Scriffignano
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Francesco Ciccia
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Ennio Lubrano
- Academic Rheumatology Unit, Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
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Lapane KL, Dubé C, Ferrucci K, Khan S, Kuhn KA, Yi E, Kay J, Liu SH. Patient perspectives on health care provider practices leading to an axial spondyloarthritis diagnosis: an exploratory qualitative research study. BMC FAMILY PRACTICE 2021; 22:251. [PMID: 34930136 PMCID: PMC8691008 DOI: 10.1186/s12875-021-01599-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 12/01/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The average time to a diagnosis for people with axial spondyloarthritis (axSpA) is 7-10 years. Delayed diagnosis may result in increased structural damage, worse physical function, and worse quality of life relative to patients with a timely axSpA diagnosis. Understanding patient experiences may provide insights for how to reduce diagnostic delays. OBJECTIVE To provide foundational knowledge about patient experiences with healthcare providers leading to an axSpA diagnosis. METHODS We conducted an exploratory qualitative research study with six focus groups interviews with participants recruited from three rheumatology clinics within the United States (MA (n = 3); CO (n = 2); PA (n = 1)) that included a total of 26 adults (10 females, 16 males) with rheumatologist confirmed diagnosis of axSpA in 2019. Focus groups were ~ 2 h, audio recorded, transcribed, and subject to dual coding. The codes reviewed were in relation to the patients' diagnostic experiences. RESULTS Patients described frustrating and lengthy diagnostic journeys. They recognized that the causes of diagnostic delays in axSpA are multifactorial (e.g., no definitive diagnostic test, disease characteristics, lack of primary care provider's awareness about axSpA, trust). Patients described how doctors minimized or dismissed complaints about symptoms or told them that their issues were psychosomatic. Patients believed the healthcare system contributed to diagnostic delays (e.g., lack of time in clinical visits, difficulty accessing rheumatologists, health insurance challenges). Advice to physicians to reduce the diagnostic delay included allowing time for patients to give a complete picture of their illness experience, listening to, and believing patients, earlier referral to rheumatology, provision of HLA-B27 gene testing, and that physicians need to partner with their patients. CONCLUSIONS Patients desire a definitive test that could be administered earlier in the course of axSpA. Until such a test is available, patients want clinicians who listen to, believe, and partner with them, and who will follow them until a diagnosis is reached. Educating primary care clinicians about guidelines and referral for diagnosis of axSpA could reduce diagnostic delay.
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Affiliation(s)
- Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA.
| | - Catherine Dubé
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA
| | - Katarina Ferrucci
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sara Khan
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA
| | - Kristine A Kuhn
- Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Esther Yi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Jonathan Kay
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA
- Division of Rheumatology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Division of Rheumatology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Shao-Hsien Liu
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA
- Division of Rheumatology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Chimenti MS, Alten R, D'Agostino MA, Gremese E, Kiltz U, Lubrano E, Moreno M, Pham T, Ramonda R, Spinelli FR, Perella C, Andreoli L. Sex-associated and gender-associated differences in the diagnosis and management of axial spondyloarthritis: addressing the unmet needs of female patients. RMD Open 2021; 7:rmdopen-2021-001681. [PMID: 34876490 PMCID: PMC8655606 DOI: 10.1136/rmdopen-2021-001681] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/11/2021] [Indexed: 11/03/2022] Open
Abstract
Emerging evidence suggests that axial spondyloarthritis (axSpA) should not be seen as a predominantly male disease, as the non-radiographic form occurs with roughly equal frequency in women and men. However, men and women experience this disease differently. The purpose of this review is to highlight sex-associated and gender-associated differences in the patient's journey through the diagnosis and management of axSpA, in order to increase the awareness about the unmet needs of female axSpA patients.Female patients experience a longer diagnostic delay compared with men, possibly due to the different pattern of clinical presentations across genders. Therefore, it is crucial to sensitise physicians to pay attention and identify the red flags of axSpA in women and promote early referral to a rheumatologist. Women with a diagnosis of axSpA experience greater limitations in physical function, although they have less structural spinal damage compared with men. Women tend to have less adherence and a lower response to treatment, so more gender-oriented data are needed about drugs used for axSpA, especially biological disease-modifying antirheumatic drugs.Lifestyle factors have a strong impact on the disease course. Interventions regarding physical activity, smoking cessation and diet should be communicated to the patients, with particular attention to the gender-related cultural background.Patients of childbearing age living with axSpA should be engaged in a discussion about reproductive health, in terms of preservation of fertility, management of pregnancy and delivery and use of biologic drugs during pregnancy and breastfeeding.
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Affiliation(s)
- Maria-Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Rieke Alten
- Internal Medicine II, Rheumatology, Schlosspark-Klinik, University Medicine Berlin, Berlin, Germany
| | - Maria-Antonieta D'Agostino
- Rheumatology Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy.,Inserm U1173, Infection et inflammation, Laboratory of Excellence Inflamex, Université Versailles-Paris-Saclay, Montigny-le-Bretonneux, France
| | - Elisa Gremese
- Rheumatology Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Uta Kiltz
- Internal Medicine and Rheumatology, Rheumazentrum Ruhrgebiet, Herne, Germany.,Rheumatology Department, Ruhr University Bochum, Bochum, Germany
| | - Ennio Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy
| | - Mireia Moreno
- Rheumatology Department, Hospital Universitario Parc Taulí, Barcelona, Spain
| | - Thao Pham
- Rheumatology, Aix-Marseille-University, Marseille, France.,Rheumatology Department, Assistance Publique-Hôpitaux de Marseille (APHM), Marseille, France
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine-DIMED, University Hospital of Padova, Padova, Italy
| | - Francesca-Romana Spinelli
- Rheumatology Unit, Department of Internistic, Anaesthesiologic and Cardiovascular Sciences, Sapienza Universita Editrice, Roma, Lazio, Italy
| | - Chiara Perella
- Immunology, Hepatology and Dermatology, Novartis AG, Basel, Basel-Stadt, Switzerland
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy .,Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili di Brescia, Brescia, Italy
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6
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McInnes IB, Szekanecz Z, McGonagle D, Maksymowych WP, Pfeil A, Lippe R, Song IH, Lertratanakul A, Sornasse T, Biljan A, Deodhar A. A review of JAK-STAT signalling in the pathogenesis of spondyloarthritis and the role of JAK inhibition. Rheumatology (Oxford) 2021; 61:1783-1794. [PMID: 34668515 PMCID: PMC9071532 DOI: 10.1093/rheumatology/keab740] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/20/2021] [Indexed: 12/16/2022] Open
Abstract
Spondyloarthritis (SpA) comprises a group of chronic inflammatory diseases with overlapping clinical, genetic and pathophysiological features including back pain, peripheral arthritis, psoriasis, enthesitis and dactylitis. Several cytokines are involved in the pathogenesis of SpA, variously contributing to each clinical manifestation. Many SpA-associated cytokines, including IL-23, IL-17, IL-6, type I/II interferon and tumour necrosis factor signal directly or indirectly via the Janus kinase (JAK)–signal transducer and activator of transcription pathway. JAK signalling also regulates development and maturation of cells of the innate and adaptive immune systems. Accordingly, disruption of this signalling pathway by small molecule oral JAK inhibitors can inhibit signalling implicated in SpA pathogenesis. Herein we discuss the role of JAK signalling in the pathogenesis of SpA and summarize the safety and efficacy of JAK inhibition by reference to relevant SpA clinical trials.
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Affiliation(s)
- Iain B McInnes
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals, Leeds, UK
| | - Walter P Maksymowych
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Ralph Lippe
- AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
| | | | | | | | | | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
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7
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Xiang L, Fong W, Low AHL, Leung YY, Gandhi M, Xin X, Uy EJB, Hamilton L, Thumboo J. Early identification of axial spondyloarthritis in a multi-ethnic Asian population. Clin Rheumatol 2021; 41:1095-1103. [PMID: 34625882 DOI: 10.1007/s10067-021-05951-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/01/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION/OBJECTIVES To address the diagnostic delay in axial spondyloarthritis (axSpA), we have cross-culturally adapted the Hamilton axSpA questionnaire, a self-administered screening questionnaire, in the Singapore population. In this study, we compared the performance of various scoring methods for this questionnaire in detecting axSpA. METHOD The questionnaire was self-administered by eligible subjects. Scoring methods included method A, the original questionnaire scoring, and methods B-E, scoring developed based on the Assessment of SpondyloArthritis International Society (ASAS) criteria for inflammatory back pain (IBP) and the referral, classification and both referral and classification of axSpA, respectively. The reference standard was diagnosis by a rheumatologist. Since the ASAS criteria-based scoring methods were mainly based on clinical axSpA features, self-report and rheumatologist-assessment of clinical axSpA features were also compared in subjects with axSpA. RESULTS Of 1418 subjects (age: 54 ± 14 years, female: 73%) recruited, 46 were diagnosed with axSpA by a rheumatologist. Sensitivities of methods A-E were 35%, 61%, 63%, 48% and 83%, respectively. Self-report of clinical axSpA features exceeded rheumatologist-assessment for arthritis (83 vs 26%), good response to NSAIDs (37 vs 30%), enthesitis (35 vs 30%), dactylitis (20 vs 2%) and family history for axSpA (13 vs 4%). The reverse was true for IBP (41 vs 63%) and uveitis (4 vs 15%). CONCLUSIONS A self-administered questionnaire using the ASAS referral and classification criteria-based scoring yielded relatively high sensitivity in detecting axSpA in subjects newly referred to rheumatology clinics. This supports its evaluation as a screening and referral tool in the general population in future studies. Key Points • A self-administered questionnaire could be used as a screening and referral tool. • ASAS referral and classification criteria-based scoring yielded relatively high sensitivity. • Inaccurate perception of clinical axSpA features was observed in axSpA patients.
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Affiliation(s)
- Ling Xiang
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Andrea Hsiu Ling Low
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Ying Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Mihir Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore.,Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore.,Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore.,The Center for Child Health Research, Tampere University, Tampere, Finland
| | - Xiaohui Xin
- Academic Clinical Program for Medicine, Singapore General Hospital, Singapore, Singapore
| | - Elenore Judy B Uy
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore
| | - Louise Hamilton
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
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8
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Nygaard A, Hendricks O, Loft AG, Christiansen AA, Brandslund I, Jurik AG, Schiøttz-Christensen B. Complement C3d is not associated with axial spondyloarthritis and magnetic resonance imaging changes at the sacroiliac joint. Scand J Rheumatol 2021; 51:382-389. [PMID: 34470588 DOI: 10.1080/03009742.2021.1946255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To investigate the associations between complement C3d and inflammatory and structural changes by magnetic resonance imaging (MRI) at the sacroiliac joints (SIJ) suggestive of axial spondyloarthritis, according to the Assessment of SpondyloArthritis international Society (ASAS) criteria, in patients with low back pain.Method: This was a cross-sectional study of patients referred to the Spine Centre of Southern Denmark owing to unspecified low back pain (Spines of Southern Denmark cohort). The patients were divided into three groups: group 1: patients fulfilling the ASAS criteria for axial spondyloarthritis (axSpA, n = 96); group 2: patients with either a positive MRI of the SIJ and no spondyloarthritis features, or a negative MRI of the SIJ but positive human leucocyte antigen-B27 and one spondyloarthritis feature (non-axSpA, n = 38); group 3: patients with unspecified low back pain for > 3 months (control group, n = 82). Complement C3d was measured with double-decker rocket immunoelectrophoresis and evaluated in relation to the group division and baseline findings by SIJ MRI.Results: In total, 184 C3d analyses were performed. The mean ± sd level of C3d was 33.8 ± 8.1 AU/mL. There were no differences in C3d levels between the three patient groups, mean values being: axSpA = 34.3 ± 7.9 AU/mL, non-axSpA = 33.5 ± 6.9 AU/mL, and controls = 33.4 ± 9.2 AU/mL. The level of C3d was not related to MRI findings.Conclusions: In these patients, complement C3d was not associated with active or structural SIJ changes on MRI suggestive of axial spondyloarthritis.
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Affiliation(s)
- A Nygaard
- Lillebaelt Hospital, University Hospital of Southern Denmark, Middelfart, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - O Hendricks
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Rheumatology, The Danish Hospital for Rheumatology, Sonderborg, Denmark
| | - A G Loft
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - A A Christiansen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Rheumatology, The Danish Hospital for Rheumatology, Sonderborg, Denmark
| | - I Brandslund
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Immunology and Biochemistry, Lillebaelt Hospital, Vejle, Denmark
| | - A G Jurik
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - B Schiøttz-Christensen
- Lillebaelt Hospital, University Hospital of Southern Denmark, Middelfart, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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9
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Xiang L, Low AHL, Leung YY, Fong W, Gandhi M, Yoon S, Lau TC, Koh DR, Thumboo J. Interval between symptom onset and diagnosis among patients with autoimmune rheumatic diseases in a multi-ethnic Asian population. Int J Rheum Dis 2021; 24:1061-1070. [PMID: 34232556 DOI: 10.1111/1756-185x.14165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/22/2021] [Accepted: 06/13/2021] [Indexed: 12/19/2022]
Abstract
AIM The interval between symptom onset and diagnosis (pre-diagnosis interval) can at times be longer than is ideal in patients with autoimmune rheumatic diseases (ARDs). In this study, we aimed to characterize this interval and to identify its associated factors. METHOD We characterized pre-diagnosis interval into 4 intervals: Interval #1 between symptom onset and first visit to healthcare professionals; Interval #2 between first visit to healthcare professionals and rheumatology referral; Interval #3 between rheumatology referral and first rheumatology assessment; and Interval #4 between first rheumatology assessment and diagnosis. Median regression models were used to identify factors associated with longer pre-diagnosis interval and Interval #1. RESULTS Among 259 patients (median age = 52.0 [41.6-61.9] years, 71% female, rheumatoid arthritis [n = 75], axial spondyloarthritis [axSpA] [n = 40] and psoriatic arthritis [n = 35]), median pre-diagnosis interval was 11.5 (4.7-36.0) months. Interval #1 (median = 4.9 months) was significantly longer than Intervals #2-#4 (median = 0.3, 1.5, and 0.0 months, respectively). Patients with axSpA had significantly longer pre-diagnosis interval (median = 38.7 months) and Interval #1 (median = 26.6 months) than patients with the other ARDs. Median regression suggested that patients referred from specialty care had significantly longer pre-diagnosis interval (median difference = 7.7 months) and Interval #1 (median difference = 6.4 months) compared to those referred from primary care. CONCLUSION A long pre-diagnosis interval was observed among patients with ARDs (especially axSpA), due largely to a long interval between symptom onset and the first visit to healthcare professionals. This highlights the importance of interventions targeting patients prior to their first visit to healthcare professionals in reducing pre-diagnosis interval.
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Affiliation(s)
- Ling Xiang
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrea Hsiu Ling Low
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Ying Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Mihir Gandhi
- Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Biostatistics, Singapore Clinical Research Institute.,Tampere Center for Child Health Research, Tampere University, Tampere, Finland
| | - Sungwon Yoon
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Tang Ching Lau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Medicine, National University Hospital, Singapore
| | - Dow Rhoon Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Medicine, National University Hospital, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
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10
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Sperti M, Malavolta M, Ciniero G, Borrelli S, Cavaglià M, Muscat S, Tuszynski JA, Afeltra A, Margiotta DPE, Navarini L. JAK inhibitors in immune-mediated rheumatic diseases: From a molecular perspective to clinical studies. J Mol Graph Model 2021; 104:107789. [DOI: 10.1016/j.jmgm.2020.107789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/21/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022]
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11
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Gut microbiota-microRNA interactions in ankylosing spondylitis. Autoimmun Rev 2021; 20:102827. [PMID: 33864943 DOI: 10.1016/j.autrev.2021.102827] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/17/2021] [Indexed: 12/20/2022]
Abstract
Ankylosing spondylitis (AS) is a chronic autoimmune inflammatory disability that is part of the rheumatic disease group of spondyloarthropathies. AS commonly influences the joints of the axial skeleton. The contributions to AS pathogenesis of genetic susceptibility (particularly HLA-B27 and ERAP-1) and epigenetic modifications, like non-coding RNAs, as well as environmental factors, have been investigated over the last few years. But the fundamental etiology of AS remains elusive to date. The evidence summarized here indicates that in the immunopathogenesis of AS, microRNAs and the gut microbiome perform critical functions. We discuss significant advances in the immunological mechanisms underlying AS and address potential cross-talk between the gut microbiome and host microRNAs. This critical interaction implicates a co-evolutionary symbiotic link between host immunity and the gut microbiome.
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12
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Walsh JA, Pei S, Penmetsa GK, Overbury RS, Clegg DO, Sauer BC. Identifying Patients With Axial Spondyloarthritis in Large Datasets: Expanding Possibilities for Observational Research. J Rheumatol 2020; 48:685-692. [PMID: 33259327 DOI: 10.3899/jrheum.200570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Observational research of axial spondyloarthritis (axSpA) is limited by a lack of methods for identifying diverse axSpA phenotypes in large datasets. Algorithms were previously designed to identify a broad spectrum of patients with axSpA, including patients not identifiable with diagnosis codes. The study objective was to estimate the performance of axSpA identification methods in the general Veterans Affairs (VA) population. METHODS A patient sample with known axSpA status (n = 300) was established with chart review. For feasibility, this sample was enriched with veterans with axSpA risk factors. Algorithm performance outcomes included sensitivities, positive predictive values (PPV), and F1 scores (an overall performance metric combining sensitivity and PPV). Performance was estimated with unweighted outcomes for the axSpA-enriched sample and inverse probability weighted (IPW) outcomes for the general VA population. These outcomes were also assessed for traditional identification methods using diagnosis codes for the ankylosing spondylitis (AS) subtype of axSpA. RESULTS The mean age was 54.7 and 92% were male. Unweighted F1 scores (0.59-0.74) were higher than IPW F1 scores (0.48-0.65). The full algorithm had the best overall performance (F1IPW 0.65). The Early Algorithm was the most inclusive (sensitivityIPW 0.90, PPVIPW 0.38). The traditional method using ≥ 2 AS diagnosis codes from rheumatology had the highest PPV (PPVIPW 0.84, sensitivityIPW 0.34). CONCLUSION The axSpA identification methods demonstrated a range of performance attributes in the general VA population that may be appropriate for various types of studies. The novel identification algorithms may expand the scope of research by enabling identification of more diverse axSpA populations.
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Affiliation(s)
- Jessica A Walsh
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA.
| | - Shaobo Pei
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Gopi K Penmetsa
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Rebecca S Overbury
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Daniel O Clegg
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Brian C Sauer
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
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13
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Lapane KL, Khan S, Shridharmurthy D, Beccia A, Dubé C, Yi E, Kay J, Liu SH. Primary care physician perspectives on barriers to diagnosing axial Spondyloarthritis: a qualitative study. BMC FAMILY PRACTICE 2020; 21:204. [PMID: 32993510 PMCID: PMC7526414 DOI: 10.1186/s12875-020-01274-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/21/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. Factors that contribute to this delay are multifactorial and include the lack of diagnostic criteria (although classification criteria exist) for axSpA and the difficulty in distinguishing inflammatory back pain, a key symptom of axSpA, from other highly prevalent forms of low back pain. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians. METHODS We conducted a qualitative research study which included 18 US primary care physicians, balanced by gender. Physicians provided informed consent to participate in an in-depth interview (< 60 min), conducted in person (n = 3) or over the phone (n = 15), in 2019. The analysis focuses on thoughts about factors contributing to diagnostic delay in axSpA. RESULTS Physicians noted that the disease characteristics contributing to diagnostic delay include: back pain is common and axSpA is less prevalent, slow progression of axSpA, intermittent nature of axSpA pain, and in the absence of abnormal radiographs of the spine or sacroiliac joints, there is no definitive test for axSpA. Patient characteristics believed to contribute to diagnostic delay included having multiple conditions in need of attention, infrequent interactions with the health care system, and "doctor shopping." Doctors noted that patients wait until the last moments of the clinical encounter to discuss back pain. Problematic physician characteristics included lack of rapport with patients, lack of setting appropriate expectations, and attribution of back pain to other factors. Structural/system issues included short appointments, lack of continuity of care, insufficient insurance coverage for tests, lack of back pain clinics, and a shortage of rheumatologists. CONCLUSION Primary care physicians agreed that lengthy axSpA diagnosis delays are challenging to address owing to the multifactorial causes (e.g., disease characteristics, patient characteristics, lack of definitive tests, system factors).
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Affiliation(s)
- Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA. .,Sherman Center, University of Massachusetts Medical School, 55 Lake Avenue North, 6th floor, Worcester, MA, 01655, USA.
| | - Sara Khan
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Divya Shridharmurthy
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.,Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Ariel Beccia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.,Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Catherine Dubé
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Esther Yi
- Novartis Pharmaceuticals Corporation, 59 Route 10, East Hanover, NJ, 07936, USA
| | - Jonathan Kay
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.,Division of Rheumatology, Department of Medicine, University of Massachusetts Medical School, Worcester, 55 Lake Avenue North, Worcester, MA, 01605, USA.,Division of Rheumatology, UMass Memorial Medical Center, 119 Belmont St, Worcester, MA, 01605, USA
| | - Shao-Hsien Liu
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.,Division of Rheumatology, Department of Medicine, University of Massachusetts Medical School, Worcester, 55 Lake Avenue North, Worcester, MA, 01605, USA
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14
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Motta F, Carena MC, Selmi C, Vecellio M. MicroRNAs in ankylosing spondylitis: Function, potential and challenges. J Transl Autoimmun 2020; 3:100050. [PMID: 32743531 PMCID: PMC7388379 DOI: 10.1016/j.jtauto.2020.100050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/24/2022] Open
Abstract
Epigenetic mechanisms such as DNA methylation, histone modifications and non-coding RNA, are considered the essential connection between a disorder's onset and the environment, on a permissive genetic background. Among autoimmune and inflammatory-mediated disorders, Ankylosing Spondylitis (AS), a chronic arthritis of the spine, is a very good example for the weight of epigenetics' contribution. MicroRNAs (miRNAs) are single-stranded nucleotides which regulate gene expression and are involved in pathological and physiological processes. In this manuscript we provide a clarification on the role of microRNAs in AS, with a focus on the mechanisms of pathogenesis. In specific, we have examined the contribution of miRNAs in the processes of inflammation, new bone formation and T-cell function, and the pathways (i.e. Wnt, BMP, TGFβ signalling etc.) they regulate. The utility of miRNAs in better understanding AS pathogenesis is undisputed and their utility as therapeutic opportunity is strongly increasing.
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Affiliation(s)
- Francesca Motta
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, IRCCS, Rozzano, Milan, Italy
| | - Maria Cristina Carena
- Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Italy
| | - Matteo Vecellio
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, IRCCS, Rozzano, Milan, Italy.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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15
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Lubrano E, Perrotta FM, Manara M, D'Angelo S, Ramonda R, Punzi L, Addimanda O, Salvarani C, Marchesoni A. Improvement of Function and Its Determinants in a Group of Axial Spondyloarthritis Patients Treated with TNF Inhibitors: A Real-Life Study. Rheumatol Ther 2020; 7:301-310. [PMID: 32062827 PMCID: PMC7211226 DOI: 10.1007/s40744-020-00197-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION The aim of this work is to investigate the improvement of physical function and its determinants in axial spondyloarthritis (SpA) patients treated with tumor necrosis factor (TNF) inhibitors in a real clinical practice setting. METHODS An observational study was conducted in patients with axial SpA treated with anti-TNF from 2010 to 2018 with a minimum 6 months of follow-up. All patients fulfilled ASAS or the modified New York criteria. The Bath Ankylosing Spondylitis Metrology Index (BASMI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) were used as objective and self-reported functional indices. The improvement of function and factors associated were evaluated for the present study, as well as disease activity and patient-reported outcome measures. RESULTS A total of 183 patients with axial SpA were examined. Among them, 27 were non-radiographic axial SpA, while the remaining 156 were ankylosing spondylitis patients. BASFI and BASMI significantly improved during follow-up. Improvement of metrology index BASMI inverse correlated with disease duration (rho - 0.2, p = 0.009) and directly correlated with the improvement of BASDAI (rho 0.26, p = 0.003) and CRP (rho 0.26, p = 0.0003). Improvement of BASFI significantly inversely correlated with disease duration and directly correlated with the improvement of BASDAI, CRP, and baseline ESR. Male sex, lower disease duration, high ESR, and the improvement of BASDAI were found to be associated with the improvement of BASFI. CONCLUSIONS Our results showed that in real-life settings, patients improve in BASMI and BASFI. Furthermore, factors associated with this improvement were identified.
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Affiliation(s)
- Ennio Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy.
| | - Fabio Massimo Perrotta
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy
| | - Maria Manara
- Day Hospital di Reumatologia, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO, Milano, Italy
| | - Salvatore D'Angelo
- Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Clinical and Experimental Medicine DIMED, University of Padova, Padua, Italy
| | - Leonardo Punzi
- Rheumatology Unit, Department of Clinical and Experimental Medicine DIMED, University of Padova, Padua, Italy
| | - Olga Addimanda
- SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda Ospedaliera-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Antonio Marchesoni
- Day Hospital di Reumatologia, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO, Milano, Italy
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16
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Perrotta FM, Musto A, Lubrano E. New Insights in Physical Therapy and Rehabilitation in Axial Spondyloarthritis: A Review. Rheumatol Ther 2019; 6:479-486. [PMID: 31410786 PMCID: PMC6858478 DOI: 10.1007/s40744-019-00170-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Indexed: 12/13/2022] Open
Abstract
Axial spondyloarthritis (axSpA) is a chronic and inflammatory rheumatic disease characterized by pain, structural and functional impairments, and reduced mobility and potential deformity of the axial skeleton. Treatment of axSpA includes pharmacological and non-pharmacological therapy. However, in the biologic era, unmet needs still remain for patients intolerant to or non-responders to biologic drugs and despite the development of new treatments, physical therapy and rehabilitation are of crucial importance in the management of axSpA patients. The aim of this manuscript is to review the current evidence on the assessment, physical therapy, and rehabilitation in axSpA patients.
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Affiliation(s)
- Fabio Massimo Perrotta
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università Degli Studi del Molise, Campobasso, Italy.
| | - Antonio Musto
- U.O.S. di Riabilitazione e Prevenzione Cardiologica, Ospedale "Antonio Cardarelli", Campobasso, Italy
| | - Ennio Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università Degli Studi del Molise, Campobasso, Italy
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Abstract
PURPOSE OF REVIEW In this review article, we describe the development and application of machine-learning models in the field of rheumatology to improve the detection and diagnosis rates of underdiagnosed rheumatologic conditions, such as ankylosing spondylitis and axial spondyloarthritis (axSpA). RECENT FINDINGS In an attempt to aid in the earlier diagnosis of axSpA, we developed machine-learning models to predict a diagnosis of ankylosing spondylitis and axSpA using administrative claims and electronic medical record data. Machine-learning algorithms based on medical claims data predicted the diagnosis of ankylosing spondylitis better than a model developed based on clinical characteristics of ankylosing spondylitis. With additional clinical data, machine-learning algorithms developed using electronic medical records identified patients with axSpA with 82.6-91.8% accuracy. These two algorithms have helped us understand potential opportunities and challenges associated with each data set and with different analytic approaches. Efforts to refine and validate these machine-learning models are ongoing. SUMMARY We discuss the challenges and benefits of machine-learning models in healthcare, along with potential opportunities for its application in the field of rheumatology, particularly in the early diagnosis of axSpA and ankylosing spondylitis.
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Affiliation(s)
| | | | - Esther Yi
- The University of Texas at Austin, Austin
- Baylor Scott and White Health, Temple, Texas
| | - Yujin Park
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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18
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Pelechas E, Kaltsonoudis E, Voulgari PV, Drosos AA. Unmet needs in the treatment of ankylosing spondylitis: a long-term observational study from a single university center. Rheumatol Int 2019; 39:663-668. [PMID: 30877371 DOI: 10.1007/s00296-019-04277-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/08/2019] [Indexed: 12/17/2022]
Abstract
Despite the progress in the treatment of ankylosing spondylitis (AS), a significant number of patients do not achieve low disease activity (LDA). The aim of the study is to estimate the size of unmet needs in the treatment of AS in a long-term observational study. Between January 2003 and December 2017, 220 patients with radiographic SpA were evaluated fulfilling the ASAS criteria. They were followed up at predefined times and were naive to biological treatment with anti-tumor necrosis factor agents (anti-TNFs) and the interleukin (IL)-17 inhibitor. NSAIDs, all anti-TNFs and the IL-17 inhibitor secukinumab were used according to the European, United States and Canadian guidelines for AS. During follow-up, several clinical parameters including disease activity scores were recorded. All 220 patients had an active disease and received at least two NSAIDs for 3 months. The anti-TNF of first choice was infliximab-51%, followed by adalimumab-27% and etanercept-22%. During follow-up, 22 patients were excluded from the study (18 lost, 4 never received anti-TNF due to comorbidities). From the rest (198), 12 did not receive anti-TNFs (8 due to sustained LDA on NSAIDs solely and 4 due to treatment denial). Finally, 186 (94%) were treated with anti-TNFs demonstrating sustained long-term LDA. However, 16 patients never achieved LDA despite they received two or three anti-TNFs or the IL-17 inhibitor. Thus, a total of 20 (10.1%) patients never achieved LDA. This is the first study aiming to estimate the gap and the size of unmet needs in AS patients using the international guidelines and recommendations for AS treatment, which is 10.1%.
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Affiliation(s)
- Eleftherios Pelechas
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Evripidis Kaltsonoudis
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece.
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Walsh JA, Pei S, Penmetsa G, Hansen JL, Cannon GW, Clegg DO, Sauer BC. Identification of Axial Spondyloarthritis Patients in a Large Dataset: The Development and Validation of Novel Methods. J Rheumatol 2019; 47:42-49. [PMID: 30877217 DOI: 10.3899/jrheum.181005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Observational axial spondyloarthritis (axSpA) research in large datasets has been limited by a lack of adequate methods for identifying patients with axSpA, because there are no billing codes in the United States for most subtypes of axSpA. The objective of this study was to develop methods to accurately identify patients with axSpA in a large dataset. METHODS The study population included 600 chart-reviewed veterans, with and without axSpA, in the Veterans Health Administration between January 1, 2005, and June 30, 2015. AxSpA identification algorithms were developed with variables anticipated by clinical experts to be predictive of an axSpA diagnosis [demographics, billing codes, healthcare use, medications, laboratory results, and natural language processing (NLP) for key SpA features]. Random Forest and 5-fold cross validation were used for algorithm development and testing in the training subset (n = 451). The algorithms were additionally tested in an independent testing subset (n = 149). RESULTS Three algorithms were developed: Full algorithm, High Feasibility algorithm, and Spond NLP algorithm. In the testing subset, the areas under the curve with the receiver-operating characteristic analysis were 0.96, 0.94, and 0.86, for the Full algorithm, High Feasibility algorithm, and Spond NLP algorithm, respectively. Algorithm sensitivities ranged from 85.0% to 95.0%, specificities from 78.0% to 93.6%, and accuracies from 82.6% to 91.3%. CONCLUSION Novel axSpA identification algorithms performed well in classifying patients with axSpA. These algorithms offer a range of performance and feasibility attributes that may be appropriate for a broad array of axSpA studies. Additional research is required to validate the algorithms in other cohorts.
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Affiliation(s)
- Jessica A Walsh
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA. .,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center.
| | - Shaobo Pei
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Gopi Penmetsa
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Jared Lareno Hansen
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Grant W Cannon
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Daniel O Clegg
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Brian C Sauer
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
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Scriffignano S, Perrotta FM, De Socio A, Lubrano E. Role of comorbidities in spondyloarthritis including psoriatic arthritis. Clin Rheumatol 2018; 38:3-10. [DOI: 10.1007/s10067-018-4332-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/04/2018] [Accepted: 10/08/2018] [Indexed: 02/06/2023]
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Selmi C, Bin Gao, Gershwin ME. The long and latent road to autoimmunity. Cell Mol Immunol 2018; 15:543-546. [PMID: 29568115 DOI: 10.1038/s41423-018-0018-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/19/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy. .,Department BIOMETRA, University of Milan, Milan, Italy.
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute for Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA
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