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Berr K, Ziehfreund S, Welcker M, Biedermann T, Zink A. A qualitative exploration of the patient journey in axial spondyloarthritis towards a people-centered understanding. Sci Rep 2024; 14:19977. [PMID: 39198468 PMCID: PMC11358462 DOI: 10.1038/s41598-024-70420-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 08/16/2024] [Indexed: 09/01/2024] Open
Abstract
This exploratory qualitative study aims to gain a people-centered understanding of the patient journey in axial spondyloarthritis (axSpA). Semi-structured interviews were conducted with 15 individuals diagnosed with axSpA, aged 18 years and older, who were purposively recruited from a rheumatologic practice in southern Germany. The interviews were carried out as web-based video calls between September and October 2021, audio-recorded, transcribed verbatim, and analyzed according to Kuckartz's qualitative content analysis. Patient journey narratives encompassed both healthcare journeys and personal journeys. Healthcare journeys were characterized as fragmented and difficult to navigate, with diagnosis often marking a turning point toward more coordinated care. Post-diagnosis, new challenges emerged (e.g., time management for treatment). Personal journeys comprised perceptions of axSpA in social contexts (e.g., stigmatization) and the continuous interplay of comorbidities and biographical events with healthcare related to axSpA. This study proposes a people-centered perspective on the patient journey in axSpA, emphasizing the interplay of biographies, comorbidities, and social context with healthcare events. Recognizing these personal factors in clinical practice is encouraged to address complex health needs and tailor treatment to each individual. Further efforts should promote collaboration between medical disciplines and integrate healthcare and social support at all stages of the axSpA patient journey.
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Affiliation(s)
- Kristina Berr
- Department of Dermatology and Allergy, TUM School of Medicine and Health, Technical University of Munich, Biedersteiner Str. 29, 80802, Munich, Germany
| | - Stefanie Ziehfreund
- Department of Dermatology and Allergy, TUM School of Medicine and Health, Technical University of Munich, Biedersteiner Str. 29, 80802, Munich, Germany
| | - Martin Welcker
- Medizinisches Versorgungszentrum für Rheumatologie Dr. M. Welcker GmbH, Planegg, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy, TUM School of Medicine and Health, Technical University of Munich, Biedersteiner Str. 29, 80802, Munich, Germany
| | - Alexander Zink
- Department of Dermatology and Allergy, TUM School of Medicine and Health, Technical University of Munich, Biedersteiner Str. 29, 80802, Munich, Germany.
- Division of Dermatology and Venereology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
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2
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Dong T, Li X, Yu W, Liu Y, Yang J. Identification of sex-specific biomarkers related to programmed cell death and analysis of immune cells in ankylosing spondylitis. Sci Rep 2024; 14:15358. [PMID: 38965390 PMCID: PMC11224221 DOI: 10.1038/s41598-024-65745-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 06/24/2024] [Indexed: 07/06/2024] Open
Abstract
Ankylosing spondylitis (AS) stands as a persistent inflammatory ailment predominantly impacting the axial skeleton, with the immune system and inflammation intricately entwined in its pathogenesis. This study endeavors to elucidate gender-specific patterns in immune cell infiltration and diverse forms of cell demise within the AS milieu. The aim is to refine the diagnosis and treatment of gender-specific AS patients, thereby advancing patient outcomes. In the pursuit of our investigation, two datasets (GSE25101 and GSE73754) pertinent to ankylosing spondylitis (AS) were meticulously collected and normalized from the GEO database. Employing the CIBERSORT algorithm, we conducted a comprehensive analysis of immune cell infiltration across distinct demographic groups and genders. Subsequently, we discerned differentially expressed genes (DEGs) associated with various cell death modalities in AS patients and their healthy counterparts. Our focus extended specifically to ferroptosis-related DEGs (FRDEGs), cuproptosis-related DEGs (CRDEGs), anoikis-related DEGs (ARDEGs), autophagy-related DEGs (AURDEGs), and pyroptosis-related DEGs (PRDEGs). Further scrutiny involved discerning disparities in these DEGs between AS patients and healthy controls, as well as disparities between male and female patients. Leveraging machine learning (ML) methodologies, we formulated disease prediction models employing cell death-related DEGs (CDRDEGs) and identified biomarkers intertwined with cell death in AS. Relative to healthy controls, a myriad of differentially expressed genes (DEGs) linked to cell death surfaced in AS patients. Among AS patients, 82 FRDEGs, 29 CRDEGs, 54 AURDEGs, 21 ARDEGs, and 74 PRDEGs were identified. In male AS patients, these numbers were 78, 33, 55, 24, and 94, respectively. Female AS patients exhibited 66, 41, 40, 17, and 82 DEGs in the corresponding categories. Additionally, 36 FRDEGs, 14 CRDEGs, 19 AURDEGs, 10 ARDEGs, and 36 PRDEGs exhibited differential expression between male and female AS patients. Employing machine learning techniques, LASSO, RF, and SVM-RFE were employed to discern key DEGs related to cell death (CDRDDEGs). The six pivotal CDRDDEGs in AS patients, healthy controls, were identified as CLIC4, BIRC2, MATK, PKN2, SLC25A5, and EDEM1. For male AS patients, the three crucial CDRDDEGs were EDEM1, MAP3K11, and TRIM21, whereas for female AS patients, COX7B, PEX2, and RHEB took precedence. Furthermore, the trio of DDX3X, CAPNS1, and TMSB4Y emerged as the key CDRDDEGs distinguishing between male and female AS patients. In the realm of immune correlation, the immune infiltration abundance in female patients mirrored that of healthy controls. Notably, key genes exhibited a positive correlation with T-cell CD4 memory activation when comparing male and female patient samples. This study engenders a more profound comprehension of the molecular underpinnings governing immune cell infiltration and cell death in ankylosing spondylitis (AS). Furthermore, the discernment of gender-specific disparities among AS patients underscores the clinical significance of these findings. By identifying DEGs associated with diverse cell death modalities, this study proffers invaluable insights into potential clinical targets for AS patients, taking cognizance of gender-specific nuances. The identification of gender-specific biological targets lays the groundwork for the development of tailored diagnostic and therapeutic strategies, heralding a pivotal step toward personalized care for AS patients.
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Affiliation(s)
- Tiantian Dong
- Center for External Treatment of Traditional Chinese Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Xuhao Li
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Wenyan Yu
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Yuanxiang Liu
- Department of Neurology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China.
| | - Jiguo Yang
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China.
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3
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Dong T, Li X, Yu W, Liu Y, Yang J. Identification of sex-specific biomarkers related to programmed cell death and analysis of immune cells in ankylosing spondylitis. Sci Rep 2024; 14:15358. [PMID: 38965390 DOI: 10.1038/s41598-024-65745-3影响因子:] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 06/24/2024] [Indexed: 07/25/2024] Open
Abstract
Ankylosing spondylitis (AS) stands as a persistent inflammatory ailment predominantly impacting the axial skeleton, with the immune system and inflammation intricately entwined in its pathogenesis. This study endeavors to elucidate gender-specific patterns in immune cell infiltration and diverse forms of cell demise within the AS milieu. The aim is to refine the diagnosis and treatment of gender-specific AS patients, thereby advancing patient outcomes. In the pursuit of our investigation, two datasets (GSE25101 and GSE73754) pertinent to ankylosing spondylitis (AS) were meticulously collected and normalized from the GEO database. Employing the CIBERSORT algorithm, we conducted a comprehensive analysis of immune cell infiltration across distinct demographic groups and genders. Subsequently, we discerned differentially expressed genes (DEGs) associated with various cell death modalities in AS patients and their healthy counterparts. Our focus extended specifically to ferroptosis-related DEGs (FRDEGs), cuproptosis-related DEGs (CRDEGs), anoikis-related DEGs (ARDEGs), autophagy-related DEGs (AURDEGs), and pyroptosis-related DEGs (PRDEGs). Further scrutiny involved discerning disparities in these DEGs between AS patients and healthy controls, as well as disparities between male and female patients. Leveraging machine learning (ML) methodologies, we formulated disease prediction models employing cell death-related DEGs (CDRDEGs) and identified biomarkers intertwined with cell death in AS. Relative to healthy controls, a myriad of differentially expressed genes (DEGs) linked to cell death surfaced in AS patients. Among AS patients, 82 FRDEGs, 29 CRDEGs, 54 AURDEGs, 21 ARDEGs, and 74 PRDEGs were identified. In male AS patients, these numbers were 78, 33, 55, 24, and 94, respectively. Female AS patients exhibited 66, 41, 40, 17, and 82 DEGs in the corresponding categories. Additionally, 36 FRDEGs, 14 CRDEGs, 19 AURDEGs, 10 ARDEGs, and 36 PRDEGs exhibited differential expression between male and female AS patients. Employing machine learning techniques, LASSO, RF, and SVM-RFE were employed to discern key DEGs related to cell death (CDRDDEGs). The six pivotal CDRDDEGs in AS patients, healthy controls, were identified as CLIC4, BIRC2, MATK, PKN2, SLC25A5, and EDEM1. For male AS patients, the three crucial CDRDDEGs were EDEM1, MAP3K11, and TRIM21, whereas for female AS patients, COX7B, PEX2, and RHEB took precedence. Furthermore, the trio of DDX3X, CAPNS1, and TMSB4Y emerged as the key CDRDDEGs distinguishing between male and female AS patients. In the realm of immune correlation, the immune infiltration abundance in female patients mirrored that of healthy controls. Notably, key genes exhibited a positive correlation with T-cell CD4 memory activation when comparing male and female patient samples. This study engenders a more profound comprehension of the molecular underpinnings governing immune cell infiltration and cell death in ankylosing spondylitis (AS). Furthermore, the discernment of gender-specific disparities among AS patients underscores the clinical significance of these findings. By identifying DEGs associated with diverse cell death modalities, this study proffers invaluable insights into potential clinical targets for AS patients, taking cognizance of gender-specific nuances. The identification of gender-specific biological targets lays the groundwork for the development of tailored diagnostic and therapeutic strategies, heralding a pivotal step toward personalized care for AS patients.
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Affiliation(s)
- Tiantian Dong
- Center for External Treatment of Traditional Chinese Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Xuhao Li
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Wenyan Yu
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Yuanxiang Liu
- Department of Neurology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China.
| | - Jiguo Yang
- School of Acupuncture-Moxibusion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China.
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4
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Selmi C, Chimenti MS, Novelli L, Parikh BK, Morello F, de Vlam K, Ciccia F. Pain in axial spondyloarthritis: role of the JAK/STAT pathway. Front Immunol 2024; 15:1341981. [PMID: 38464510 PMCID: PMC10921361 DOI: 10.3389/fimmu.2024.1341981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/05/2024] [Indexed: 03/12/2024] Open
Abstract
Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that is characterized by new bone formation in the axial musculoskeletal system, with X-ray discriminating between radiographic and non-radiographic forms. Current therapeutic options include non-steroidal anti-inflammatory drugs in addition to biological disease-modifying anti-rheumatic drugs that specifically target tumor necrosis factor-alpha (TNFα) or interleukin (IL)-17. Pain is the most critical symptom for axSpA patients, significantly contributing to the burden of disease and impacting daily life. While the inflammatory process exerts a major role in determining pain in the early phases of the disease, the symptom may also result from mechanical and neuromuscular causes that require complex, multi-faceted pharmacologic and non-pharmacologic treatment, especially in the later phases. In clinical practice, pain often persists and does not respond further despite the absence of inflammatory disease activity. Cytokines involved in axSpA pathogenesis interact directly/indirectly with the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling cascade, a fundamental component in the origin and development of spondyloarthropathies. The JAK/STAT pathway also plays an important role in nociception, and new-generation JAK inhibitors have demonstrated rapid pain relief. We provide a comprehensive review of the different pain types observed in axSpA and the potential role of JAK/STAT signaling in this context, with specific focus on data from preclinical studies and data from clinical trials with JAK inhibitors.
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Affiliation(s)
- Carlo Selmi
- Department of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of “Medicina dei Sistemi”, University of Rome Tor Vergata, Rome, Italy
| | | | - Bhumik K. Parikh
- Global Medical Affairs, AbbVie, Inc., Mettawa, IL, United States
| | | | - Kurt de Vlam
- Department of Rheumatology, University Hospital Leuven, Leuven, Belgium
- Skeletal Biology and Engineering Research Center (SBE), Department of Development and Regeneration, KULeuven, Leuven, Belgium
| | - Francesco Ciccia
- Department of Precision Medicine Napoli, Università degli Studi della Campania “Luigi Vanvitelli”, Caserta, Italy
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Mease PJ, Blachley T, Malatestinic WN, Harrold LR, Dube B, Lisse JR, Bolce RJ, Hunter TM. Effectiveness of bDMARDs in ankylosing spondylitis patients by biologic use: experience from the CorEvitas PsA/SpA Registry. Curr Med Res Opin 2024; 40:315-323. [PMID: 38050693 DOI: 10.1080/03007995.2023.2291160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 11/30/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE To describe bDMARD initiators by biologic experience among ankylosing spondylitis (AS) patients and change in disease activity and patient-reported outcomes (PROs) in real-world US patients. METHODS We included patients ≥18 years with AS based on physician diagnosis enrolled between 3/2013 and 11/2019 in the CorEvitas Psoriatic Arthritis (PSA)/Spondyloarthritis Registry (NCT02530268). Patients concurrently diagnosed with PSA were excluded. Baseline (bDMARD initiation) demographics, comorbidities, disease characteristics, treatment, and PROs were collected. Response rates and changes in disease activity and PROs between baseline and 6- and 12- month follow-up visits were calculated. RESULTS Of the 489 AS patients in the PsA/SpA Registry, 254 AS (52.0%) patients initiated a bDMARD at enrollment or during follow-up (total initiations: AS = 313). Of the 313 AS initiations, 179 (57.2%) had a 6-month follow-up, 122 (39.0%) had a 12-month follow-up, and 94 (30.0%) had a 6- and 12-month follow-up visit. For those AS initiators with a 6-month follow-up, the mean age was 49.1 years, 44.4% were female, and 70.4%, 47.5%, 96.1%, and 46.9% had never used cDMARDs, TNFis, non-TNFis, and bDMARDs, respectively. Of these 179 AS initiators, 20.1% and 14.0% achieved ASAS20/40, respectively. Further, only 34% achieved low disease activity (ASDAS <2.1). When stratified by biologic-naivete and biologic-experience, the ASAS 20/40 achievement rates were 26.2% and 14.7%, and 21.4% and 7.4%, respectively, for this cohort. CONCLUSION Although AS patients initiate bDMARDs, many do not achieve optimal treatment responses. Future research is needed to investigate the aspects associated with inadequate improvement and treatment response to bDMARDs.
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Affiliation(s)
- Philip J Mease
- Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, WA, USA
| | | | | | - Leslie R Harrold
- CorEvitas, LLC, Waltham, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
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Bandinelli F, Martinelli-Consumi B, Manetti M, Vallecoccia MS. Sex Bias in Diagnostic Delay: Are Axial Spondyloarthritis and Ankylosing Spondylitis Still Phantom Diseases in Women? A Systematic Review and Meta-Analysis. J Pers Med 2024; 14:91. [PMID: 38248792 PMCID: PMC10817445 DOI: 10.3390/jpm14010091] [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: 12/24/2023] [Revised: 01/01/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Diagnostic delay (DD) is associated with poor radiological and quality of life outcomes in axial spondyloarthritis (ax-SpA) and ankylosing spondylitis (AS). The female (F) population is often misdiagnosed, as classification criteria were previously studied mostly in males (M). We conducted a systematic review to investigate (i) the difference in DD between the sexes, the impact of HLA*B27 and clinical and social factors (work and education) on this gap, and (ii) the possible influence of the year of publication (before and after the 2009 ASAS classification criteria), geographical region (Europe and Israel vs. extra-European countries), sample sources (mono-center vs. multi-center studies), and world bank (WB) economic class on DD in both sexes. We searched, in PubMed and Embase, studies that reported the mean or median DD or the statistical difference in DD between sexes, adding a manual search. Starting from 399 publications, we selected 26 studies (17 from PubMed and Embase, 9 from manual search) that were successively evaluated with the modified Newcastle-Ottawa Scale (m-NOS). The mean DD of 16 high-quality (m-NOS > 4/8) studies, pooled with random-effects meta-analysis, produces results higher in F (1.48, 95% CI 0.83-2.14, p < 0.0001) but with significant results at the second analysis only in articles published before the 2009 ASAS classification criteria (0.95, 95% CI 0.05-1.85, p < 0.0001) and in extra-European countries (3.16, 95% CI 2.11-4.22, p < 0.05). With limited evidence, some studies suggest that DD in F might be positively influenced by HLA*B27 positivity, peripheral involvement, and social factors.
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Affiliation(s)
- Francesca Bandinelli
- Rheumatology Department, Usl Tuscany Center, San Giovanni di Dio Hospital, 50143 Florence, Italy;
| | | | - Mirko Manetti
- Section of Anatomy and Histology, Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Maria Sole Vallecoccia
- Department of Emergency and Critical Care, Santa Maria Nuova Hospital, 50122 Florence, Italy;
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Kiwalkar S, Howard R, Choi D, Deodhar A. A mixed methods study to uncover impediments to accurate diagnosis of nonradiographic axial spondyloarthritis in the USA. Clin Rheumatol 2023; 42:2811-2822. [PMID: 37347434 DOI: 10.1007/s10067-023-06671-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION/OBJECTIVES Delayed diagnosis of axial spondyloarthritis (axSpA) is well documented; little is known about the diagnostic journey and impediments for US patients with nonradiographic axSpA (nr-axSpA). It is hypothesized that impediments are varied and exist at both the healthcare provider (HCP) and patient levels. This study aims to understand patient experiences and contributors to delayed nr-axSpA diagnosis in the USA. METHOD Interviews of adults with rheumatologist-diagnosed nr-axSpA, recruited through Spondylitis Association of America outreach and patient panels, and of rheumatologists, explored the diagnostic journey and diagnostic barriers. Emerging themes were further explored in an online patient survey. A multiple logistic regression analysis evaluated the main outcome variable, factors affecting time to nr-axSpA diagnosis. RESULTS Interviews were conducted with 25 patients and 16 rheumatologists. Survey responses from 186 eligible patients revealed median time from symptom onset to diagnosis of nr-axSpA was 3.25 years. Delayed diagnosis was significantly more likely for women and people in rural areas. Most patients consulted ≥4 different types of HCPs before a rheumatologist and ≥2 rheumatologists before diagnosis. Impediments to timely diagnosis included insidious chronic pain; episodic symptom patterns attributed to activity; symptoms other than chronic lumbosacral back pain requiring medical consultation; and unfamiliarity with and misperceptions about nr-axSpA among HCPs, radiologists, and rheumatologists. CONCLUSIONS Delayed nr-axSpA diagnosis is common and reflects HCP knowledge gaps and frequent patient presentation with dominant nonaxial symptoms. Targeted HCP education, research into early disease patterns, and interventions sensitive to the broader spectrum of nr-axSpA manifestations are needed to improve timely diagnosis. Key Points • Patients with nr-axSpA often see multiple types of HCPs, and multiple rheumatologists, before receiving a diagnosis. • Both patients and HCPs are unfamiliar with nr-axSpA and its symptoms, lacking understanding that nr-axSpA can occur in young people, females, and those presenting with normal x-rays. • Disease recognition by nonrheumatology HCPs is key for early referral. • Education on cardinal features, epidemiology, burden, and benefits of timely nr-axSpA diagnosis is warranted for HCPs who commonly manage back pain.
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Affiliation(s)
- Sonam Kiwalkar
- The Vancouver Clinic, Washington State University, 700 NE 87th Avenue, Suite 330, Vancouver, WA, 98664, USA.
| | - Richard Howard
- Spondylitis Association of America, 16430 Ventura Blvd, Suite 300, Encino, CA, 91436, USA
| | - Dongseok Choi
- Oregon Health & Science University-Portland State University School of Public Health, Oregon Health & Science University, 1810 SW 5th Ave. Suite 510, Portland, OR, 97201, USA
| | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, 3270 SW Pavilion Loop, Portland, OR, 97239, USA
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Barnett R, Gaffney K, Sengupta R. Diagnostic delay in axial spondylarthritis: A lost battle? Best Pract Res Clin Rheumatol 2023; 37:101870. [PMID: 37658016 DOI: 10.1016/j.berh.2023.101870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/03/2023]
Abstract
Diagnostic delay in axial spondylarthritis (axSpA) remains an unacceptable worldwide problem; with evidence suggesting significant detrimental impact both clinically on the individual, and economically on society. There is therefore, a need for global action across various healthcare professions that come into contact with patients living, and suffering, with undiagnosed axSpA. Recent estimates of the median diagnostic delay suggest that globally, individuals with axSpA wait between 2 and 6 years for a diagnosis - revealing a clear benchmark for improvement. This timespan presents a window of opportunity for earlier diagnosis and intervention, which will likely improve patient outcomes. This review describes the current diagnostic delay as estimated across countries and over time, before presenting evidence from published strategies that may be implemented to improve this delay across primary and secondary care, including for specialties treating extra-musculoskeletal manifestations of axSpA (ophthalmology, gastroenterology, dermatology). Ongoing campaigns tackling delayed diagnosis in axSpA are also highlighted.
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Affiliation(s)
- Rosemarie Barnett
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK; Rheumatology Department, Royal National Hospital for Rheumatic Diseases & Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK.
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk & Norwich, University Hospital, Colney Lane, Norwich NR4 7UY, UK.
| | - Raj Sengupta
- Rheumatology Department, Royal National Hospital for Rheumatic Diseases & Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK.
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Lan NTT, Tat Bang H, Thu TTA, Anh NTM, Tap NV. Quality of Life and Related Factors in Patients With Ankylosing Spondylitis: A Cross-Sectional Study Using 36-Item Short Form Survey (SF-36). Cureus 2023; 15:e44695. [PMID: 37809169 PMCID: PMC10551724 DOI: 10.7759/cureus.44695] [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: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Ankylosing spondylitis is a chronic condition that affects the vertebral and sacroiliac joints, causing progressive back pain and stiffness. Patients with this condition experience a lower quality of life compared to the general population, with physical health being more impacted than mental health. In Vietnam, little attention has been given to the quality of life of patients with ankylosing spondylitis, and there are conflicting studies on the factors that affect their quality of life. Therefore, it is essential to assess the quality of life of these patients to provide appropriate recommendations for improving their overall well-being. METHODOLOGY The descriptive cross-sectional study was conducted on patients with ankylosing spondylitis who visited University Medical Center Ho Chi Minh City from March 2022 to May 2022. Participants were interviewed face-to-face using the 36-item short form survey (SF-36) questionnaire and the visual analogue scale. In addition, some information related to ankylosing spondylitis was also collected through medical records. RESULTS AND CONCLUSION Seventy-five patients met the inclusion criteria with a median age of 33 (26 - 37); men accounted for 68%. The mean physical and mental health scores on the SF-36 scale were 37.73 ± 9.30 and 47.04 ± 7.11, respectively. Young age, lower pain score and duration of illness, and higher education were associated with a high physical health score with p<0.05. Similarly, the educational level and occupation were positively correlated, and pain scores were inversely correlated with mental health with p< 0.05.
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Affiliation(s)
| | - Ho Tat Bang
- Thoracic and Vascular Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
- Department of Health Organization and Management, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
| | - Tran Thi Anh Thu
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
- Department of Health Communication, Binh Thanh Medical Center, Ho Chi Minh City, VNM
| | - Nguyen Thi My Anh
- Faculty of Nursing and Medical Technology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
| | - Nguyen Van Tap
- Faculty of Medical Management, Nguyen Tat Thanh University, Ho Chi Minh City, VNM
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Magrey M, Walsh JA, Flierl S, Howard RA, Calheiros RC, Wei D, Khan MA. The International Map of Axial Spondyloarthritis Survey: A US Patient Perspective on Diagnosis and Burden of Disease. ACR Open Rheumatol 2023; 5:264-276. [PMID: 37095710 PMCID: PMC10184009 DOI: 10.1002/acr2.11543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that causes inflammation in the axial skeleton, resulting in structural damage and disability. We aimed to understand the effect of axSpA on work activity, day-to-day function, mental health, relationships, and quality of life and to examine barriers to early diagnosis. METHODS A 30-minute quantitative US version of the International Map of Axial Spondyloarthritis survey was administered online to US patients aged 18 years and older with a diagnosis of axSpA who were under the care of a health care provider from July 22 to November 10, 2021. This analysis describes demographics, clinical characteristics, journey to axSpA diagnosis, and disease burden. RESULTS We surveyed 228 US patients with axSpA. Patients had a mean diagnostic delay of 8.8 years, with a greater delay in women versus men (11.2 vs. 5.2 years), and 64.5% reported being misdiagnosed before receiving an axSpA diagnosis. Most patients (78.9%) had active disease (Bath Ankylosing Spondylitis Disease Activity Index score ≥4), reported psychological distress (57.0%; General Health Questionnaire 12 score ≥3), and experienced a high degree of impairment (81.6%; Assessment of Spondyloarthritis International Society Health Index score ≥6). Overall, 47% of patients had a medium or high limitation in activities of daily living, and 46% were not employed at survey completion. CONCLUSION The majority of US patients with axSpA had active disease, reported psychological distress, and reported impaired function. US patients experienced a substantial delay in time to diagnosis of axSpA that was twice as long in women versus men.
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Affiliation(s)
- Marina Magrey
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio
| | - Jessica A Walsh
- University of Utah School of Medicine and Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
| | | | | | | | - David Wei
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Muhammad A Khan
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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11
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Bamford S, Tahir H, Ladan Z, Hanumunthadu D. Patient Survey Exploring the Burden of Inflammatory Back Pain in Patients With Uveitis. Cureus 2023; 15:e37473. [PMID: 37187633 PMCID: PMC10176535 DOI: 10.7759/cureus.37473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
Background In the UK, diagnostic delays remain a challenge in axial spondyloarthritis (axSpA). Studies have shown that acute anterior uveitis is the most common extra-articular manifestation associated with axSpA. As part of a National Axial Spondyloarthritis Society (NASS) Aspiring to Excellence quality improvement project, this study aimed to ascertain the burden of inflammatory back pain (IBP) in patients attending a uveitis clinic and to establish the number of these patients who had not been referred to a rheumatologist, thereby contributing to the diagnostic delay. The secondary aims were to explore the factors contributing to the diagnostic delay. Methods A 22-question patient survey was created to identify the burden of back pain in patients attending a specialist uveitis clinic at a London NHS Trust. Participants were recruited when attending their clinic appointments. Survey content included patient demographics and whether they had experienced back pain for longer than three months. The Berlin Criteria was used to identify the presence of inflammatory back pain, and it was also ascertained whether participants had a previous diagnosis of axSpA. Participants were asked if they had seen any healthcare professionals regarding their back pain and the total number of consultations they had had with each profession. Results A cohort of 50 patients who attended the uveitis clinic at the Royal Free London NHS Trust completed the survey between February and July 2022. The mean age of the respondents was 52 years with a mean length of time with uveitis of 6.57 years. Of them, 64% were female and 36% were male. Forty per cent (40%) of participants (20 respondents) reported experiencing back pain for more than three months and 12% (six respondents) had a diagnosis of axSpA. Of those who reported back pain for more than three months, the mean age of onset of back pain was 28.6 years. Of the 14 participants (28%) who had back pain and were not diagnosed with axSpA, nine (18%) fulfilled the Berlin criteria for IBP. All participants had seen a GP or allied health professional specifically for their back pain. On average, respondents had seen two allied healthcare professionals, but only 40% (eight) of respondents with back pain had been seen by a rheumatologist. Conclusions In this study, the data highlights that inflammatory back pain is common in patients with uveitis and the majority of patients with inflammatory back pain had not been referred to a rheumatology service and potentially have undiagnosed axSpA. Contributing factors to this potential delay in diagnosis include a lack of awareness of axSpA and its presenting features and associated conditions and a lack of onward referral for a specialist rheumatology opinion. This highlights the need for public, patient and healthcare professional education and the development of timely referral pathways to reduce delays in diagnosis.
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Affiliation(s)
- Sian Bamford
- Physiotherapy, Royal Free London NHS Foundation Trust, London, GBR
| | - Hasan Tahir
- Medicine, University College London, London, GBR
- Rheumatology, Royal Free London NHS Foundation Trust, London, GBR
| | - Zahra Ladan
- General Medicine, Royal Free London NHS Foundation Trust, London, GBR
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12
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Tarannum S, Widdifield J, Wu CF, Johnson SR, Rochon P, Eder L. Understanding sex-related differences in healthcare utilisation among patients with inflammatory arthritis: a population-based study. Ann Rheum Dis 2023; 82:283-291. [PMID: 36130810 PMCID: PMC9887399 DOI: 10.1136/ard-2022-222779] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Our aim was to compare patterns of musculoskeletal-related healthcare utilisation between male and female patients before and after the diagnosis of inflammatory arthritis (IA). METHODS We used Ontario administrative health data to create three inception cohorts of adult patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) diagnosed between April 2010 and March 2017. Healthcare utilisation indicators including visits to physicians, and use of musculoskeletal imaging and laboratory tests were assessed in each year for 3 years before and after diagnosis and compared between male and female patients using regression models adjusting for sociodemographic factors and comorbidities. Results were reported as ORs with 95% CIs for female patients compared with male patients. RESULTS A total of 41 277 patients with RA (69% female), 8150 patients with AS (51% female) and 6446 patients with PsA (54% female) were analysed.Similar trends of sex-related differences were observed in all three cohorts. Before diagnosis, female patients were more likely to visit rheumatologists (OR 1.32-2.28) and family physicians (OR 1.03-1.15) for musculoskeletal reasons, whereas male patients were more likely to visit the emergency for musculoskeletal reasons (OR 0.76-0.87). A similar female predominance was observed regarding musculoskeletal imaging and laboratory tests before diagnosis. After diagnosis, female patients were more likely to remain in rheumatology care (OR 1.12-1.24). CONCLUSION Female patients with IA have higher healthcare utilisation than male patients which may indicate biological differences in disease course or sociocultural differences in healthcare-seeking behaviour.
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Affiliation(s)
- Sanjana Tarannum
- Depetment of Medieine and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Widdifield
- Sunnybrook Research Institute, Sunnybrook Hospital, Toronto, Ontario, Canada,Institute for Clinical Evaluative Sciences, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - C Fangyun Wu
- Institute for Clinical Evaluative Sciences, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Sindhu R Johnson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Division of Rheumatology, Department of Medicine, Toronto Western and Mount Sinai Hospitals, Toronto, Ontario, Canada
| | - Paula Rochon
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Department of Geriatrics, Women’s Age Lab; Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Lihi Eder
- Depetment of Medieine and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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13
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Zhou C, Liang T, Jiang J, Zhang Z, Chen J, Chen T, Chen L, Sun X, Huang S, Zhu J, Wu S, Zhan X, Liu C. Immune cell infiltration-related clinical diagnostic model for Ankylosing Spondylitis. Front Genet 2022; 13:949882. [PMID: 36263434 PMCID: PMC9575679 DOI: 10.3389/fgene.2022.949882] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background: The pathogenesis and diagnosis of Ankylosing Spondylitis (AS) has remained uncertain due to several reasons, including the lack of studies on the local and systemic immune response in AS. To construct a clinical diagnostic model, this study identified the micro RNA-messenger RNA (miRNA-mRNA) interaction network and immune cell infiltration-related hub genes associated with AS. Materials and Methods: Total RNA was extracted and purified from the interspinous ligament tissue samples of three patients with AS and three patients without AS; miRNA and mRNA microarrays were constructed using the extracted RNA. Bioinformatic tools were used to construct an miRNA-mRNA network, identify hub genes, and analyze immune infiltration associated with AS. Next, we collected the blood samples and clinical characteristics of 359 patients (197 with AS and 162 without AS). On the basis of the clinical characteristics and results of the routine blood tests, we selected immune-related cells whose numbers were significantly different in patients with AS and patients without AS. Univariate and multivariate logistic regression analysis was performed to construct a nomogram. Immunohistochemistry staining analysis was utilized to verify the differentially expression of LYN in AS and controls. Results: A total of 225 differentially expressed miRNAs (DE miRNAs) and 406 differentially expressed mRNAs (DE mRNAs) were identified from the microarray. We selected 15 DE miRNAs and 38 DE mRNAs to construct a miRNA-mRNA network. The expression of LYN, an immune-related gene, correlated with the counts of monocytes, neutrophils, and dendritic cells. Based on the independent predictive factors of sex, age, and counts of monocytes, neutrophils, and white blood cells, a nomogram was established. Receiver operating characteristic (ROC) analysis was performed to evaluate the nomogram, with a C-index of 0.835 and AUC of 0.855. Conclusion:LYN, an immune-related hub gene, correlated with immune cell infiltration in patients with AS. In addition, the counts of monocytes and neutrophils were the independent diagnostic factors for AS. If verified in future studies, a diagnostic model based on these findings may be used to predict AS effectively.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Xinli Zhan
- *Correspondence: Xinli Zhan, ; Chong Liu,
| | - Chong Liu
- *Correspondence: Xinli Zhan, ; Chong Liu,
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14
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Yang W, Rong L, Xu Q, Fu X, Deng X, Hu A, Jiang Y. Identification of symptom clusters in patients with ankylosing spondylitis. Int J Rheum Dis 2022; 25:1137-1144. [PMID: 35906783 DOI: 10.1111/1756-185x.14391] [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: 04/26/2022] [Revised: 06/04/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
Abstract
Symptom cluster refers to a group of 3 or more related symptoms that occur together. Our objectives were to: (1) investigate the frequency, severity and gender difference of symptoms in patients with ankylosing spondylitis (AS); and (2) identify symptom clusters in AS patients. A cross-sectional questionnaire-based survey was conducted using the Patient Health Questionnaire Symptoms Group combined with self-designed variables. Demographic and symptom variables between male and female patients in terms of C-reactive protein (CRP) and human leukocyte antigen (HLA)-B27 status were analyzed with 2-tailed independent t test for continuous variables and Chi-square or Fisher's exact test for categorical variables. Symptom clusters were extracted and analyzed by principal component analysis. There were 122 AS patients included in the study. The most severe symptoms included severe back pain, extremity or joint pain, difficulty in breathing, constipation, intestine discomfort and diarrhea. Stomachache was more prevalent in male patients in which odds ratio was 4.60 (CI 1.59-12.97) (P = .006). Patients with HLA-B27 negativity or a higher CRP value were more likely to have dry mouth. Four symptom clusters were classified, which explained 58.4% of the total variation. They were named as the gastrointestinal-cardiac cluster, the fatigue-sleep disturbance cluster, the headache-chest pain cluster, and the mouth-eye cluster. The symptoms appeared to cluster into 4 groups in AS patients, which should be noticed in clinical care.
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Affiliation(s)
- Wen Yang
- Department of Rheumatology and Immunology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Li Rong
- Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Quan Xu
- Department of Rheumatology and Immunology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaoli Fu
- Department of Rheumatology and Immunology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaohong Deng
- Department of Nursing, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ailing Hu
- Department of Nursing, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yutong Jiang
- Department of Rheumatology and Immunology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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15
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Gregory WJ, Kaur J, Bamford S, Tahir H. A Survey of Diagnostic Delay in Axial Spondyloarthritis Across Two National Health Service (NHS) Rheumatology Services. Cureus 2022; 14:e23670. [PMID: 35510018 PMCID: PMC9060761 DOI: 10.7759/cureus.23670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Diagnostic delay is an ongoing challenge in axial spondyloarthritis (axial SpA). A recent, comprehensive literature review has found a mean average of 8.7 years of delay between symptom onset and formal diagnosis in the United Kingdom (UK). The primary aim of this study was to identify delays to diagnosis experienced by patients with axial SpA under the ongoing care of two urban National Health Service (NHS) rheumatology services. The secondary aims were (a) to count healthcare professional (HCP) interactions after symptom onset but prior to the diagnosis, (b) to compare our data to published delay to diagnosis research and (c) to explore contributing factors locally and the variation between the two UK rheumatology services. Methods A 14-question survey was created to identify the delay to diagnosis and contributing factors across two urban NHS axial SpA services, from the onset of symptoms to diagnosis and commencement of treatment. Participants were recruited from clinic visits between August and November 2021 and completed the survey either on paper or via online survey software, both with HCP support. Results Those completing the survey formed a cohort of 106 participants with an established diagnosis of axial SpA who attended the axial SpA services at either Royal Free NHS Foundation Trust or Salford Care Organisation, Northern Care Alliance NHS Foundation Trust. The mean time from the onset of symptoms to the diagnosis of axial SpA was similar across centres despite the differences in demographics, with Royal Free at 5.72 years and Salford Royal at 5.96 years. When reviewing via median diagnostic delay, there was a notable difference with Royal Free at 6.09 years and Salford Royal at 4.27 years. Across the two sites, between the onset of symptoms and the diagnosis of axial SpA, 90% of the participants saw a general practitioner (GP), of which 63% of the patients saw a GP 1-5 times, 23% saw 5-10 times and 14% saw more than 10 times. Many participants also saw other HCPs, including physiotherapists, other manual therapists and hospital specialists prior to diagnosis. In addition, 32% saw one other HCP, 18% two other HCPs, 9% three, 7% four and 2.7% five other HCPs prior to diagnosis. Close to 80% of the patients stated that they had received adequate axial SpA education at diagnosis, and 76% of the patients were aware of who to contact in the event of a flare. Conclusions These data highlight that the mean average time to diagnosis for both trusts was between five and six years, somewhat lower than the 8.7-year national UK average. However, despite being specialist centres, these data are a long way from the National Axial Spondyloarthritis Society (NASS) “Gold Standard” of one year time to diagnosis. The contributors to this include lack of HCP and community awareness about axial SpA, its recognition and appropriate onwards referral. There is a need for concerted ways of working for the development of patient pathways and public and HCP education to reduce this delay to allow the ambitious NASS Gold Standard of one year time to diagnosis to be achieved.
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16
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Zhdan VM, Volchenko HV, Babanina M. MY, Tkachenko MV, Kyrian OA. AXIAL SPONDYLOARTHRITIS. CLINICAL DEFINITION AND DIAGNOSTIC APPROACHES. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-4-167-49-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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17
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Winkler AE, Miller M. Update on Axial Spondyloarthritis. MISSOURI MEDICINE 2022; 119:79-83. [PMID: 36033135 PMCID: PMC9312440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Understanding of the spondyloarthritis diseases has changed significantly in the last 15 years. It is now clear that there are patients with and without radiographic changes and the terminology has changed to reflect that: radiographic axial spondyloarthritis and non-radiographic axial spondyloarthritis. In addition, the importance of the presence of inflammatory back pain with spondyloarthritis in making the diagnosis is now well established. It is also clear that women are much more likely to develop axial spondyloarthritis than previously thought. Finally, there are treatments now available to treat axial spondyloarthritis and more hopefully to be approved in the next year.
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Affiliation(s)
- Anne E Winkler
- Rheumatologist, and practices in Springfiield, Missouri. She is also Adjunct Clinical Faculty at Missouri State University and Missouri Medicine Editorial Board member for Rheumatology
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18
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Schwartzman S, Ruderman EM. A Road Map of the Axial Spondyloarthritis Continuum. Mayo Clin Proc 2022; 97:134-145. [PMID: 34801248 DOI: 10.1016/j.mayocp.2021.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 12/17/2022]
Abstract
Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease characterized by inflammatory low back pain, inflammation in peripheral joints and entheses, and other extra-articular or systemic manifestations. Although our understanding of the natural history of axSpA has been limited by incomplete knowledge of disease pathogenesis, axSpA is increasingly understood as a spectrum of axial, peripheral, and extra-articular inflammatory conditions that includes nonradiographic axSpA and radiographic axSpA, also known as ankylosing spondylitis. In this narrative review, we present a road map of this axSpA continuum, highlighting genetic risk factors for the development of axSpA, triggers of disease, and reasons for and implications of diagnostic delay. We present a detailed overview of the spectrum of axSpA clinical manifestations and highlight factors known to influence the risk of disease progression. Finally, we provide some expert commentary on the practical use of this road map to assist health care providers in the identification of axSpA in clinical practice.
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Affiliation(s)
| | - Eric M Ruderman
- Northwestern University Feinberg School of Medicine, Chicago, IL
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19
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Patient Perspectives on Biologics for Axial Spondyloarthritis in a Cross-sectional Study in a Predominantly Female Population: Treatment Satisfaction, Wear-off Between Doses, and Use of Supplemental Medication. Rheumatol Ther 2021; 9:509-520. [PMID: 34958453 PMCID: PMC8964844 DOI: 10.1007/s40744-021-00417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction There is limited information regarding treatment experience of patients with axial spondyloarthritis/ankylosing spondylitis (axSpA/AS) receiving biological disease-modifying antirheumatic drugs (bDMARDs). Here we characterize patient experiences and perspectives, including satisfaction among those currently treated with bDMARD therapy for axSpA/AS. We also assess the use of supplemental medication during perceived wear-off between doses. Methods Adult participants from the United States within the ArthritisPower registry with physician-diagnosed axSpA/AS were invited to complete electronic patient-reported outcome measures and an online survey about their perspectives of treatment. Analysis compared patient characteristics and treatment satisfaction by whether wear-off in axSpA/AS between bDMARD doses was reported. Results Of 128 patients currently taking a DMARD, the mean age was 46.9 (10.3) years, 82.0% were female, and 93.8% were White. A total of 78 (60.9%) perceived wear-off with their current bDMARD before the next dose, 19 (14.8%) did not experience wear-off and 31 (24.2%) were unsure about wear-off. Mean (standard deviation [SD]) Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score indicated poor disease control in all patients receiving bDMARDs (6.4 [1.8]); worse for those perceiving wear-off between doses versus those who did not perceive wear-off or were unsure (6.8 [1.6] vs. 5.9 [2.0], p = 0.011). Patients experiencing wear-off reported being ‘very satisfied’ or ‘somewhat satisfied’ with their treatment less frequently than patients without wear-off (73.1 vs. 89.5%, respectively). Of patients reporting wear-off, 82.1% (n = 64) used supplemental medications during wear-off (non-steroidal anti-inflammatory drugs [68.8%, n = 44], muscle relaxants [42.2%, n = 27], and/or opioids [37.5%, n = 24]). Conclusions In a predominantly female sample of bDMARD-treated patients with axSpA/AS and high disease activity, the majority expressed treatment satisfaction. However, most experienced wear-off between doses and relied on supplemental medications, including opioids, to manage symptoms. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00417-6.
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Deodhar A, Kruzikas D, Zhou L, Biljan A, Saffore CD. Geographic Variations in Diagnosis and Treatment of Ankylosing Spondylitis in the United States: A Real-World Study. Rheumatol Ther 2021; 9:447-463. [PMID: 34927217 PMCID: PMC8964895 DOI: 10.1007/s40744-021-00406-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/18/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Diagnosis difficulties are common for ankylosing spondylitis (AS) patients, leading to inadequate and inconsistent treatment. We evaluated the national and geographic variability in disease diagnosis and treatment in the United States. Methods This retrospective, cross-sectional analysis utilized the IBM® MarketScan® Administrative Claims Database from 2014 to 2019. AS patients ≥ 18 years of age with continuous medical and pharmacy enrollment during the calendar year and complete geographic information during the study period were included. Patient cohorts assessed were D1 (≥ 1 AS diagnoses within each calendar year of assessment between 2014 and 2019), D2 (≥ 2 non-rheumatologist AS diagnoses), and D3 (≥ 2 rheumatologist AS diagnoses). For D2 and D3, diagnoses were ≥ 6 months apart, but within 18 months. Annual AS diagnostic prevalence and treatment rates were determined from 2014 to 2019 nationally and per state in 2019. Treatments assessed were disease-modifying antirheumatic drugs (DMARDs), opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and methotrexate. Results Nationally, AS diagnostic prevalence increased from 2014 to 2019, with 2019 rates of 9.6 (D1), 5.1 (D2), and 3.5 (D3) per 10,000 persons. Diagnostic prevalence varied between states, which was not explained by age, sex, racial distribution, or rheumatologists per capita. Nationally, a greater percentage of D3 patients vs. D1 and D2 patients received biologic/targeted synthetic DMARDs (bDMARD/tsDMARDs) and conventional synthetic DMARD. Opioid use ranged from 37 to 40% in 2019 and decreased from 2014 for all cohorts. Corticosteroid and methotrexate use decreased slightly, while NSAID and bDMARD/tsDMARD use generally increased from 2014 to 2019. Conclusions AS diagnostic prevalence is increasing nationally, though it remains low among some states. bDMARD/tsDMARDs use was more common among patients treated by rheumatologists. Opioid and corticosteroid use is decreasing, though national rates remain high with significant state variability. Further education is needed, particularly in states with low prevalence and inadequate treatment, to improve diagnosis and treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00406-9.
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Affiliation(s)
- Atul Deodhar
- Department of Medicine, Rheumatology Clinics, Oregon Health and Science University, Portland, OR, USA.
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Abstract
BACKGROUND Axial spondyloarthritis (axSpA) is a chronic, rheumatic disease characterized by inflammation of the sacroiliac joint, spine, and entheses. Axial spondyloarthritis affects up to 1.4% of adults in the United States and is associated with decreased quality of life, increased mortality, and substantial health care-related costs, imposing a high burden on patients, their caregivers, and society. SUMMARY OF WORK Diagnosing axSpA can be difficult. In this review, we seek to help rheumatologists in recognizing and diagnosing axSpA. MAJOR CONCLUSIONS A discussion of challenges associated with diagnosis is presented, including use and interpretation of imaging, reasons for diagnostic delays, differences in disease presentation by sex, and differential diagnoses of axSpA. FUTURE RESEARCH DIRECTIONS The early diagnosis of axSpA and advances in available therapeutic options have improved patient care and disease management, but delays in diagnosis and treatment remain common. Additional research and education are critical for recognizing diverse axSpA presentations and optimizing management early in the course of disease.
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Affiliation(s)
- Jessica A. Walsh
- From the University of Utah School of Medicine and Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT
| | - Marina Magrey
- The MetroHealth System and School of Medicine, Case Western Reserve University, Cleveland, OH
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22
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Nowell WB, Gavigan K, Hunter T, Malatestinic WN, Bolce RJ, Lisse JR, Himelein C, Curtis JR, Walsh JA. Treatment Satisfaction and Decision-making from the Patient Perspective in Axial Spondyloarthritis: Real-World Data from a Descriptive Cross-sectional Survey Study from the ArthritisPower Registry. ACR Open Rheumatol 2021; 4:85-94. [PMID: 34758105 PMCID: PMC8754015 DOI: 10.1002/acr2.11365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 01/17/2023] Open
Abstract
Objective Aims were to 1) to characterize patient decision‐making with treatment for axial spondyloarthritis (axSpA) and 2) to explore relationships among decision‐making, treatment satisfaction, and biologic disease modifying antirheumatic drugs (bDMARDs). Methods ArthritisPower participants with physician‐diagnosed axSpA were invited to complete an online survey about their treatment and their most recent physician visit. Analysis compared treatment decision by satisfaction and bDMARD status. Results Among the 274 participants, 87.2% were female, and the mean age was 50 years. Of participants, 79.5% had researched treatment before their most recent physician visit, and 56.9% discussed treatment change at their most recent physician visit. Of treatment‐change discussions, 69.2% of them were related to escalation, compared with deescalation (27.6%) and/or switching (39.1%). Among those participants who discussed a change, 73.7% agreed to it because they felt that their disease was not being controlled (54.9%) or felt that it could be better controlled on new treatment (20.3%). Top symptoms prompting change were back/buttock pain (63.3%), other joint pain (55.1%), and fatigue (54.1%). Among bDMARD‐treated participants (n = 128), important factors for treatment decisions were prevention of long‐term axSpA consequences (92.9%) and doctor's advice (87.5%). Among 43.4% of participants reporting treatment dissatisfaction, 37% did not discuss treatment change. Current bDMARD use was more common in satisfied (61.9%) than dissatisfied participants (26.9%). Conclusion In this cross‐sectional study of a predominantly female axSpA population, patients frequently researched treatment options and discussed escalation with their providers. Under two‐thirds of participants who were dissatisfied with treatment discussed changes at their most recent visit. Current bDMARD use was associated with higher satisfaction, and bDMARD users considered prevention of long‐term consequences and doctor's advice to be very important for decision‐making.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jessica A. Walsh
- University of UtahSalt Lake CityUtah
- George E. Wahlen Veterans Affairs Medical Center, RheumatologySalt Lake CityUtah
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23
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Cooksey R, Rahman MA, Kennedy J, Brophy S, Choy E. Biologic use in psoriatic arthritis and ankylosing spondylitis patients: a descriptive epidemiological study using linked, routine data in Wales, UK. Rheumatol Adv Pract 2021; 5:rkab042. [PMID: 34632260 PMCID: PMC8496109 DOI: 10.1093/rap/rkab042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Roxanne Cooksey
- Division of Infection and Immunity, CREATE Centre, Section of
Rheumatology, School of Medicine, Cardiff University,
Cardiff
- Health Data Research UK, Swansea University Medical
School, Swansea
- National Centre for Population Health and Wellbeing
Research, Swansea, UK
| | | | - Jonathan Kennedy
- Health Data Research UK, Swansea University Medical
School, Swansea
| | - Sinead Brophy
- Health Data Research UK, Swansea University Medical
School, Swansea
- National Centre for Population Health and Wellbeing
Research, Swansea, UK
| | - Ernest Choy
- Division of Infection and Immunity, CREATE Centre, Section of
Rheumatology, School of Medicine, Cardiff University,
Cardiff
- National Centre for Population Health and Wellbeing
Research, Swansea, UK
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24
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Dube CE, Lapane KL, Ferrucci KA, Beccia AL, Khan SK, Yi E, Kay J, Kuhn KA, Ogdie A, Liu SH. Personal Experiences with Diagnostic Delay Among Axial Spondyloarthritis Patients: A Qualitative Study. Rheumatol Ther 2021; 8:1015-1030. [PMID: 34059989 PMCID: PMC8217406 DOI: 10.1007/s40744-021-00321-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION On average, patients with axial spondyloarthritis (axSpA) suffer from symptoms up to 13 or more years before diagnosis, contributing to psychological distress and healthcare burden METHODS: We conducted six semi-structured focus groups with 26 axSpA patients (from 3 rheumatology practices located in the states of Massachusetts, Colorado, and Pensylvania, USA) exploring early disease and diagnostic experiences. Verbatim transcripts were coded using a start list with emerging thematic codes added. A qualitative thematic analysis was performed RESULTS: Many participants described meandering and frustrating diagnostic journeys. Participants reported that intermittent axSpA symptoms and idiopathic pain contributed to physician confusion and delay in patients seeking care. Participants were sometimes perceived as somaticizing, drug-seeking, or "crazy." Diagnostic delay led to frustration and mental suffering. Doctors "giving up" was considered profoundly negative. Stories of symptoms fell into five areas: (1) pain; (2) stiffness; (3) impact on sleep; (4) impact on daily activities; and (5) changes with weather. Self-advocacy and family advocacy were considered essential. Participants suggested wider use of HLA-B27 testing and development of a definitive diagnostic test CONCLUSION: Most participants described significant suffering prior to axSpA diagnosis which could have been avoided with earlier intervention. Further research on the early disease experiences of axSpA patients is needed.
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Affiliation(s)
- Catherine E Dube
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, USA.
| | - 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
| | - Katarina A 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
| | - Ariel L Beccia
- 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 K Khan
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01655, 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, UMass Memorial Medical Center, Worcester, MA, USA
| | - Kristine A Kuhn
- Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexis Ogdie
- Epidemiology and Biostatistics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Rheumatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 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, UMass Memorial Medical Center, Worcester, MA, USA
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25
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Li Z, Wu X, Leo PJ, De Guzman E, Akkoc N, Breban M, Macfarlane GJ, Mahmoudi M, Marzo-Ortega H, Anderson LK, Wheeler L, Chou CT, Harrison AA, Stebbings S, Jones GT, Bang SY, Wang G, Jamshidi A, Farhadi E, Song J, Lin L, Li M, Wei JCC, Martin NG, Wright MJ, Lee M, Wang Y, Zhan J, Zhang JS, Wang X, Jin ZB, Weisman MH, Gensler LS, Ward MM, Rahbar MH, Diekman L, Kim TH, Reveille JD, Wordsworth BP, Xu H, Brown MA. Polygenic Risk Scores have high diagnostic capacity in ankylosing spondylitis. Ann Rheum Dis 2021; 80:1168-1174. [PMID: 34161253 PMCID: PMC8364478 DOI: 10.1136/annrheumdis-2020-219446] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 12/26/2022]
Abstract
Objective We sought to test the hypothesis that Polygenic Risk Scores (PRSs) have strong capacity to discriminate cases of ankylosing spondylitis (AS) from healthy controls and individuals in the community with chronic back pain. Methods PRSs were developed and validated in individuals of European and East Asian ethnicity, using data from genome-wide association studies in 15 585 AS cases and 20 452 controls. The discriminatory values of PRSs in these populations were compared with other widely used diagnostic tests, including C-reactive protein (CRP), HLA-B27 and sacroiliac MRI. Results In people of European descent, PRS had high discriminatory capacity with area under the curve (AUC) in receiver operator characteristic analysis of 0.924. This was significantly better than for HLA-B27 testing alone (AUC=0.869), MRI (AUC=0.885) or C-reactive protein (AUC=0.700). PRS developed and validated in individuals of East Asian descent performed similarly (AUC=0.948). Assuming a prior probability of AS of 10% such as in patients with chronic back pain under 45 years of age, compared with HLA-B27 testing alone, PRS provides higher positive values for 35% of patients and negative predictive values for 67.5% of patients. For PRS, in people of European descent, the maximum positive predictive value was 78.2% and negative predictive value was 100%, whereas for HLA-B27, these values were 51.9% and 97.9%, respectively. Conclusions PRS have higher discriminatory capacity for AS than CRP, sacroiliac MRI or HLA-B27 status alone. For optimal performance, PRS should be developed for use in the specific ethnic groups to which they are to be applied.
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Affiliation(s)
- Zhixiu Li
- Queensland University of Technology, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Faculty of Health, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Xin Wu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, Shanghai, China
| | - Paul J Leo
- Queensland University of Technology, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Faculty of Health, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Erika De Guzman
- Australian Translational Genomics Centre, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Nurullah Akkoc
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - Maxime Breban
- UMR 1173, Inserm, University of Versailles Saint-Quentin, Montigny-le-Bretonneux, France.,Service de Rhumatologie, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France.,Laboratoire d'Excellence Inflamex, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Gary J Macfarlane
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK.,Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Mahdi Mahmoudi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Tehran, Iran (the Islamic Republic of)
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Lisa K Anderson
- Australian Translational Genomics Centre, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Lawrie Wheeler
- Australian Translational Genomics Centre, Queensland University of Technology (QUT), Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Chung-Tei Chou
- Division of Allergy, Immunology, Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Andrew A Harrison
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Simon Stebbings
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Gareth T Jones
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK.,Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - So-Young Bang
- Hanyang University Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea (the Republic of)
| | - Geng Wang
- University of Queensland Diamantina Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Ahmadreza Jamshidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Tehran, Iran (the Islamic Republic of)
| | - Elham Farhadi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Tehran, Iran (the Islamic Republic of)
| | - Jing Song
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, Shanghai, China
| | - Li Lin
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, Shanghai, China
| | - Mengmeng Li
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, Shanghai, China
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Nicholas G Martin
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Margaret J Wright
- Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia
| | - MinJae Lee
- Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yuqin Wang
- State Key Laboratory of Optometry, Ophthalmology, and Vision Science, Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jian Zhan
- Institute for Glycomics, Griffith University, Nathan, Queensland, Australia
| | - Jin-San Zhang
- Center for Precision Medicine, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.,Institute of Life Sciences, Wenzhou University, Wenzhou, Zhejiang, China
| | - Xiaobing Wang
- Rheumatology Department, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zi-Bing Jin
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Sciences Key Lab, Beijing, Beijing, China
| | - Michael H Weisman
- Department of Medicine/Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lianne S Gensler
- Division of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mohammad Hossein Rahbar
- Internal Medicine, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Laura Diekman
- Department of Internal Medicine, Division of Rheumatology, McGovern Medical School at The University of Texas Health Science Center, Houston, Texas, USA
| | - Tae-Hwan Kim
- Hanyang University Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea (the Republic of)
| | - John D Reveille
- Department of Internal Medicine, Division of Rheumatology, McGovern Medical School at The University of Texas Health Science Center, Houston, Texas, USA
| | - Bryan Paul Wordsworth
- NIHR Oxford Musculoskeletal Biomedical Research Unit, Botnar Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Huji Xu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, Shanghai, China .,School of Clinical Medicine, Tsinghua University, Beijing, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Tsinghua University, Beijing, China
| | - Matthew A Brown
- Center for Precision Medicine, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China .,NIHR Biomedical Research Centre at Guy's and Saint Thomas' NHS Foundation Trust and King's College London, London, UK
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26
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Wordsworth BP, Cohen CJ, Davidson C, Vecellio M. Perspectives on the Genetic Associations of Ankylosing Spondylitis. Front Immunol 2021; 12:603726. [PMID: 33746951 PMCID: PMC7977288 DOI: 10.3389/fimmu.2021.603726] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/05/2021] [Indexed: 12/11/2022] Open
Abstract
Ankylosing spondylitis (AS) is a common form of inflammatory spinal arthritis with a complex polygenic aetiology. Genome-wide association studies have identified more than 100 loci, including some involved in antigen presentation (HLA-B27, ERAP1, and ERAP2), some in Th17 responses (IL6R, IL23R, TYK2, and STAT3), and others in macrophages and T-cells (IL7R, CSF2, RUNX3, and GPR65). Such observations have already helped identify potential new therapies targeting IL-17 and GM-CSF. Most AS genetic associations are not in protein-coding sequences but lie in intergenic regions where their direct relationship to particular genes is difficult to assess. They most likely reflect functional polymorphisms concerned with cell type-specific regulation of gene expression. Clarifying the nature of these associations should help to understand the pathogenic pathways involved in AS better and suggest potential cellular and molecular targets for drug therapy. However, even identifying the precise mechanisms behind the extremely strong HLA-B27 association with AS has so far proved elusive. Polygenic risk scores (using all the known genetic associations with AS) can be effective for the diagnosis of AS, particularly where there is a relatively high pre-test probability of AS. Genetic prediction of disease outcomes and response to biologics is not currently practicable.
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Affiliation(s)
- B Paul Wordsworth
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford Institute of Musculoskeletal Sciences, Oxford, United Kingdom.,Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Carla J Cohen
- Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Connor Davidson
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Matteo Vecellio
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford Institute of Musculoskeletal Sciences, Oxford, United Kingdom.,Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom.,Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
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27
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Yi E, Dai D, Piao OW, Zheng JZ, Park Y. Health care utilization and cost associated with switching biologics within the first year of biologic treatment initiation among patients with ankylosing spondylitis. J Manag Care Spec Pharm 2021; 27:27-36. [PMID: 33043820 PMCID: PMC10394190 DOI: 10.18553/jmcp.2020.19433] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Costs associated with biologic switching and discontinuation can be high in chronic inflammatory diseases. Inappropriate use of medications may have cost implications for both payers and patients. Understanding of biologic utilization and switching rates is lacking among patients with ankylosing spondylitis (AS). OBJECTIVE To compare direct costs of treatment switchers, nonswitchers, and discontinuers among patients with AS who newly initiated a biologic. METHODS Patients aged ≥ 18 years with an AS diagnosis and ≥ 1 pharmacy claim for an FDA-approved subcutaneous biologic for AS between January 1, 2016, and December 31, 2016 (identification period) were identified from the Truven Health MarketScan Databases. At the time of biologic initiation (index date), eligible patients were continuously enrolled with medical and pharmacy claims for ≥ 1 year before (baseline period) and ≥ 1 year after the index date (follow-up period). Patients with AS were categorized into 3 mutually exclusive groups of nonswitchers (patients who remained on their index biologic), switchers (patients who had a prescription for a biologic therapy other than their index biologic), and discontinuers (patients who had gaps in prescription claims [> 120 days]) based on their biologic utilization pattern during the 1-year follow-up period. Health care costs (inflated to year 2017 costs) during follow-up were described across the 3 groups separately and by disease. Adjusted health care resource utilization and costs during 1-year follow-up were estimated, controlling for age, sex, fulltime work status, and Charlson Comorbidity Index (Deyo's modification) during the baseline period. RESULTS A total of 791 patients with AS who were newly initiating a biologic were categorized as switchers (15.4%), nonswitchers (53.1%), and discontinuers (31.5%). Switchers and discontinuers had higher all-cause health care utilization than nonswitchers during the 1-year follow-up period. Switchers had higher mean total health care costs than nonswitchers ($71,280 vs. $66,573) due to increased medical ($13,897 vs. $12,043) and pharmacy costs ($57,384 vs. $54,530). Discontinuers had the lowest total health care costs ($41,179) but had the highest medical costs ($19,079). Adjusted analyses for covariates confirmed similar trends as the unadjusted analysis, where discontinuers had significantly lower total health care and pharmacy costs but had higher medical costs (with increased emergency department and outpatient visits) than nonswitchers (all P < 0.001). Switchers had increased outpatient visits and costs versus nonswitchers in the adjusted analysis (P < 0.001); small sample sizes in the switcher group may have limited the ability to detect significant trends in the adjusted analysis. CONCLUSIONS Biologic switching resulted in higher total health care costs than remaining on the same biologic in patients with AS. These findings highlight the clinical and economic impact of discontinuing or switching biologic therapies in patients with AS, which may inform treatment and/or formulary decision making. DISCLOSURES This study was sponsored by Novartis Pharmaceuticals (East Hanover, NJ). Yi, Dai, and Park are employed by Novartis. Piao was an employee of KMK Consulting, supporting Novartis at the time of this study; Zheng is an employee of KMK Consulting and works as a consultant for Novartis. Portions of this work were presented at the 2019 AMCP Managed Care and Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA; and AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.
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Affiliation(s)
- Esther Yi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Dong Dai
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | | | | | - Yujin Park
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
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28
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Cepon-Robins TJ. Measuring attack on self: The need for field-friendly methods development and research on autoimmunity in human biology. Am J Hum Biol 2020; 33. [PMID: 33289250 DOI: 10.1002/ajhb.23544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Autoimmune and inflammatory disorder (AIID) prevalence appears to be increasing in all but the world's poorest regions and countries. Autoimmune diseases occur when there is a breakdown in processes that regulate inflammation and self-recognition by immune cells. Very few field-based studies have been conducted among Indigenous populations and underserved communities with limited access to medical care. This is due, in part, to the fact that autoimmune diseases are difficult to diagnose, even in clinical settings. In remote field settings these difficulties are compounded by the absence of infrastructure necessary for sample storage and analysis, and the lack of hospital/clinic access for more invasive diagnostic procedures. Because of these limitations, little is known about the prevalence of autoimmunity outside wealthy regions and clinical settings. AIMS The present paper discusses why AIID are of critical importance in human biology research and why more work needs to be devoted to validating, testing, and utilizing methods for detecting autoantibodies and other biomarkers related to autoimmunity in field-friendly, minimally invasively-collected samples. This paper reviews some of the methods used to diagnose AIIDs in clinical settings, and highlights methods that have been used in studies within human biology and related fields, emphasizing the invasiveness of specific methods and their feasibility in remote field settings. DISCUSSION AND CONCLUSIONS Risk for AIID is affected by several reproductive, dietary, environmental, and genetic factors. Human biologists have unique perspectives that they can bring to autoimmunity research, and more population-based studies on autoimmunity are needed within these and related fields.
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Affiliation(s)
- Tara J Cepon-Robins
- Department of Anthropology, University of Colorado Colorado Springs, Colorado Springs, Colorado, USA
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29
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Barnett R, Ingram T, Sengupta R. Axial spondyloarthritis 10 years on: still looking for the lost tribe. Rheumatology (Oxford) 2020; 59:iv25-iv37. [PMID: 33053196 PMCID: PMC7566532 DOI: 10.1093/rheumatology/keaa472] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.
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Affiliation(s)
- Rosemarie Barnett
- Axial Spondyloarthritis Service, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust
- Department of Computer Science, University of Bath
| | - Thomas Ingram
- Axial Spondyloarthritis Service, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust
- Department for Health, University of Bath
| | - Raj Sengupta
- Axial Spondyloarthritis Service, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
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30
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Wright GC, Kaine J, Deodhar A. Understanding differences between men and women with axial spondyloarthritis. Semin Arthritis Rheum 2020; 50:687-694. [PMID: 32521322 DOI: 10.1016/j.semarthrit.2020.05.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
Axial spondyloarthritis (axSpA) is a chronic inflammatory immune-mediated disease resulting in inflammatory low back pain and other inflammatory manifestations in peripheral joints and entheses. AxSpA encompasses both ankylosing spondylitis (AS), in which patients present with definitive sacroiliitis visible on radiographic imaging, as well as nonradiographic axSpA (nr-axSpA), in which such changes may not be discernable. Emerging evidence suggests that women and men experience axSpA differently. Although the prevalence of AS is approximately 2- to 3- fold higher in men than in women, nr-axSpA occurs with roughly equal frequency in women and men. The goal of this review is to increase awareness of sex differences in axSpA by exploring the distinct manifestations of disease and disease characteristics in women, the overall clinical burden, recommendations for diagnosis, and potential treatment options. We summarize and contextualize the results of recent studies that illuminate sex differences in nr-axSpA and AS, including differences in disease manifestation and progression. It is important that sex differences in axSpA are understood and considered when diagnosing and treating the spectrum of axSpA, including AS and nr-axSpA.
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Affiliation(s)
- Grace C Wright
- Association of Women in Rheumatology, 345 E 37th Street, Suite 303C, New York, NY 10016, USA.
| | - Jeffrey Kaine
- Independent Healthcare Associates, Inc, Cullowhee, NC, USA
| | - Atul Deodhar
- Oregon Health & Science University, Portland, OR, USA
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31
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Ogdie A, Nowell WB, Applegate E, Gavigan K, Venkatachalam S, de la Cruz M, Flood E, Schwartz EJ, Romero B, Hur P. Patient perspectives on the pathway to psoriatic arthritis diagnosis: results from a web-based survey of patients in the United States. BMC Rheumatol 2020; 4:2. [PMID: 31938764 PMCID: PMC6953285 DOI: 10.1186/s41927-019-0102-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There are limited real-world data on the diagnostic experiences of patients with psoriatic arthritis (PsA), including medical care sought and potential barriers to diagnosis. We aim to describe patient experiences related to receiving a PsA diagnosis. METHODS Ours was a mixed-method, 2-phase study. Phase 1 comprised concept elicitation and cognitive interviews with clinical experts and adults diagnosed with PsA to develop a cross sectional, web-based survey. US adults with a self-reported PsA diagnosis were recruited through a patient support community (CreakyJoints), an online patient research registry (ArthritisPower), and social media outreach. In Phase 2, the online survey collected data on sociodemographics, clinical symptoms, disease burden, and diagnosis history of survey respondents with PsA. RESULTS Of the 203 respondents included, 172 (84.7%) were female, and the mean (SD) age was 51.6 (10.8) years. The time between seeking medical attention and receiving a diagnosis was < 6 months for 69 respondents, 6 months to 4 years for 68 respondents, and ≥ 5 years for 66 respondents. Most respondents sought care from general practitioners (79.8%) and rheumatologists (66.5%). Common initial symptoms that led respondents to seek medical attention were joint pain (70.0%) and stiffness (53.7%). Among the initial symptoms that led respondents to seek care, joint pain, swollen joints, and sausage-like fingers or toes (indicating dactylitis) were more common among respondents with shorter time to diagnosis, whereas stiffness, fatigue, enthesitis (indicated by foot problems, tendon and ligament pain), and back pain were more common among respondents with longer time to diagnosis. Common misdiagnoses were psychosomatic issues (26.6%) and osteoarthritis (21.7%). Respondents with shorter times to diagnosis had lower frequencies of misdiagnosis. CONCLUSIONS Respondents with PsA reported delays in diagnosis and misdiagnoses on their journey to a PsA diagnosis. Symptom differences, such as enthesitis and stiffness, were noted among respondents with shorter vs longer time to diagnosis. Increased understanding of diagnostic barriers may lead to earlier diagnosis and appropriate management to improve outcomes.
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Affiliation(s)
- Alexis Ogdie
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
- Hospital of the University of Pennsylvania, 3400 Spruce Street, 5 White Building, Philadelphia, PA 19104-4283 USA
| | | | | | - Kelly Gavigan
- Global Healthy Living Foundation, Upper Nyack, NY USA
| | | | | | | | | | | | - Peter Hur
- Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
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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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