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McDermott GC, Monshizadeh A, Selzer F, Zhao SS, Ermann J, Katz JN. Factors Associated With Diagnostic Delay in Axial Spondyloarthritis: Impact of Clinical Factors and Social Vulnerability. Arthritis Care Res (Hoboken) 2024; 76:541-549. [PMID: 37881826 PMCID: PMC10963166 DOI: 10.1002/acr.25264] [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: 03/13/2023] [Revised: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE Patients with axial spondyloarthritis (axSpA) often experience significant delay between symptom onset and diagnosis for reasons that are incompletely understood. We investigated associations between demographic, medical, and socioeconomic factors and axSpA diagnostic delay. METHODS We identified patients meeting modified New York criteria for ankylosing spondylitis (AS) or 2009 Assessment of Spondyloarthritis International Society criteria for axSpA in the Mass General Brigham health care system between December 1990 and October 2021. We determined the duration of diagnostic delay, defined as the duration of back pain symptoms reported at diagnosis, as well as disease manifestations and specialty care prior to diagnosis from the electronic health record. We obtained each patient's Social Vulnerability Index (SVI) by mapping their address to the US Centers for Disease Control SVI Atlas. We examined associations among disease manifestations, SVI, and diagnostic delay using ordinal logistic regression. RESULTS Among 554 patients with axSpA who had a median diagnostic delay of 3.8 years (interquartile range 1.1-10), peripheral arthritis (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.45-0.93) and older age at symptom onset (OR 0.83, 95% CI 0.78-0.88 per five years) were associated with shorter delay. AS at diagnosis (OR 1.85, 95% CI 1.30-2.63), a history of uveitis prior to diagnosis (OR 2.77, 95% CI 1.73-4.52), and higher social vulnerability (defined as national SVI 80th to 99th percentiles; OR 1.99, 95% CI 1.06-3.84) were associated with longer diagnostic delay. CONCLUSION Older age at back pain onset and peripheral arthritis were associated with shorter delay, whereas uveitis was associated with longer diagnostic delay. Patients with higher socioeconomic vulnerability had longer diagnostic delay independent of clinical factors.
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Affiliation(s)
- Gregory C McDermott
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Faith Selzer
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Joerg Ermann
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeffrey N Katz
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Chao YJ, Hung JH, Lin CP, Kuo HK, Chen SN, Hwang YS, Li KJ, Lin CJ, Hwang DK, Sheu SJ. Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan. Ocul Immunol Inflamm 2024; 32:226-233. [PMID: 36701640 DOI: 10.1080/09273948.2023.2165113] [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: 10/23/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan. PURPOSE To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan. METHODS A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed. RESULTS A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus. CONCLUSIONS This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.
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Affiliation(s)
- Yu-Jang Chao
- Department of Ophthalmology, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jia-Horung Hung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Chang-Ping Lin
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Hsi-Kung Kuo
- Department of Ophthalmology, Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan, ROC
| | - San-Ni Chen
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
- Department of Medication, China Medical University, Taichung, Taiwan, ROC
| | - Yih-Shiou Hwang
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan, ROC
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC
- Department of Ophthalmology, Chang Gung Memorial Hospital, Xiamen Branch, Xiamen, China
- Department of Ophthalmology, Jen-Ai Hospital Dali Branch, Taichung, Taiwan
| | - Ko-Jen Li
- Division of Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
- Department of Optometry, Asia University, Taichung, Taiwan, ROC
| | - De-Kuang Hwang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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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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Rademacher J, Müllner H, Diekhoff T, Haibel H, Igel S, Pohlmann D, Proft F, Protopopov M, Rios Rodriguez V, Torgutalp M, Pleyer U, Poddubnyy D. Keep an Eye on the Back: Spondyloarthritis in Patients With Acute Anterior Uveitis. Arthritis Rheumatol 2023; 75:210-219. [PMID: 35905288 DOI: 10.1002/art.42315] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/02/2022] [Accepted: 07/20/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study was undertaken to analyze the prevalence of spondyloarthritis (SpA) in patients with acute anterior uveitis (AAU), to identify parameters associated with the presence of SpA, and to evaluate the performance of referral algorithms for identifying patients with a high probability of having SpA. METHODS Prospectively recruited consecutive patients with noninfectious AAU underwent structured rheumatologic assessment including magnetic resonance imaging of the sacroiliac joints, allowing a definitive diagnosis/exclusion of concomitant SpA. Fisher's exact test and Mann-Whitney U test were used to compare AAU patients with SpA and AAU patients without SpA. Furthermore, logistic regression analyses were performed. The predictive performance of SpA referral strategies was analyzed by calculating the sensitivity, specificity, positive predictive value, and positive and negative likelihood ratios. RESULTS Among the 189 AAU patients evaluated, 106 (56%) were diagnosed as having SpA. The majority of SpA patients (93%) had predominantly axial SpA and 7 patients had peripheral SpA. In 74 patients (70%), the SpA diagnosis was established for the first time. In multivariable logistic regression analysis, psoriasis (odds ratio [OR] 12.5 [95% confidence interval (95% CI) 1.3-120.2]), HLA-B27 positivity (OR 6.3 [95% CI 2.4-16.4]), elevated C-reactive protein level (OR 4.8 [95% CI 1.9-12.4]), and male sex (OR 2.1 [95% CI 1.1-4.2]) were associated with the presence of SpA. None of the ophthalmologic parameters were found to be predictive of SpA. The Dublin Uveitis Evaluation Tool (DUET) showed higher specificity for SpA recognition than the Assessment of SpondyloArthritis international Society (ASAS) tool for the early referral of patients with a suspected diagnosis of axial SpA (specificity for SpA 42% versus 28%), whereas the sensitivity of the ASAS tool was slightly higher than the DUET tool (sensitivity for SpA 80% versus 78%). However, more than 20% of the AAU patients in this study who were diagnosed as having SpA would have been missed by both referral strategies. CONCLUSION Our study revealed a high prevalence of SpA in AAU patients overall, as well as a high prevalence of previously undiagnosed SpA in AAU patients. Therefore, we propose rheumatologic evaluation for all AAU patients with musculoskeletal symptoms.
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Affiliation(s)
- Judith Rademacher
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Epidemiology unit, German Rheumatism Research Centre, Berlin, Germany
| | - Hanna Müllner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Torsten Diekhoff
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Berlin, Germany
| | - Hildrun Haibel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Sabrina Igel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Dominika Pohlmann
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Ophthalmology, Berlin, Germany
| | - Fabian Proft
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Mikhail Protopopov
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Valeria Rios Rodriguez
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Murat Torgutalp
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Berlin, Germany
| | - Uwe Pleyer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Ophthalmology, Berlin, Germany
| | - Denis Poddubnyy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Epidemiology unit, German Rheumatism Research Centre, Berlin, Germany
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Kukafka R, Phang JK, Woon TH, Liew JW, Dubreuil M, Proft F, Ramiro S, Molto A, Navarro-Compán V, de Hooge M, Meghnathi B, Ziade N, Zhao SS, Llop M, Baraliakos X, Fong W. Social Media Use Among Members of the Assessment of Spondyloarthritis International Society: Results of a Web-Based Survey. J Med Internet Res 2023; 25:e39155. [PMID: 36626201 PMCID: PMC9875001 DOI: 10.2196/39155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The use of social media in health care may serve as a beneficial tool for education, information dissemination, telemedicine, research, networking, and communications. To better leverage the benefits of social media, it is imperative to understand the patterns of its use and potential barriers to its implementation in health care. A previous study in 2016 that investigated social media use among young clinical rheumatologists (≤45 years) and basic scientists showed that there was substantial social media use among them for social and professional reasons. However, there is a limited inquiry into social media use in different areas of rheumatology, such as spondyloarthritis. OBJECTIVE We aimed to explore the motivations, barriers, and patterns of social media use among an international group of experts in spondyloarthritis. METHODS We distributed a web-based survey via email from March 2021 to June 2021 to 198 members of the Assessment of Spondyloarthritis International Society. It contained 24 questions about demographic characteristics, patterns of current social media use, and perceptions of utility. Univariable and multivariable logistic regression analyses were performed to identify the characteristics associated with use trends. RESULTS The response rate was 78.8% (156/198). Of these, 93.6% (146/156) of participants used at least one social media platform. Apart from internet-based shopping and entertainment, the use of social media for clinical updates (odds ratio [OR] 6.25, 95% CI 2.43-16.03) and research updates (OR 3.45, 95% CI 1.35-8.78) were associated with higher social media consumption. Among the respondents, 66% (103/156) used social media in a work-related manner. The use of social media for new web-based resources (OR 6.55, 95% CI 2.01-21.37), interaction with international colleagues (OR 4.66, 95% CI 1.21-17.90), and establishing a web-based presence (OR 4.05, 95% CI 1.25-13.13) were associated with higher levels of consumption for work-related purposes. Time investment, confidentiality concerns, and security concerns were the top 3 challenges to a wider adoption of social media. CONCLUSIONS Most respondents (103/156, 66%) use social media in a work-related manner. Professional development, establishing a web-based presence, and international collaboration were associated with higher use. Challenges to social media adoption should be addressed to maximize its benefits.
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Affiliation(s)
| | - Jie Kie Phang
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Ting Hui Woon
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Jean W Liew
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, United States
| | - Maureen Dubreuil
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, United States
| | - Fabian Proft
- Division of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | - Anna Molto
- Rheumatology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | - Bhowmik Meghnathi
- Department of Rheumatology & Clinical Immunology, Marengo Care Institute of Medical Sciences Hospital, Ahmedabad, India
| | - Nelly Ziade
- Department of Rheumatology, Saint-Joseph University, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Maria Llop
- Rheumatology, Parc Taulí Hospital Universitari, Sabadell, Spain
| | | | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore.,National University of Singapore, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Abd El Meged Nage S, Esmail A. Calprotectin as a Biomarker for Diagnosis and Severity of Acute Noninfectious Anterior Uveitis in Egyptian Patients. Clin Ophthalmol 2022; 16:4109-4120. [PMID: 36536923 PMCID: PMC9759012 DOI: 10.2147/opth.s389780] [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: 09/13/2022] [Accepted: 11/18/2022] [Indexed: 09/01/2023] Open
Abstract
PURPOSE To study the relation between serum calprotectin level and acute noninfectious anterior uveitis in Egyptian patients. METHODS An observational prospective study carried out at Menoufia University Hospital during the period from March 2021 till June 2022, after informed consent from all studied patients. This study included 20 eyes of patients with Acute Anterior Uveitis (AAU) and 20 eyes healthy individuals matched sex and age as the control group. Full history taking, ophthalmological examination and serum calprotectin levels were performed for both patients and controls. RESULTS Serum calprotectin levels were substantially higher in patients' eyes with acute anterior uveitis than in healthy eyes (61.45±7.89 vs 32.50±11.64; 95% CI: 22.58-35.32; P < 0.001). ROC curve analysis showed that the cut-off point of serum calprotectin in severity detection of AAU was ≥58.0, with sensitivity of 95%, specificity of 43% at AUC of 0.986, with reached to significant level (p < 0.001). CONCLUSION Serum calprotectin levels were significantly elevated with positive previous uveitis and marked grade indicating a possible role of calprotectin in the pathogenesis of non-infectious AAU. The serum calprotectin cut-off points for severity detection of AAU were 58.0, with sensitivity of 95% and specificity of 43%. Finally, we identified serum calprotectin as a potential biomarker for detection of anterior uveitis severity and patients' morbidity risk. Further investigation with large sample size is needed to assess the relationship between calprotectin and uveitis activity.
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Affiliation(s)
| | - Ahmed Esmail
- Ophthalmology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
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Eder L. Spondyloarthritis Among Patients With Uveitis: Can We Improve Referral Pathways? J Rheumatol 2022; 49:659-660. [PMID: 35569829 DOI: 10.3899/jrheum.220263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delays in diagnosis remain a major gap in the care of patients with axial spondyloarthritis (axSpA). Despite efforts to improve awareness among family physicians and nonrheumatologist specialists, the average duration from onset of symptoms to diagnosis of axSpA is approximately 8 years,1 which is one of the longest in rheumatology. Such delays in diagnosis are associated with late initiation of therapy and worse disease outcomes.
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Affiliation(s)
- Lihi Eder
- LE is supported by Canada Research Chair (Tier 2) in Inflammatory Rheumatic Diseases and Early Researcher Award from Ontario Ministry of Science, Research and Innovation. L. Eder, MD, PhD, Associate Professor of Medicine, University of Toronto and Women's College Hospital, Toronto, Ontario, Canada. LE received consultation fees and educational grants from Novartis, Pfizer, Eli Lilly, Janssen, AbbVie, and UCB. Address correspondence to Dr. L. Eder, 76 Grenville Street, Women's College Hospital, Toronto, ON M5S 1B2, Canada.
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van Bentum RE, Verbraak FD, Wolf S, Ongkosuwito J, Boers M, Tan HS, van der Horst-Bruinsma IE. High prevalence of previously undiagnosed axial spondyloarthritis in patients referred with anterior uveitis and chronic back pain - the SpEYE study. J Rheumatol 2022; 49:680-687. [DOI: 10.3899/jrheum.210345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/22/2022]
Abstract
Objective To reduce the diagnostic delay in axial spondyloarthritis (axSpA), guidelines recommend to refer patients with acute anterior uveitis (AAU) and chronic back pain (CBP) to a rheumatologist. This observational study evaluated the prevalence of previously unrecognized axSpA in AAU patients with CBP in daily practice, referred by ophthalmologists who had received instructions to increase awareness. Methods All AAU patients referred with CBP (≥3 months, started <45 years of age), from five Ophthalmology clinics underwent rheumatologic assessment, including pelvic X-rays. Patients with previously diagnosed rheumatic disease and established other cause of AAU were excluded. The primary endpoint was a clinical axSpA diagnosis by the rheumatologist. Results Eighty-one patients fulfilled the referral criteria (52% male, 56% HLA-B27 positive, median age 41 years, median CBP duration 10 years). In total, 58% (n=47) had recurring AAU, of whom 87% already had CBP during previous AAU attacks. After assessment, 23% (n=19) of patients were clinically diagnosed with definite-axSpA (10/19 radiographic), 40% (n=32) were suspicious of axSpA and 37% (n=30) did not have axSpA. AxSpA was diagnosed more often in men (33% of the men versus 13% of women). Conclusion A high prevalence of axSpA was found in AAU patients referred because of CBP. There was substantial diagnostic delay in the majority of patients with recurring AAU, as many already had back pain during previous AAU flares. In AAU, screening for CBP and prompt referral has a high diagnostic yield, and should consistently be promoted among ophthalmologists.
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Clinical Features and Prevalence of Spondyloarthritis in a Cohort of Italian Patients Presenting with Acute Nongranulomatous Anterior Uveitis. J Immunol Res 2022; 2022:6632081. [PMID: 35087912 PMCID: PMC8789471 DOI: 10.1155/2022/6632081] [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] [Received: 12/31/2020] [Revised: 11/02/2021] [Accepted: 12/24/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To describe the clinical features of acute nongranulomatous anterior uveitis (NGAU) patients and to estimate the prevalence of concomitant spondyloarthritis (SpA). Methods Retrospective study of consecutive patients affected by NGAU referred to the Ocular Immunology Unit of the AUSL-IRCCS di Reggio Emilia, Italy, between January 2016 and January 2019. All patients underwent ophthalmic evaluation and blood test with HLA-B27 typing and were referred to a rheumatologist to identify any undiagnosed SpA. SpA was classified according to the Assessment of SpondyloArthritis international Society (ASAS) criteria in axial or peripheral SpA. Patients were divided into two groups: NGAU with associated SpA (SpA+) and NGAU without SpA (SpA-). Clinical and demographic features of the two groups, including sex, HLA-B27, family history of rheumatic disease, uveitis laterality, course, and severity of ocular inflammation, complications, and treatment, were compared. Results Ninety-nine patients with NGAU were enrolled, of whom 36 (36%) with a diagnosis of SpA: 14 with peripheral SpA and 22 with axial SpA. The prevalence of SpA was higher in HLA-B27-positive patients than in HLA-B27-negative patients (50% vs. 15%, p < 0.0001). The multivariate logistic regression (R2 = 0.28) for SpA diagnosis identified as significant predictive factors: age at diagnosis (odds ratio [OR] = 0.95, 95% confidence interval [CI]: 0.91-0.99) and HLA-B27+ (OR = 5.32, 95% CI: 1.80-15.70). Conclusions Our results confirmed the high prevalence of undiagnosed SpA in patients with NGAU, suggesting that, regardless of HLA-B27 status, in the presence of IBP and/or peripheral arthritis, patients with NGAU must be referred to the rheumatologist to allow earlier diagnosis.
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Bubova K, Hasikova L, Mintalova K, Gregova M, Kasalicky P, Klimova A, Brichova M, Svozilkova P, Heissigerova J, Vencovsky J, Pavelka K, Senolt L. The Prevalence of MRI-Defined Sacroiliitis and Classification of Spondyloarthritis in Patients with Acute Anterior Uveitis: A Longitudinal Single-Centre Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12010161. [PMID: 35054328 PMCID: PMC8774303 DOI: 10.3390/diagnostics12010161] [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] [Received: 11/29/2021] [Revised: 01/03/2022] [Accepted: 01/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Acute anterior uveitis (AAU) is a relatively common extra-musculoskeletal manifestation of axial spondyloarthritis (axSpA); however, data on the prevalence of active sacroiliitis in patients with AAU are limited. Methods: 102 patients with AAU and 39 healthy subjects (HS) underwent clinical assessment and sacroiliac joint MRI. Patients with absence of active sacroiliitis were reassessed after two years. International Spondyloarthritis Society (ASAS) classification criteria for axSpA (regardless of patient’s age) and expert opinion for definitive diagnosis of axSpA were applied. Results: Although chronic back pain was equally present in both groups, bone marrow edema (BME) in SIJ and BME highly suggestive of axSpA was found in 52 (51%) and in 33 (32%) patients with AAU compared with 11 (28%) and none in HS, respectively. Out of all AAU patients, 41 (40%) patients fulfilled the ASAS classification criteria for axSpA, and 29 (28%) patients were considered highly suggestive of axSpA based on clinical features. Two out of the 55 sacroiliitis-negative patients developed active sacroiliitis at the two-year follow-up. Conclusions: One-third of patients with AAU had active inflammation on SIJ MRI and clinical diagnosis of axSpA. Therefore, patients with AAU, especially those with chronic back pain, should be referred to a rheumatologist, and the examination should be repeated if a new feature of SpA appears.
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Affiliation(s)
- Kristyna Bubova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
- Correspondence: ; Tel.: +420-234075-111; Fax: +420-224914-451
| | - Lenka Hasikova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Katerina Mintalova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Monika Gregova
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | | | - Aneta Klimova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Michaela Brichova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Petra Svozilkova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Jarmila Heissigerova
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic; (A.K.); (M.B.); (P.S.); (J.H.)
| | - Jiri Vencovsky
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
| | - Ladislav Senolt
- Institute of Rheumatology, 12850 Prague, Czech Republic; (L.H.); (K.M.); (M.G.); (J.V.); (K.P.); (L.S.)
- Department of Rheumatology, 1st Faculty of Medicine, Charles University, 12850 Prague, Czech Republic
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Coath FL, Gaffney K. Inflammatory back pain: a concept, not a diagnosis. Curr Opin Rheumatol 2021; 33:319-325. [PMID: 33973548 DOI: 10.1097/bor.0000000000000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The concept of inflammatory back pain (IBP) describes a cohort of patients with chronic back pain (CBP) who have distinct clinical characteristics, rather than being a diagnosis in and of itself. IBP is a common and important feature of axial spondyloarthritis (axSpA) but this is not the only differential. This review examines the utility of IBP in both primary and secondary care settings. RECENT FINDINGS There are a number of suggested referral strategies for patients with suspected axSpA that include IBP. These strategies attempt to strike a balance between ensuring potential axSpA patients are not overlooked, whilst simultaneously not overwhelming secondary care services. Their success relies on the clinicians who first encounter these patients being familiar with IBP as a concept; however, it is still poorly recognized by many healthcare professionals. IBP may be helpful as part of a referral strategy; however, other clinical features, laboratory investigations and radiology must be incorporated for the final diagnostic outcome in axSpA. SUMMARY Delayed diagnosis is a major clinical problem in axSpA and is associated with worse clinical outcomes. When recognized and utilized correctly, IBP can be a useful tool to promote prompt referral to rheumatology services.
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Affiliation(s)
- Fiona Louise Coath
- Rheumatology Department, Norfolk and Norwich Hospital, Colney Lane, Norwich, UK
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Russell MD, Coath F, Yates M, Bechman K, Norton S, Galloway JB, Ledingham J, Sengupta R, Gaffney K. Diagnostic delay is common for patients with axial spondyloarthritis: results from the National Early Inflammatory Arthritis Audit. Rheumatology (Oxford) 2021; 61:734-742. [PMID: 33982063 PMCID: PMC8824413 DOI: 10.1093/rheumatology/keab428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/10/2021] [Indexed: 01/20/2023] Open
Abstract
Objectives Updated guidelines for patients with axial SpA (axSpA) have sought to reduce diagnostic
delay by raising awareness among clinicians. We used the National Early Inflammatory
Arthritis Audit (NEIAA) to describe baseline characteristics and time to diagnosis for
newly referred patients with axSpA in England and Wales. Methods Analyses were performed on sociodemographic and clinical metrics, including time to
referral and assessment, for axSpA patients (n = 784) recruited to the
NEIAA between May 2018 and March 2020. Comparators were patients recruited to the NEIAA
with RA (n = 9270) or mechanical back pain (MBP;
n = 370) in the same period. Results Symptom duration prior to initial rheumatology assessment was longer in axSpA than RA
patients (P < 0.001) and non-significantly longer in axSpA than MBP
patients (P = 0.062): 79.7% of axSpA patients had symptom durations of
>6 months, compared with 33.7% of RA patients and 76.0% of MBP patients. Following
referral, the median time to initial rheumatology assessment was longer for axSpA than
RA patients (36 vs 24 days; P < 0.001) and similar
to MBP patients (39 days; P = 0.30). Of the subset of patients deemed
eligible for early inflammatory arthritis pathway follow-up, fewer axSpA than RA
patients had disease education provided (77.5% vs 97.8%) and RA
patients reported a better understanding of their condition and treatment. Conclusion Diagnostic delay in axSpA remains a major challenge despite improved disease
understanding and updated referral guidelines. Disease education is provided to fewer
axSpA than RA patients, highlighting the need for specialist clinics and support
programmes for axSpA patients.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Fiona Coath
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Raj Sengupta
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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Derakhshan MH, Dean L, Jones GT, Siebert S, Gaffney K. Predictors of extra-articular manifestations in axial spondyloarthritis and their influence on TNF-inhibitor prescribing patterns: results from the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis. RMD Open 2021; 6:rmdopen-2020-001206. [PMID: 32641447 PMCID: PMC7425116 DOI: 10.1136/rmdopen-2020-001206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/11/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Extra-articular manifestations (EAMs) are important systemic features of axial spondyloarthritis (axSpA), which may influence the choice of tumour necrosis factor-inhibitor (TNFi). We examined the cumulative incidence and predictors of EAMs and the influence of these on first TNFi choice in a 'real-world' cohort of patients with axSpA. METHODS Clinical and patient-reported outcomes of 2420 patients with axSpA from 83 centres were collected by the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis. Lifestyle factors for EAMs (acute anterior uveitis (AAU), inflammatory bowel diseases (IBD), psoriasis) were compared with those without EAMs. Also, the association between pretreatment EAMs and choice of first TNFi (adalimumab, etanercept, certolizumab) was analysed. RESULTS AAU was directly associated with human leukocyte antigen (HLA)-B27 (incidence rate ratio (IRR) 1.95, 95% CI 1.40 to 2.73) and inversely associated with ever-smoking (IRR=0.71, 95% CI 0.55 to 0.92). For both psoriasis and IBD, there was an inverse relationship with HLA-B27 (IRR 0.54, 95% CI 0.36 to 0.79 and IRR 0.63, 95% CI 0.43 to 0.91, respectively). A diagnosis of either AAU (OR 3.79, 95% CI 2.11 to 6.80) or IBD (OR 5.50, 95% CI 2.09 to 14.46) was associated with preference for adalimumab versus others. In contrast, a diagnosis of either AAU (OR 0.14, 95% CI 0.06 to 0.33) or IBD (OR 0.17, 95% CI 0.05 to 0.57) was associated with less preference for etanercept over other TNFi. CONCLUSION The higher occurrence of AAU and lower occurrence of psoriasis and IBD in HLA-B27-positive patients with axSpA are consistent with current pathophysiology. Patients with previous AAU and IBD are more likely to be prescribed adalimumab and less likely to receive etanercept, consistent with the superior efficacy of monoclonal TNFi for these indications. Future work will determine whether EAMs influence TNFi survival, or effectiveness, and whether this varies between agents.
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Affiliation(s)
- Mohammad H Derakhshan
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK ,
| | - Linda Dean
- Epidemiology Group, Univesity of Aberdeen, Aberdeen, UK
| | | | - Stefan Siebert
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK ,
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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: 18] [Impact Index Per Article: 4.5] [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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Rademacher J, Poddubnyy D, Pleyer U. Uveitis in spondyloarthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20951733. [PMID: 32963592 PMCID: PMC7488890 DOI: 10.1177/1759720x20951733] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
Uveitis is the most frequent extra-articular manifestation of axial spondyloarthritis (SpA), occurring in up to one-third of the patients. In the majority of patients, uveitis is acute, anterior and unilateral and presents with photosensitivity, sudden onset of pain and blurred vision. Topical steroids are an effective treatment; however, recurrent or refractory cases may need conventional disease-modifying antirheumatic drugs or biological treatment with monoclonal tumor necrosis factor (TNF) inhibitors, thus also influencing treatment strategy of the underlying SpA. Though the exact pathogenesis of SpA and uveitis remains unknown, both seem to result from the interaction of a specific, mostly shared genetical background (among other HLA-B27 positivity), external influences such as microbiome, bacterial infection or mechanical stress and activation of the immune system resulting in inflammation. Up to 40% of patients presenting with acute anterior uveitis (AAU) have an undiagnosed SpA. Therefore, an effective referral strategy for AAU patients is needed to shorten the diagnostic delay of SpA and enable an early effective treatment. Further, the risk for ophthalmological manifestations increases with the disease duration in SpA; and patients presenting with ocular symptoms should be referred to an ophthalmologist. Thus, a close collaboration between patient, rheumatologist and ophthalmologist is needed to optimally manage ocular inflammation in SpA.
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Affiliation(s)
- Judith Rademacher
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Hindenburgdamm 30, Berlin, 10117, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Uwe Pleyer
- Department of Ophthalmology, Campus Virchow, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Yong CY, Hamilton J, Benepal J, Griffiths K, Clark ZE, Rush A, Sengupta R, Martindale J, Gaffney K. Awareness of axial spondyloarthritis among chiropractors and osteopaths: findings from a UK Web-based survey. Rheumatol Adv Pract 2019; 3:rkz034. [PMID: 31616854 PMCID: PMC6785804 DOI: 10.1093/rap/rkz034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/23/2019] [Indexed: 12/28/2022] Open
Abstract
Objective Chiropractors and osteopaths are important professional partners in the management of axial spondyloarthritis (axSpA). In view of recent advances in diagnosis and treatment, we sought to understand their current knowledge and working practices. Methods A Web-based survey was advertised to chiropractors and osteopaths via the Royal College of Chiropractors and the Institute of Osteopathy. Results Of 382 completed responses [237 chiropractors (62%) and 145 osteopaths (38%)], all were familiar with AS, but only 63 and 25% were familiar with the terms axSpA and non-radiographic axSpA, respectively. Seventy-seven per cent were confident with inflammatory back pain. Respondents routinely asked about IBD (91%), psoriasis (81%), acute anterior uveitis (49%), peripheral arthritis (71%), genitourinary/gut infection (56%), enthesitis (30%) and dactylitis (20%). Eighty-seven per cent were aware of the association between axSpA and HLA-B27. Only 29% recognized that axSpA was common in women. Forty per cent recommend an X-ray (pelvic in 80%) and, if normal, 27% would recommend MRI of the sacroiliac joints and whole spine. Forty-four per cent were aware of biologic therapies. Forty-three per cent were confident with the process of onward referral to rheumatology via the general practitioner (GP). The principal perceived barrier to onward referral was reluctance by the GP to accept their professional opinion. Conclusion Overall knowledge of ankylosing spondylitis is good, but the term axSpA is poorly understood. Specific learning needs include gender preponderance, awareness of acute anterior uveitis and the availability of biological therapies. There is lack of confidence in the onward referral process to rheumatology via the GP.
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Affiliation(s)
- Cee Y Yong
- Department of Rheumatology, North West Anglia NHS Foundation Trust, Huntingdon
| | - Jill Hamilton
- National Ankylosing Spondylitis Society, Hammersmith, London
| | | | | | - Zoë E Clark
- Howe Osteopaths and Diss Osteopathy & Natural Health Clinic, Diss
| | | | - Raj Sengupta
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath
| | - Jane Martindale
- Department of Physiotherapy, Wrightington, Wigan and Leigh NHS Foundation Trust, Lancaster
| | - Karl Gaffney
- Department of Rheumatology, Norfolk & Norwich University Hospital NHS Trust, Norwich, UK
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