Ankylosing spondylitis in iran; late diagnosis and its causes

Factors Associated With Diagnostic Delay in Axial Spondyloarthritis: Impact of Clinical Factors and Social Vulnerability

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.

Sex Bias in Diagnostic Delay: Are Axial Spondyloarthritis and Ankylosing Spondylitis Still Phantom Diseases in Women? A Systematic Review and Meta-Analysis

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.

The Journey to Diagnose Spondyloarthritis in Patients From Riyadh: A Cross-Sectional Study

Introduction  Ankylosing spondylitis, now frequently referred to as spondyloarthritis (SpA), is a chronic inflammatory disease causing axial arthritis and inflammatory lower back pain resulting in the eventual impairment of spinal mobility. Moreover, its systemic complications include stiffness and inflexibility, restriction of lung capacity and function, eye inflammation, compression spinal fractures, and heart problems. Hence, early diagnosis and intervention play a key role in preventing acute complications and improving the quality of life. Objective  We aimed to estimate the average duration of diagnosis, the average number of doctors visited, and the association between the specialty of the first physician and the length of SpA diagnosis delay. Methods A cross-sectional retrospective study was conducted from November 2019 to April 2020 with patients from King Khalid University Hospital, Riyadh, Saudi Arabia. The patients were 18 years and older and diagnosed with SpA. Call interviews were conducted and patients' medical charts were reviewed. The data were analyzed using the Statistical Package for Social Sciences statistical software, version 23 (IBM Corp., Armonk, NY). Result  The total sample was 101 patients: 59 (58.4%) males and 42 (41.6%) females. The average duration from the onset of symptoms until seeking medical advice (lag 1) and from seeking medical advice until the definite diagnosis (lag 2) was 24.74 ± 48.13 and 16.16 ± 34.62 months, respectively. The average number of doctors visited between the first medical encounter and the final diagnosis was 3.56 ± 5.3. Patients who consulted rheumatologists as the first medical encounter showed less delay in diagnosis compared to patients who sought non-rheumatologists, such as orthopedists, emergency physicians, and general physicians (11.81 ± 33.35 months vs. 26.63 ± 44.28, 26.96 ± 44.88, and 44.33 ± 65.75 months, respectively). Conclusion  Patients with SpA who were not seen by rheumatologists took a longer period till the final diagnosis than those who visited rheumatologists earlier in the course of the disease. Therefore, more studies are required to define the exact factors leading to the delay.

Responding to and Driving Change in Rheumatology: Report from the 12th International Immunology Summit 2021

The coronavirus disease 2019 (COVID-19) pandemic has accelerated changes to rheumatology daily clinical practice. The main goal of the 12th International Immunology Summit, held 25-26 June, 2021 (virtual meeting), was to provide direction for these active changes rather than undergoing change reactively in order to improve patient outcomes. This review describes and explores the concept of change in rheumatology clinical practice based on presentations from the Immunology Summit. Many of the changes to rheumatology practice brought about by the COVID-19 pandemic may be considered as having a positive impact on disease management and may help with the long-term development of more patient-focused treatment. Rheumatologists can contribute key knowledge regarding the use of immunosuppressive agents in the context of the pandemic, and according to the European League Against Rheumatism, they should be involved in any multidisciplinary COVID-19 guideline committees. New technologies, including telemedicine and artificial intelligence, represent an opportunity for physicians to individualise patient treatment and improve disease management. Despite major advances in the treatment of rheumatic diseases, the efficacy of available disease-modifying anti-rheumatic drugs (DMARDs) remains suboptimal and data regarding serological biomarkers are limited. Synovial tissue biomarkers, such as CD68+ macrophages, have shown promise in elucidating pathogenesis and targeting treatment to the individual patient. In spondyloarthritis (SpA) or psoriatic arthritis (PsA), information regarding the effectiveness of the available agents with different mechanisms of action may be integrated to manage patients using a treat-to-target approach. Early diagnosis of SpA and PsA is important for optimisation of treatment response and long-term outcomes. Improving our understanding of disease pathogenesis and practice methods may help reduce diagnostic delays, thereby optimising disease outcomes in patients with rheumatic diseases.

Diagnostic delay in axial spondyloarthritis: a systematic review

Identification of axial spondyloarthritis (axSpA) remains challenging, frequently resulting in a diagnostic delay for patients. Current benchmarks of delay are usually reported as mean data, which are typically skewed and therefore may be overestimating delay. Our aim was to determine the extent of median delay patients’ experience in receiving a diagnosis of axSpA and examine whether specific factors are associated with the presence of such delay. We conducted a systematic review across five literature databases (from inception to November 2021), with studies reporting the average time period of diagnostic delay in patients with axSpA being included. Any additional information examining associations between specific factors and delay were also extracted. A narrative synthesis was used to report the median range of diagnostic delay experienced by patients with axSpA and summarise which factors have a role in the delay. From an initial 11,995 articles, 69 reported an average time period of diagnostic delay, with 25 of these providing a median delay from symptom onset to diagnosis. Across these studies, delay ranged from 0.67 to 8 years, with over three-quarters reporting a median of between 2 years and 6 years. A third of all studies reported median delay data ranging from just 2 to 2.3 years. Of seven variables reported with sufficient frequency to evaluate, only ‘gender’ and ‘family history of axSpA’ had sufficient concordant data to draw any conclusion on their role, neither influenced the extent of the delay. Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay and this remains an extensive worldwide problem. This is further compounded by a mixed picture of the disease, patient and healthcare-related factors influencing delay.

Key points • Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay. • Median diagnostic delay typically ranges from 2 to 6 years globally. • Neither ‘gender’ nor ‘family history of axSpA’ influenced the extent of diagnostic delay experienced. • Diagnostic delay based on mean, rather than median, data influences the interpretation of the delay time period and consistently reports a longer delay period.

Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis

Background

Delay to diagnosis in axial SpA (axSpA) is longer than in many other rheumatic diseases. Prolonged delay is associate with poorer outcomes, including functional impairment and quality of life. Our aims were to describe global variation in delay to diagnosis, factors associated with delay, and delay compared with PsA.

Methods

We searched MEDLINE, PubMed, Embase and Web of Science using a predefined protocol. Diagnostic delay was defined as years between the age at symptom onset and at diagnosis. We pooled the mean delay using random effects inverse variance meta-analysis. We examined variations in pooled estimates using prespecified subgroup analyses and sources of heterogeneity using meta-regression.

Results

A total of 64 studies reported the mean diagnostic delay in axSpA patients. The pooled mean delay was 6.7 years (95% CI 6.2, 7.2) with high levels of heterogeneity. Delay to diagnosis did not improve over time when stratifying results by year of publication. Studies from high-income countries (defined by the World Bank) reported longer delays than those from middle-income countries. Factors consistently reported to be associated with longer delays were lower education levels, younger age at symptom onset and absence of extra-articular manifestations (EAMs). The pooled estimate for diagnostic delay from 8 PsA studies was significantly shorter, at 2.6 years (95% CI 1.6, 3.6).

Conclusion

For axSpA patients, delay to diagnosis remains unacceptably prolonged in many parts of the world. Patient factors (e.g. education) and disease presentation (onset age and EAMs) should inform campaigns to improve delay.

Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review

INTRODUCTION

Few studies have evaluated the impact of delayed diagnosis of axial spondyloarthritis (axSpA) on the overall burden of disease. The objective of this review was to evaluate the available literature on the clinical, economic, and humanistic burden of delayed diagnosis in patients with axSpA.

METHODS

This systematic literature review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the MEDLINE and Embase databases for English-language publications of original research articles (up to July 12, 2018) and conference abstracts (January 1, 2014, to July 12, 2018) reporting studies of adult patients with delayed diagnosis of axSpA associated with clinical, economic, or humanistic burden. Retrieved publications were screened for eligibility by two independent reviewers; discrepancies were resolved by a third independent reviewer. Data were extracted by one reviewer and validated by a second independent reviewer.

RESULTS

A total of 1391 publications were retrieved, of which 21 met the inclusion criteria and were included in the analysis. Of these, 15 reported data on clinical burden, nine on economic burden, and six on humanistic burden, with eight studies reporting a combination of clinical, economic, and/or humanistic burden. Patients with a delayed diagnosis of axSpA generally had higher disease activity, worse physical function, and more structural damage than those who received an earlier diagnosis. Patients with a delayed diagnosis also had a greater likelihood of work disability and higher direct and indirect healthcare costs than those who received an earlier diagnosis. Delayed diagnosis was associated with a greater likelihood for depression, negative psychological impacts, and worse quality of life.

CONCLUSIONS

Delayed axSpA diagnosis was associated with more functional impairment, higher healthcare costs, and worse quality of life, highlighting the importance of early recognition of axSpA to reduce extensive burden on patients and society. Plain language summary available for this article.

Real-World Patient Experience on the Path to Diagnosis of Ankylosing Spondylitis

Introduction

We describe the journey to diagnosis of ankylosing spondylitis (AS) from the patient perspective and examine differences in this journey by sex.

Methods

US adults aged ≥ 18 years with a self-reported AS diagnosis were recruited online through CreakyJoints, a patient support community, and ArthritisPower, a patient research registry. Respondents completed a web-based survey on sociodemographics, disease burden, and diagnosis history. Results were stratified by sex and time to diagnosis using two-sample t tests and χ² tests, respectively, to observe differences across the groups; P < 0.05 was considered statistically significant.

Results

Among 235 respondents, 174 (74.0%) were female. Mean (SD) ages of female and male respondents were 48.6 (10.6) and 53.1 (10.3) years, respectively. From the time respondents began seeking medical attention, 87 were diagnosed within ≤ 1 year, 71 in 2–9 years, and 77 after ≥ 10 years. Symptoms that led respondents to seek treatment were back pain (73.2%) and joint pain (63.8%); fatigue and difficulty sleeping were more common among respondents with longer times to diagnosis. During the diagnosis process, men with AS tended to receive quicker AS diagnosis compared with women. Overall, commonly reported initial diagnoses among respondents with longer time to AS diagnosis included back problems and psychosomatic disorders. Significantly more women reported misdiagnoses of fibromyalgia (20.7 vs. 6.6%) and psychosomatic disorders (40.8 vs. 23.0%) compared with men.

Conclusions

Diagnosis delays and misdiagnoses were common among respondents with AS. Increasing awareness about AS among referring providers may minimize diagnosis delay.

Funding

Novartis Pharmaceuticals Corporation.

Plain Language Summary

Plain language summary available for this article.

Electronic Supplementary Material

The online version of this article (10.1007/s40744-019-0153-7) contains supplementary material, which is available to authorized users.

Clinical patterns and characteristics of ankylosing spondylitis in China

The study aimed to determine whether unique clinical patterns of AS may exist in China, specifically to explore the different clinical manifestations caused by gender, HLA-B27 status, and age at disease onset. The multicenter cross-sectional survey was conducted and 1251 patients were enrolled across China, representing a broad spectrum of Chinese AS patients. The mean age at onset and diagnosis were 29.2 (11.4) and 33.5 (12.6) years, respectively. The male/female ratio was 2.7:1. Acute anterior uveitis (AAU) was experienced in 10.3% of AS patients and 9.1% patients had juvenile-onset AS (JoAS). Men were significantly younger at onset and diagnosis and showed a higher frequency of HLA-B27 positivity, JoAS, and AAU than women. HLA-B27-positive patients had a younger age of onset than HLA-B27-negative patients. HLA-B27-positive patients were nearly three times as likely to develop AAU than negative patients (P = 0.04). JoAS patients had a family history of AS more often than adult-onset AS (AoAS) patients, and 4.9% of JoAS patients underwent surgical treatments, a rate more than six times that of AoAS patients (P = 0.01). Men had higher levels of C-reactive protein than women, as did HLA-B27 positives compared to negative patients, and JoAS compared to AoAS (all P < 0.05). The clinical patterns of our AS patients were similar to those in other studies in non-Chinese cohort: (1) the age at onset was 29.2 (11.4) years, which was older than found in other studies; (2) men were more likely be HLA-B27 carriers than women; and (3) AAU was less common in Chinese patients.

Higher risk of incident ankylosing spondylitis in patients with uveitis: a secondary cohort analysis of a nationwide, population-based health claims database

OBJECTIVES

Ankylosing spondylitis (AS) is a progressive, systemic, inflammatory autoimmune disease that typically affects young adults. Uveitis is a common extra-articular manifestation of AS. Nevertheless, the magnitude of the risk of AS among patients with uveitis is not clear. The aim of this secondary retrospective cohort study was to investigate the risk of incident AS in patients with uveitis using data from a nationwide, population-based health claims research database.

METHOD

Using Taiwan's National Health Insurance Research Database, we identified 6637 patients with uveitis between 2000 and 2012. A comparison cohort was assembled, which consisted of five patients without uveitis, based on frequency matching for gender, 10 year age interval, and index year, for each patient with uveitis. Both groups were followed until diagnosis of AS or the end of the follow-up period. A Poisson regression model was used to calculate the incidence rate ratio for AS between the uveitis cohort and the comparison cohort.

RESULTS

Patients with uveitis exhibited a significantly higher incidence of AS than the comparison cohort (adjusted incidence rate ratio = 2.57, p < 0.001). Subgroup analysis with stratification by the interval between the diagnosis of uveitis and AS indicated that the adjusted incidence rates were significantly higher in the uveitis cohort with an interval of up to 7.9 years.

CONCLUSION

A significant increased risk in AS among patients with uveitis was observed, with a time lag of up to 7.9 years between the diagnosis of uveitis and subsequent diagnosis of AS.

Prevalence and awareness of sacroiliac joint alterations on lumbar spine CT in low back pain patients younger than 40 years

Background Computed tomography (CT) examinations of the lumbar spine are commonly performed in patients aged ≤40 years due to low back pain (LBP). Purpose To investigate the prevalence and awareness of radiologists for the presence of structural post-inflammatory/other sacroiliac joint (SIJ) alterations on lumbar spine CTs of young patients with LBP. Material and Methods A total of 484 lumbar spine CT examinations (272 men, 212 women; average age, 31 years; age range, 18-40 years) of patients with LBP in which the entire SIJs were visualized were retrospectively reviewed. SIJs were scored (consensus) by two senior radiologists (study reading) for the presence of post-inflammatory structural SIJ findings or other SIJs alterations. The original reports were compared to the study reading. Fifty CT examinations were re-evaluated for reliability assessment (intra-class correlation coefficient [ICC]). Results A total of 150 (31%) abnormal SIJ examinations were registered (ICC: r = 0.7-0.8; P < 0.0001): suspected sacroiliitis = 50 (10.2%); definite sacroiliitis = 16 (3.3%); osteitis-condensans-ilii = 38 (7.8%); diffuse idiopathic skeletal hyperostosis = 24 (5%); degenerative changes = 22 (4.5%); accessory SIJ = 22 (4.5%); and tumor = 1. The SIJs were referenced 39 times (8.0%) in the original readings: pathological findings (n = 15); and normal SIJ (n = 24). Total diagnostic accuracy for these reports only and for the entire readings were 49% and 69%, respectively, and 13% and 1.3%, respectively, for the pathological findings. Conclusion Sacroiliitis and other SIJ alterations are prevalent in young individuals with LBP, albeit, the majority of these alterations are not recognized nor reported by senior radiologists thus may delay efficacious treatment.

Understanding How the Diagnostic Delay of Spondyloarthritis Differs Between Women and Men: A Systematic Review and Metaanalysis

OBJECTIVE

To identify empirical evidence of diagnostic delay in spondyloarthritis (SpA), determine whether sex-related differences persist, and conduct an analysis from that perspective of the possible causes, including the influence of quality research, in this group of inflammatory rheumatic diseases.

METHODS

A systematic review was done of delay in diagnosis of SpA in MEDLINE and EMBASE and other sources. Study quality was determined in line with the Strengthening The Reporting of OBservational studies in Epidemiology (STROBE) statement. A metaanalysis of 13 papers reporting sex-disaggregated data was performed to evaluate sex-related differences in diagnostic delay. The global effect of diagnostic delay by sex was calculated using means difference (D) through a fixed effects model.

RESULTS

The review included 23,883 patients (32.3% women) from 42 papers. No significant differences between the sexes were detected for symptoms at disease onset or during evolution. However, the mean for delay in diagnosis of SpA showed sex-related differences, being 8.8 years (7.4-10.1) for women and 6.5 (5.6-7.4) for men (p = 0.01). Only 40% of papers had high quality. A metaanalysis included 12,073 participants (31.2% women). The mean global effect was D = 0.6 years (0.31-0.89), indicating that men were diagnosed 0.6 year (7 months) before women.

CONCLUSION

Delay in diagnosis of SpA persists, and is longer in women than in men. There are no significant sex-related differences in symptoms that could explain sex-related differences in diagnostic delay. Methodological and possible publication bias could result in sex-biased medical practice.

Association of rs11209032 and rs1004819 Polymorphisms in Interleukin-23 Receptor Gene With Ankylosing Spondylitis

Objectives

This study aims to investigate the distribution of human leukocyte antigen B27 (HLA-B27) alleles (+/-) and interleukin-23 receptor (IL-23R) gene rs11209032 and rs1004819 polymorphisms among ankylosing spondylitis (AS) patients in a Turkish cohort.

Patients and methods

The study sample comprised 106 AS patients (89 males, 18 females; mean age 38.9±10 years; range 19 to 65 years) and 82 healthy controls (70 males, 12 females; mean age 32.15±7.07 years; range 19 to 51 years). Distribution of HLA-B27 alleles (+)/(-) in AS patients were observed by reverse hybridization technique. Genotyping of IL-23R rs11209032 and rs1004819 polymorphisms of AS patients and healthy controls were performed by real time polymerase chain reaction.

Results

Of the AS patients, 69 (65.1%) were HLA-B27 positive. Distribution of rs11209032 genotype frequencies in AS group were 31.1% for GG, 50.9% for GA, and 17.9% for AA; while in control group, it was 34.1% for GG, 53.7% for GA, and 12.2% for AA. Distribution of rs1004819 genotype frequencies in AS group were 30.2% for CC, 52.8% for CT, and 17.0% for TT; while in control group, it was 42.7% for CC, 46.3% for CT, and 11.0% for TT. There was no significant difference between AS patients and controls in terms of genotype frequencies of IL-23R gene rs11209032 and rs1004819 polymorphisms.

Conclusion

No association was found between AS and IL23R rs11209032 and rs1004819 polymorphisms in this Turkish AS cohort.