Evaluation of the current use of MRI to aid the diagnosis of axial spondyloarthritis in the UK: results from a freedom of information request

AIM

To evaluate the impact of recommendations from the 2019 consensus exercise conducted by radiologists and rheumatologists on the use of magnetic resonance imaging (MRI) to investigate axial spondyloarthritis (axSpA) in clinical practice.

MATERIALS AND METHODS

A freedom of information (FOI) request was used to assess the use of MRI in the diagnosis of axSpA and radiologists' awareness of the 2019 guidance across all NHS Trusts and Health Boards in the UK, including England, Scotland, Northern Ireland, and Wales.

RESULTS

The FOI request was sent to 150 Trusts/Health Boards, and 93 full responses were received. Of the 93 respondents (97%), 90 reported familiarity with the term axSpA and 70/93 (75%) reported familiarity with the 2019 recommendations. Awareness of recommendations regarding specific MRI features supportive of the diagnosis of axSpA was 74/93 (80%) for the sacroiliac joints (SIJs) and 66/93 (71%) for the spine. The median wait for MRI acquisition was 2-3 months. Fifty-two of the 93 (56%) reported at least some outsourcing of axSpA MRI (33%/29% for specialist/non-specialist outsourcing respectively); 32/93 (34%) reported some scans being reported in-house by non-musculoskeletal radiologists.

CONCLUSION

There have been several positive developments in the understanding and use of MRI for the diagnosis of axSpA in the UK since the 2017 survey, although substantial scope for further improvement remains. Several new challenges have also emerged, including the increase in waiting times, reliance on outsourcing, and the reporting of MRI by non-musculoskeletal radiologists.

Emergence of behavioral phenomena and adaptation effects in human numerosity decoder using recurrent neural networks

Humans possess an innate ability to visually perceive numerosities, which refers to the cardinality of a set. Numerous studies indicate that the lateral intraparietal cortex (LIP) and other intraparietal sulcus (IPS) regions (region) of the brain contain the neurological substrates responsible for number processing. Existing computational models of number perception often focus on a limited range of numbers and fail to account for important behavioral characteristics like adaptation effects, despite simulating fundamental aspects such as size and distance effects. To address these limitations, our study develops (introduces) a novel computational model of number perception utilizing a network of neurons with self-excitatory and mutual inhibitory properties. Our approach assumes that the mean activation of the network at steady state can encode numerosity by exhibiting a monotonically increasing relationship with the input variable set size. By optimizing the total number of inhibition strengths required, we achieve coverage of the full range of numbers through three distinct intervals: 1 to 4, 5 to 17, and 21 to 50. Remarkably, this division aligns closely with the breakpoints in numerosity perception identified in behavioral studies. Furthermore, our study develops a method for decoding the mean activation into a continuous scale of numbers spanning from 1 to 50. Additionally, we propose a mechanism for dynamically selecting the inhibition strength based on current inputs, enabling the network to operate effectively across an extended (entire) range of numerosities. Our model not only sheds new light on the generation of diverse behavioral phenomena in the brain but also elucidates how continuous visual attributes and adaptation effects influence perceived numerosity.

Is Deceitful Autobiographical Memory Really Forgotten?

Autobiographical memory for deceitful events is said to be forgotten over time to reduce guilt and stress. People who engage in deceitful behavior continue to do so because they are able to stretch their memories to match their moral outlook. In this study, the authors wanted to see if participants who engage in deceitful behavior will change their behavior if they are reminded of their previous misdeeds and compare it with reminding them of past moral behavior and any neutral event. We also studied how the experience, or phenomenology of remembering, differs between immoral and moral memories. In Experiment 1, we found evidence to suggest that reminding deceptive autobiographical memory does not reduce deceptive behavior. In Experiment 2, we found evidence to suggest phenomenological characteristics of Immoral and moral memories are not significantly different from each other but they are both significantly different from that of neutral memory. This contradicts established results in the field. It is interesting to note that only emotional valence is significantly different between immoral and moral memory.

Development of a new measure to check attitude towards water conservation✰

Water Conservation is the need of the hour and attitudes towards conserving the resources is what is sure to become a priority in the coming years. In order to understand what could influence the change in attitude and thereby bring about a change of behavior, we first need to shift our attention from understanding the water crisis to understanding the existing attitude of the society towards a water crisis. In the current work we address the current attitude towards water conservation by providing baseline data about Indians' attitudes and behavior/behavioral intentions in conserving water. We introduce a scale constructed to test the Attitude towards water conservation in India. The scale consists of 20 items divided into 5 sub-scales. We conducted a nationwide survey on 430 Participants and their responses were checked for reliability. The internal consistency values of all 5 scales were ranged between 0.68 and 0.73 •Out of the 15 questions from Attitude towards water conservation from Dolnicar, S., & Hurlimann, A. (2010) 1 question was changed to suit Indian context•5 questions were added to show Perceived Moral Obligation, Behavioral Intensions and Perceived Water Rights.

POS0305 TIME TO IMPROVEMENT OF FATIGUE IN PATIENTS WITH ANKYLOSING SPONDYLITIS IN A STUDY OF TOFACITINIB

Background

Fatigue is common in patients (pts) with ankylosing spondylitis (AS) and is associated with higher levels of pain and functional disability.1 Tofacitinib is an oral JAK inhibitor approved for the treatment of AS. In pts with AS, greater improvements in fatigue were seen with tofacitinib vs placebo (PBO).2

Objectives

To estimate the time to improvement in fatigue in pts with AS treated with tofacitinib.

Methods

This post hoc analysis used data from a Phase 3 trial (NCT03502616) in pts with AS receiving tofacitinib 5 mg twice daily (BID) or PBO for 16 weeks; after Week (W)16, all pts received open-label tofacitinib until W48.2 Fatigue was assessed by Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) total score (range 0–52; higher scores indicate less fatigue3). A series of time to event analyses were performed using non-parametric Kaplan–Meier models. Median times to initial improvements in FACIT-F total score were assessed based on different thresholds. The initial improvement event was defined as time to first post-baseline week with an improvement in FACIT-F total score of at least 5%, 10%, 15% etc, up to 100%. Median times to events based on absolute changes in FACIT-F total score were also investigated.

Results

Overall, 269 pts were assessed; baseline demographics/disease characteristics have been previously reported.2 The median times to initial improvements in FACIT-F total score were significantly (p<0.05) shorter in pts receiving tofacitinib 5 mg BID vs PBO (Figure 1). For example, median time to initial improvement of 30% in FACIT-F total score was 16 weeks in pts receiving tofacitinib 5 mg BID; however, in pts receiving PBO, the median time for this event was not achieved up to W16. More pts receiving tofacitinib 5 mg BID vs PBO experienced initial improvement events up to W16 (Table 1). For example, 36.1% of pts receiving tofacitinib 5 mg BID experienced 50% improvement of fatigue up to W16, compared with 19.9% of pts receiving PBO.

Table 1.

Proportions of pts who experienced initial improvement events in FACIT-F total score up to W16

Fatigue improvement thresholdInitial improvement, n (%)p valuea25%Tofacitinib 5 mg BID82 (61.7)0.0009PBO58 (42.6)50%Tofacitinib 5 mg BID48 (36.1)0.0031PBO27 (19.9)75%Tofacitinib 5 mg BID30 (22.6)0.0626PBO19 (14.0)100%Tofacitinib 5 mg BID23 (17.3)0.1233PBO15 (11.0)

N=133 (tofacitinib 5 mg BID); N=136 (PBO)

aTest of equality over strata log-rank test, p<0.05 n, number of pts achieving an initial improvement event; N, total number of pts in each treatment group

Conclusion

In pts with AS, initial improvements in fatigue, as determined by FACIT-F total score, occurred faster and were larger in magnitude with tofacitinib vs PBO up to W16. These results may help physicians better understand the speed and magnitude for fatigue benefit in pts receiving tofacitinib.

References

[1]Turan et al. Rheumatol Int 2007; 27: 847-852.

[2]Deodhar et al. Ann Rheum Dis 2021; 80: 1004-1013.

[3]Hewlett et al. Arthritis Care Res (Hoboken) 2011; 63: S263-286.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Lauren Hogarth, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Laure Gossec Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, Roche and UCB, David Cella Consultant of: AbbVie, Alexion Pharmaceuticals, Astellas Pharma, Bayer, Bristol-Myers Squibb, Clovis Oncology, Evidera, Exelixis, Horizon Therapeutics, Janssen, Merck/Schering-Plough, National Academy of Sciences, Novartis Pharma K.K. (Japan), Pfizer Inc, PledPharma and Regeneron, Jessica A. Walsh Consultant of: AbbVie, Celgene and UCB, Raj Sengupta: None declared, Andrew G Bushmakin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Joseph C Cappelleri Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Oluwaseyi Dina Shareholder of: Pfizer Inc, Employee of: Pfizer Inc.

POS0936 DISEASE TRAJECTORIES OF AXIAL SPONDYLOARTHRITIS PATIENTS INITIATED ON BIOLOGIC DMARDs: PRELIMINARY ANALYSIS FROM A REAL-WORLD COHORT

Background

The number of biologic/targeted synthetic (b/ts) disease-modifying anti-rheumatic drugs (DMARDs) available for the treatment of axial spondyloarthritis (axSpA) are increasing. However, 1 in 4 axSpA patients may discontinue their first bDMARD within the first 12-months (1). A greater understanding of real-world axSpA disease/treatment trajectories pre- and post-bDMARD initiation is needed to inform optimal treatment for patients.

Objectives

To explore the use of biologic therapies in patients living with axSpA, and estimate the natural progression of disease and patient reported measures pre- and post- initiation of first bDMARD.

Methods

Data was extracted from the Bath SpA Research Biobank for all bio-naïve axSpA patients initiated on bDMARDs between 7th March 2000 and 1st February 2021. Patients were grouped based on first bDMARD. Linear regression models were used to explore changes in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Bath Ankylosing Spondylitis Functional Index (BASFI) over time; from 36-months before first bDMARD initiation, to 36-months after initiation. Changes in BASDAI/BASFI were estimated using piecewise mixed-effects linear regression. Models included fixed terms for age, sex, HLA-B27 status and disease duration. Switches to a second bDMARD and reasons for switching were captured.

Results

In total, 282 axSpA patients were included, and grouped into 3 cohorts based on first bDMARD: adalimumab (46.1%), etanercept (30.9%), other (23.1%; 6.4% certolizumab pegol, 5.0% golimumab, 5.3% infliximab, 0.7% rituximab, 5.7% secukinumab). Mean age at diagnosis was 30.7 (SD 11.3), 69.9% of patients were male, 11.0% diagnosed with non-radiographic axSpA and 85.3% HLA-B27 positive. In the 36-month period before bDMARD initiation, patients on average had a BASDAI score of 4.50 (95% CI 4.21-4.79) and BASFI of 4.02 (95% CI 3.68-4.38), with a linear and statistically significant worsening of 0.56 (95% CI 0.43-0.68) per year for the BASDAI and 0.55 (95% CI 0.41-0.69) for the BASFI (minimally clinically important difference defined as 1.1 and 0.6 for BASDAI and BASFI, respectively (2)). Following bDMARD initiation, patients indicated a statistically significant reduction in BASDAI to 3.13 (95% CI 2.82-3.45), 3.23 (95% CI 2.83-3.63) and 3.46 (95% CI 3.04-3.88) and reductions in the BASFI to 3.22 (95% CI 2.86-3.60), 3.06 (95% CI 2.61-3.53) and 3.64 (95% CI 3.16-4.12) for those treated with adalimumab, etanercept or other biologics respectively. Reduced scores were maintained over 36-months post initiation (Figure 1). Details of first and second bDMARD are outlined in Table 1. Reasons for switching were switch to biosimilar (32.4%), intolerance (25.1%), inefficacy (22.2%), malignancy (1.9%) or other (18.4%).

Table 1.

First and second bDMARD

First bDMARDSecond bDMARDAdalimumabEtanerceptOtherAdalimumab59 (57.3%)22 (21.4%)22 (21.4%)Etanercept28 (40.6%)37 (53.6%)4 (5.8%)Other15 (48.4%)8 (25.8%)8 (25.8%)Figure 1.

Predictive margins of BASDAI and BASFI 36-months pre- and post- bDMARD initiation

A-E, Predictive margins of the BASDAI score (overall – all components, A); BASDAI Q1 fatigue (B); BASDAI average of Q2-Q4 spinal pain, joint pain, enthesitis (C); BASDAI average of Q5-Q6 morning stiffness (D); and BASFI (E).

Conclusion

In our study population, there was clinically meaningful worsening of disease activity over 36-months prior to initiation of first bDMARD, despite baseline (36-months prior to first bDMARD initiation) BASDAI exceeding the current threshold for bDMARD treatment (BASDAI≥4). A clinically meaningful and maintained improvement in disease activity was reported across all cohorts in the 36-months following first bDMARD initiation.

References

[1]Lindström et al. Arthritis Research & Therapy. 2019;21(1):128-.

[2]Kviatkovsky et al. Journal of Rheumatology. 2016;43(9):1680-6.

Disclosure of Interests

Rosie Barnett Grant/research support from: UCB, Lewis Carpenter Consultant of: Statistical consultancy for Pfizer, Charlotte Cavill: None declared, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Lilly, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Lilly, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, UCB

AB0781 Malaysia Spondylarthritis Accelerated Management (SAM) Model: Expediting AxSpA patient journey from early referral, diagnosis and access to optimal care

Background

Axial spondyloarthritis (axSpA) is an important cause of inflammatory back pain (IBP). It is under-recognized, leading to significant delays in diagnosis. Early recognition and diagnosis are crucial to achieve the best outcomes for patients and in Malaysia, significant gaps in the clinical management of axSpA remain. Therefore, we sought to implement a strategy to improve the time to diagnosis and management of axSpA in Malaysia by collaborating and adopting guidance from an international axSpA expert.

Objectives

The objectives were to improve disease recognition among healthcare practitioners (HCPs), reducing time to specialist referral and diagnosis whilst improving disease management by developing and implementing a new patient care model called the Spondyloarthritis Accelerated Management (SAM) and measure its effectiveness in 3 Rheumatology centers in Malaysia.

Methods

The SAM initiative was developed by the Malaysian SpA Consortium Working Group involving 8 Malaysian rheumatologists from 3 local centers and 1 international axSpA expert from the UK as part of the steering committee. Selections were based on clinical expertise. The first local alignment meeting on model structure was held in July 2020 with subsequent meetings held to address key barriers to early axSpA diagnosis and timely access to quality care. A care model with feasible key performance indicators (KPIs) was established, adapted and tracked monthly in the 3 rheumatology centers (Figure 1). Referral tools were developed to facilitate early referrals to rheumatologists. These included a QR-coded ‘3-R’ referral guide1 and a patient self-screening tool with a patient self-referral letter all hosted on the Malaysian Society of Rheumatology (MSR) website, educational talks to HCPs and public awareness forums on IBP and axSpA. Data were collected on referral source, duration of referrals, knowledge on IBP in HCPs by surveys and imaging accessibility at baseline and at 1 year after the initiative was launched. Baseline data collected were from August to October 2020 and 1 year data were from November 2020 to November 2021.

Figure 1.

Summary of optimal Key performance indicators (KPIs) for Malaysia SAM

Results

At 1 year, the SAM initiative showed a 44.4% (Median: 1.33 [IQR 1-1.7] vs 1.92 [IQR 1.6-2.1]) increase in IBP referrals, a reducing trend from 9.5 (IQR 8-11.1) to 5.9 (IQR 5.1-6.8) weeks of waiting time to a first Rheumatology visit and an increase of 37.2% (34% vs 71%) in IBP patients who were seen at the rheumatology clinic within 6 weeks. All patients with IBP had x-rays (sacroiliac joints or pelvis). MRI requests in x-ray negative patients suspected of axSpA was increased by 13.9% (77.8% vs 91.7%) and waiting time for MRI was reduced by 3.1 weeks (12 vs 8.9 weeks). The IBP knowledge among 224 HCPs improved by 40.6% (45.7% vs 86.3%). The number of patients newly diagnosed with axSpA increased by 40% (Median: 5 [IQR 4-9.5] vs 7 [IQR 6.5-7]) despite the COVID-19 pandemic.

Conclusion

The SAM initiative has shown promising initial results in improving referrals of patients with IBP, promoting earlier diagnosis and establishing the importance of having timely access to optimal care. A nationwide implementation is being planned to improve the recognition of the axSpA in Malaysia.

References

[1]Lau, Ing Soo et al., Malaysian family physician, vol. 16,2 2-6. 27 May. 2021

Acknowledgements

Authors would like to acknowledge that this abstract is part of the Malaysia SpA Consortium Working Group. The SAM expert panel discussion and the preparation of this abstract were funded by Novartis (Malaysia). The authors acknowledge writing support from Vidya Sagar AEC (Novartis, Hyderabad)

Disclosure of Interests

Fariz Yahya Speakers bureau: Novartis, Eli Lilly, ZP Therapeutics, Pfizer, Janssen, Gilead, Abbvie, Upjohn, Paid instructor for: Novartis, ZP Therapeutics, Abbvie, Consultant of: Novartis, Eli Lilly, ZP Therapeutics, Pfizer, Gilead, Abbvie, Janssen, Grant/research support from: Gilead, Galapagos, Abbvie, Janssen, Novartis, Habibah Mohd Yusoof: None declared, Asmah Mohd: None declared, Shereen Ch’ng Suyin Speakers bureau: Pfizer, Boehringer Ingelheim, Johnson & Johnson, Novartis, Abbvie, Suk Chyn Gun: None declared, Mollyza Mohd Zain: None declared, Sargunan Sockalingam Speakers bureau: Novartis, Roche, Johnson & Johnson, Pfizer, Paid instructor for: Johnson & Johnson, Grant/research support from: Novartis, Siew Li Lai Employee of: Novartis, Chen Bao Jing Employee of: Novartis, John Tiong Employee of: Novartis, Ing Soo Lau: None declared, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Lilly, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Lilly, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, UCB

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

BACKGROUND

Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments.

OBJECTIVES

We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation.

METHODS

Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model.

RESULTS

Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations.

CONCLUSIONS

Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

POS0059-PARE DELAY TO DIAGNOSIS IN AXIAL SPONDYLOARTHRITIS – TIME FOR A GOLD STANDARD APPROACH

Background:

In the UK, the average time to diagnosis of axial SpA is 8.5 years (1). There is little evidence this has improved, despite the acceptance of MRI use in diagnosis (2). A recent review identified significant clinical, economic and humanistic burden from delayed diagnosis (3). Urgent action is needed to ensure delayed diagnosis is not normalized.

Objectives:

We created a proposal for a Gold Standard time to diagnosis for axial SpA and a national implementation plan (4) through consensus development with patients, healthcare professionals and professional bodies.

Methods:

A.A scoping literature review identifying where delays occur, from first symptom onset to diagnosis by a rheumatologist, and potential solutions. From this, a summary report / draft plan was produced for consultation

B.A national consultation survey to elicit views on the proposals from clinicians, healthcare professionals, professional societies and patients

C.Structured feedback to written proposals via e-consultation with clinicians and patients

D.A consensus development workshop to finalise the Gold Standard and implementation plan.

Results:

The literature review identified four delays:

1. People do not know axial SpA may be a cause of their chronic back pain

2. Primary care practitioners may not recognise features of axial SpA

3. People may be referred to non-rheumatologists who may not recognise axial SpA promptly

4. Rheumatology and radiology teams may not optimally request or interpret investigations.

202 participants responded to the summary report (74% patients, 21% healthcare professsionals, 5% professional societies). All supported the principles behind the gold standard time to diagnosis. Qualitive analysis confirmed agreement with the proposed solutions, underscoring the importance of education and visibility for axial SpA within primary care and increased public awareness. Additional proposals were suggested, including a tool in primary care to run audits on IT systems.

40 clinicians contributed to the e-consultation and 55 clinicians, policy makers, social marketing experts, health journalists and patients attended the consensus workshop. Consensus was reached on a gold standard time to diagnosis of one year, and the principles, key components and phasing of the implemention plan. This included: public awareness about axial SpA symptoms; a primary care clinical champions programme; creating a referral pathway from primary care direct to rheumatology; a secondary care service educational programme.

Conclusion:

There is consensus from UK axial SpA clinicians, patients and professional societies on the need for a Gold Standard time to diagnosis of axial SpA of one year, so that patients can live happy, healthy and productive lives.

References:

[1]Hamilton L, Gilbert A, Skerett J, et al. Services for people with ankylosing spondylitis in the UK - a survey of rheumatologists and patients. Rheumatology 2011:50:1991

[2]Sykes MP, Doll H, R Sengupta, Gaffney, K. Delay to diagnosis in axial spondyloarthritis: are we improving in the UK? Rheumatology, July 2015

[3]Yi E, Ahuja A, Rajput T, et al. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther. 2020 Mar;7(1):65–87.

[4]Webb D, Zhao S, Whalley S, et al. Gold Standard Time to Diagnosis in axial Spondyloarthritis: Consultation Document. 2020, NASS.

Disclosure of Interests:

Dale Webb Speakers bureau: Janssen, Novartis, Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB, Karl Gaffney Speakers bureau: Abbvie, Lilly, Novartis, UCB, Consultant of: Abbvie, Celltrion, Lilly, Grant/research support from: Abbvie, Pfizer, Lilly, UCB, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, Sizheng Steven Zhao: None declared, Lisa Swingler Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB.

POS0959 DIAGNOSTIC DELAY IN AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE NATIONAL EARLY INFLAMMATORY ARTHRITIS AUDIT

Background:

Diagnostic delay is a significant problem in axial spondyloarthritis (axSpA), and there is a growing body of evidence showing that delayed axSpA diagnosis is associated with worse clinical, humanistic and economic outcomes.1 International guidelines have been published to inform referral pathways and improve standards of care for patients with axSpA.2,3

Objectives:

To describe the sociodemographic and clinical characteristics of newly-referred patients with axSpA in England and Wales in the National Early Inflammatory Arthritis Audit (NEIAA), with rheumatoid arthritis (RA) and mechanical back pain (MBP) as comparators.

Methods:

The NEIAA captures data on all new patients over the age of 16 referred with suspected inflammatory arthritis to rheumatology departments in England and Wales.4 We describe baseline sociodemographic and clinical characteristics of axSpA patients (n=784) recruited to the NEIAA between May 2018 and March 2020, compared with RA (n=9,270) and MBP (n=370) during the same period.

Results:

Symptom duration prior to initial rheumatology assessment was significantly 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 to 33.7% of RA patients and 76.0% of MBP patients; 32.6% of axSpA patients had symptom durations of >5 years, compared to 3.5% of RA patients and 24.6% of MBP patients (Figure 1A). Following referral, 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). The proportion of axSpA patients assessed within 3 weeks of referral increased from 26.7% in May 2018 to 34.7% in March 2020; compared to an increase from 38.2% to 54.5% for RA patients (Figure 1B). A large majority of axSpA referrals originated from primary care (72.4%) or musculoskeletal triage services (14.1%), with relatively few referrals from gastroenterology (1.9%), ophthalmology (1.4%) or dermatology (0.4%).

Of the subset of patients with peripheral arthritis requiring EIA pathway follow-up, fewer axSpA than RA patients had disease education provided (77.5% vs. 97.8%; p<0.001), and RA patients reported a better understanding of their condition (p<0.001). HAQ-DI scores were lower at baseline in axSpA EIA patients than RA EIA patients (0.8 vs 1.1, respectively; p=0.004), whereas baseline Musculoskeletal Health Questionnaire (MSK-HQ) scores were similar (25 vs. 24, respectively; p=0.49). The burden of disease was substantial across the 14 domains comprising MSK-HQ in both axSpA and RA (Figure 1C).

Conclusion:

We have shown that diagnostic delay remains a major challenge in axSpA, despite improved disease understanding and updated referral guidelines. Patient education is an unmet need in axSpA, highlighting the need for specialist clinics. MSK-HQ scores demonstrated that the functional impact of axSpA is no less than for RA, whereas HAQ-DI may underrepresent disability in axSpA.

References:

[1]Yi E, Ahuja A, Rajput T, George AT, Park Y. Clinical, economic, and humanistic burden associated with delayed diagnosis of axial spondyloarthritis: a systematic review. Rheumatol Ther. 2020;7:65-87.

[2]NICE. Spondyloarthritis in over 16s: diagnosis and management. 2017.

[3]van der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-91.

[4]British Society for Rheumatology. National Early Inflammatory Arthritis Audit (NEIAA) Second Annual Report. 2021.

Acknowledgements:

The National Early Inflammatory Arthritis Audit is commissioned by the Healthcare Quality Improvement Partnership, funded by NHS England and Improvement, and the Welsh Government, and carried out by the British Society for Rheumatology, King’s College London and Net Solving.

Disclosure of Interests:

Mark Russell Grant/research support from: UCB, Pfizer, Fiona Coath: None declared, Mark Yates Grant/research support from: UCB, Abbvie, Katie Bechman: None declared, Sam Norton: None declared, James Galloway Grant/research support from: Abbvie, Celgene, Chugai, Gilead, Janssen, Lilly, Pfizer, Roche, UCB, Jo Ledingham: None declared, Raj Sengupta Grant/research support from: AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Karl Gaffney Grant/research support from: AbbVie, Biogen, Cellgene, Celltrion, Janssen, Lilly, Novartis, Pfizer, Roche, UCB.

POS0919 BIMEKIZUMAB SHOWS SUSTAINED LONG-TERM IMPROVEMENTS IN PATIENT-REPORTED OUTCOMES AND QUALITY OF LIFE IN ANKYLOSING SPONDYLITIS: 3-YEAR RESULTS FROM A PHASE 2B STUDY

Background:

Bimekizumab (BKZ), a monoclonal antibody that selectively inhibits interleukin (IL)-17A and IL-17F, has demonstrated clinical efficacy and safety in patients with ankylosing spondylitis (AS) treated over a period up to 96 weeks.1,2

Objectives:

To report 3-year interim patient-reported outcomes (PROs) in patients with active AS treated with BKZ in a phase 2b dose-ranging study (BE AGILE; NCT02963506) and its open-label extension (OLE; NCT03355573).

Methods:

BE AGILE study design has been described previously.1 Patients treated with BKZ 160 mg or 320 mg every 4 weeks (Q4W) at Week 48 in BE AGILE were eligible for OLE entry. All OLE patients received BKZ 160 mg Q4W. Outcome measures are reported for the OLE full analysis set (patients who entered the OLE and had ≥1 dose of BKZ and ≥1 valid efficacy variable measurement in the OLE), and include: BASDAI, BASDAI50 responder rate, BASFI, fatigue (BASDAI Q1), morning stiffness (mean of BASDAI Q5 + 6), total spinal pain (numeric rating scale [NRS]), SF-36 PCS and MCS, and ASQoL. Missing data were imputed using multiple imputation (MI; based on the missing at random assumption) for continuous variables and non-responder imputation (NRI) for dichotomous variables.

Results:

262/303 (86%) patients randomised at BE AGILE study baseline (BL) completed Week 48 on BKZ 160 mg or 320 mg, of whom 255/262 (97%) entered the OLE (full analysis set: 254). From baseline to Week 48 in BE AGILE, BKZ-treated patients showed clinically relevant improvements in disease activity (BASDAI, BASDAI50), physical function (BASFI), fatigue, morning stiffness, spinal pain, and quality of life (SF-36 PCS and MCS, ASQoL) (Figure 1). Group-level improvements in all reported continuous efficacy measures exceeded published minimally important difference (MID), minimum clinically important improvement (MCII), and/or minimum clinically important difference (MCID) thresholds (Figure 1).3,4 Efficacy in all reported outcome measures was maintained or continued to improve from Week 48 to Week 144 or 156 (Figure 1).

Conclusion:

BKZ treatment was associated with sustained and consistent efficacy in patients with active AS over 3 years, including patient-reported disease activity, physical function, fatigue, morning stiffness, spinal pain, and quality of life.

References:

[1]van der Heijde D. Ann Rheum Dis 2020;79:595–604.

[2]Baraliakos X. Arthritis Rheumatol 2020;72 (suppl 10).

[3]Ogdie A. Arthritis Care Res 2020;72 (S10):47–71.

[4]Maruish ME. User’s manual for the SF-36v2 Health Survey (3rd ed). 2011; Lincoln, RI: QualityMetric Incorporated.

Acknowledgements:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Xenofon Baraliakos Speakers bureau: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB Pharma, Paid instructor for: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB Pharma, Maxime Dougados Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie, Eli Lilly, Novartis, Pfizer and UCB Pharma, Karl Gaffney Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Eli Lilly, Novartis, UCB Pharma, Grant/research support from: AbbVie, Gilead, Eli Lilly, Novartis, UCB Pharma, Raj Sengupta Speakers bureau: AbbVie, Biogen, Celgene, MSD, Novartis, UCB Pharma, Consultant of: AbbVie, Biogen, Celgene, Eli Lilly, MSD, Novartis, UCB Pharma, Grant/research support from: AbbVie, Celgene, UCB Pharma, Marina Magrey Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, UCB Pharma, Natasha de Peyrecave Employee of: UCB Pharma, Marga Oortgiesen Employee of: UCB Pharma, Thomas Vaux Employee of: UCB Pharma, Carmen Fleurinck Employee of: UCB Pharma, Valerie Ciaravino Employee of: UCB Pharma, Atul Deodhar Speakers bureau: Janssen, Novartis, Pfizer, Consultant of: AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Gilead, GSK, Janssen, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB Pharma

Depression among Patients Presenting with Gastrointestinal Symptoms: Prevalence and Associated Factors

Gastrointestinal diseases frequently affect patients' physical and emotional wellbeing as being heavily affected by stress. This study was conducted to find out prevalence and severity of depressive symptoms among patients presenting with gastrointestinal symptoms. This cross sectional study was conducted at Outpatients Department jointly by Department of Gastroenterology and Department of Psychiatry of a tertiary care hospital in north east part of Bangladesh from November 2011 to June 2012. Consecutive patients with gastrointestinal symptoms underwent psychiatric evaluation using HDRS and analyzed. 442 patients, 38(8.6%) were found normal. Among the rest 128(28.96%), 138(31.22%), 72(16.29%) and 66(14.93%) had mild, moderate, severe and very severe depressive symptoms respectively. Female sex (95.03% vs. 89.32%), married people (93.77 vs. 86.13%), older age (98.24%), rural people (94.26% vs. 84.36%), farmers (96.36%) and house wives (96.24%) were more affected. Prevalence of depression was also higher among patients with lower socioeconomic class, less educated people and rural background. Depressive symptoms are very common in patients presenting with gastrointestinal symptoms. Awareness regarding psychiatric assessment and intervention may reduce sufferings and thus improve wellbeing of these patients.

SAT0628-HPR “IT IS THE NEVER ENDING QUEST, HOW TO MOTIVATE PEOPLE” – HEALTH PROFESSIONALS’ PERSPECTIVES ON SUPPORTING PHYSICAL ACTIVITY MAINTENANCE IN THOSE LIVING WITH AXIAL SPONDYLOARTHRITIS

Background:

Physical activity (PA) has been identified as a primary treatment option for people living with axial spondyloarthritis (axSpA) [1]. Yet, people living with axSpA can find it difficult to maintain PA at levels required to gain the evidenced benefits [2]. Intensive rehabilitation programmes harness the benefits of physical activity, but little is known about how to support PA maintenance when patients return to everyday life. The perspectives’ of health professionals involved in rehabilitation programmes can provide important and rich insights into how people living with axSpA could be helped to maintain their PA.

Objectives:

To explore health professionals‘ experiences of supporting PA maintenance during and after a rehabilitation programme for those living with axial spondyloarthritis.

Methods:

A qualitative study was conducted using semi-structured interviews. Nine health professionals (i.e., 4 physiotherapists; 1 clinical nurse specialist; 1 rheumatology SpR; 1 psychologist; 1 occupational therapist; and 1 podiatrist) who contribute to a rehabilitation programme were recruited from the Royal National Hospital for Rheumatic Diseases in Bath, UK (Mtime contributing to course = 6.79 yrs, range 1-19.25 yrs; contact time over course range = 1 to 45 hrs). Interviews were audio recorded, transcribed verbatim, and a thematic analysis employed [3].

Results:

Maintaining a physically active lifestyle is a challenge for those living with axSpA and is an issue that is currently not being addressed. Health professionals’ perspectives on supporting PA maintenance was illustrated through four main themes: (1) Social environment (group dynamic, importance of others with the same condition, immersion of the disease, external peer groups); (2) Re-framing (education, ownership, exercise off the pedestal, combating fear, routine and habit); (3) PA support (enjoyment and interest, PA as flexible, encouragement and importance, balance and realistic expectations, internal and external feedback); and (4) Challenges for health professionals (training, resources, knowledge of transition process to everyday life, difficulty motivating). The reasons why people engage in PA play a key role within each of these themes.

Conclusion:

Results emphasize the current lack of support for the maintenance of PA and the complexities and challenges involved in maintaining PA for people living with axSpA. Interventions to support PA maintenance should pay particular attention to the importance of socially supportive environments, the need for enjoyment, and the use of internal and external feedback. The challenges faced by health professionals in motivating those living with axSpA to engage in PA regularly suggests a need for more training opportunities in motivation and health behaviour change.

References:

[1]Rausch Osthoff, A., Niedermann, K., Braun, J., et al., (2012) EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases, 77 (9), pp. 1251-60.

[2]McDonald, M. T., Siebert, S., Coulter, E. H., McDonald, D. A., and Paul, L. (2019) Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: a systematic review.Rheumatology International, 39 (2), pp. 187-201.

[3]Braun, V., and Clarke, V. (2006) Using thematic analysis in psychology.Qualitative Research in Psychology, 3 (2), pp. 77-101.

Acknowledgments:

The authors would like to thank the Bath Institute for Rheumatic Diseases (BIRD) and the University of Bath for funding the PhD studentship associated with this project

Disclosure of Interests:

Thomas Ingram: None declared, Peter Rouse: None declared, Martyn Standage: None declared, Raj Sengupta Grant/research support from: Research grants from UCB, Pfizer, Abbvie and Novartis, Speakers bureau: Received honoraria for giving talks from Abbvie, Biogen, UCB, Novartis, Pfizer

FRI0309 DAILY SELF-REPORTED FLARE PROFILES IN AXIAL SPONDYLOARTHRITIS: ASSOCIATIONS BETWEEN FLARE, SYMPTOMS AND BEHAVIOUR

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease, characterised by fluctuating periods of flare and remission. Flare is a multidimensional change of disease state; whereby flare definitions have previously been formulated using validated composite indices, or through qualitative retrospective investigation of flare states. Smartphone technologies for tracking disease symptoms provide unique, daily insights into self-reported individual flare experience, and may present an opportunity to gain a more complete understanding of flare burden and symptom patterns.

Objectives:

To assess frequency and characteristics of axSpA flares, utilising data collected in the uMotif symptom tracking app.

Methods:

Patients with axSpA attending the Royal National Hospital for Rheumatic Diseases in Bath were invited to participate. Through the uMotif app, patients were sent daily reminders to log flare, pain, fatigue, sleep, recommended exercise, mood and stress using 5-point Likert scales, in addition to optional variables such as smoking and menstrual cycle. Self-reported periods of flare were identified. For each patient reporting flare within the study period, a mean ‘flare’ and ‘non-flare’ score was calculated for each variable. Paired t-tests were conducted for each variable, to investigate which variables correlate with flare status.

Results:

Between 5th April 2018 and 8th March 2019, 174 patients consented for research and logged a mean of 99.73 (SD 99.97, range 1 - 323 days) days of data. 136/174 (78%) patients recorded at least 1 flare, with 1330 flares recorded in total. For patients reporting at least 1 flare, each flare lasted a mean of 2.20 days (SD 2.53 days, range 1 – 33 days), with a mean frequency of once every 45.19 days (SD 53.06, range 3.2 -314 days). Significant relationships were identified between flare status and uMotif scores (Table 1).

Table 1.

Paired t-tests: flare vs. non-flare scores for each variable

Estimated difference^p-valueN95% CI (lower limit)95% CI (upper limit)Variable-0.870.266-2.630.88Red Painful Eyes-0.670.000*130-0.78-0.56Pain-0.570.004*25-0.94-0.20Chest Pain-0.510.005*15-0.83-0.18Hot Flushes-0.500.000*129-0.61-0.40Fatigue-0.440.1962-2.231.35Blood in Stool-0.380.000*128-0.47-0.29Mood-0.360.000*127-0.52-0.20Anti-Inflammatory Use-0.360.000*128-0.48-0.23Recommended Exercise-0.340.000*33-0.51-0.17Confidence in Self-Management-0.260.000*128-0.37-0.15Stress-0.250.17015-0.620.12Screen Time-0.190.000*130-0.26-0.12Sleep Quality-0.150.45812-0.590.28Menstrual Cycle-0.110.10322-0.250.02Eyesight0.090.1953-0.120.30Flare of Psoriasis0.050.65626-0.170.26Medication Adherence0.040.7973-0.530.61Smoking Today-0.030.48450-0.110.05Caffeine Intake

N= number of patients with both a flare and non-flare entry for each variable; CI=confidence interval

Higher variable scores indicate more positive outcomes (e.g. a higher pain score indicates less pain)

^Estimated difference between flare and non-flare entries (e.g. on average, the mean pain score of a flare entry is 0.67 [0.56– 0.78 CI] less than a non-flare entry)

*p<0.01

Conclusion:

These findings demonstrate significant relationships between a variety of patient-reported symptoms and flare, including variables that to our knowledge, have not yet been explored in axSpA. Small estimated differences were found between scores for ‘flare’ versus ‘no-flare’. Further work is needed to characterise fluctuating flare/no-flare patterns of individuals tracking daily symptoms in the uMotif app. In future research, it will be important to determine whether there is a chronological pattern of variables during the pre-flare period that can predict a flare. Greater understanding of such patterns may allow identification of the optimal timing of intervention to prevent a period of flare and improve quality of life for patients with axSpA.

Acknowledgments:

We thank UCB for funding use of the uMotif application.

Disclosure of Interests:

Rosie Barnett: None declared, Stanley Ng: None declared, Simon Jones: None declared, Matthew Young: None declared, Raj Sengupta Grant/research support from: Research grants from UCB, Pfizer, Abbvie and Novartis, Speakers bureau: Received honoraria for giving talks from Abbvie, Biogen, UCB, Novartis, Pfizer

AB0675 RED CELL DISTRIBUTION WIDTH AND FATIGUE IN AXIAL SPONDYLOARTHRITIS: A SLEEPER SIGNAL

Background:

Fatigue is a ubiquitous feature of autoimmune conditions, and axial Spondyloarthritis (axSpA) is no exception, with over 50% of patients reporting some degree of fatigue1. Erythrocyte size variability (as measured by red cell distribution width (RDW)) has been found to correlate with fatigue in a cohort of systemic lupus erythematous (SLE) patients and may reflect early iron deficiency2. We investigate whether this finding holds true in axSpA.

Objectives:

To investigate the relationships between fatigue, disease activity, and RDW (as a proxy for functional iron deficiency) in patients with axSpA.

Methods:

Cross-sectional analysis performed on patients with axSpA, as defined by the Assessment of SpondyloArthritis international Society (ASAS) criteria, enrolled in a longitudinal data collection study from October 2017 until January 2020 in a single outpatient setting. Patients required a minimum of 1 set of patient-reported outcome measures (PROMs), including the completion of a Functional Assessment of Chronic Fatigue Illness Therapy (FACIT) Fatigue Scale v4 (numerical score between 0–52 with a lower score indicating greater fatigue), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). C-reactive protein (CRP) as a biochemical marker of disease activity, as well as Haemoglobin (Hb) and RDW performed within 3 months either side of a PROMs set were extracted and matched. Only one pair of matched data was selected per patient according to the least timeframe between a set of PROMs and bloods of interest (if multiple were available). Anaemia was defined according to World Health Organisation criteria, i.e., Hb <120 g/L in females and Hb <130 g/L in males. Non-parametric analysis of variables was performed using Spearman’s rank correlation with significance defined at a p-value <0.05.

Results:

63 patients were included in the analysis (63.5% (40) male, mean time to diagnosis 11.46 (±9.04) years, 79.4% (50) HLA-B27 positive, 46% (29) current or ex-smokers). Blood parameters showed mean Hb of 139.6 (±16.03) g/L, mean RDW of 13.55 (±1.46) %, mean CRP of 5.23 (±10.82) mg/L. Mean BASDAI score of cohort was 3.69 (±2.02) and FACIT score 34.18 (±11.30). Mean absolute interval time difference between a PROMs set and bloods of interest was 16.14 (±41.11) days.

Univariate analysis showed a statistically significant, negative correlation between fatigue (FACIT) and disease activity (BASDAI), (p<0.001; r= -0.63), but failed to demonstrate an association between fatigue and Hb, RDW, or CRP. Sub-group analysis of 51 patients, following exclusion of patients with anaemia (12), engendered a significant and moderately negative correlation between fatigue and RDW (p=0.02, r=-0.32) (Figure 1), maintained a significant correlation between fatigue and BASDAI (p<0.0001, r=-0.56) and showed a non-significant association between RDW and BASDAI (p=0.07, r=0.25).

Figure 1.

Negative correlation between FACIT score and RDW

Conclusion:

These findings suggest that RDW may potentially represent a surrogate marker of disease activity in patients with axSpA. RDW may also be implicated in the multi-faceted aetiology of fatigue in axSpA patients, and may reflect functional iron deficiency. A recent cohort study of axSpA patients found anti-TNF therapy ineffective at alleviating fatigue in nearly 80% of patients1. Management of potential functional iron deficiency as reflected by RDW may offer an alternative treatment target for fatigue in these patients.

References:

[1]Bedaiwi M, Sari I, Thavaneswaran A, et al. J Rheumatol. 2015;42(12):2354.

[2]Wincup C, Parnell S, Cleanthous B, et al. Clin Exp Rheumatol. 2019 Sep-Oct;37(5):852-54.

Disclosure of Interests:

Saion Chatterjee: None declared, Chris Wincup: None declared, Anisur Rahman: None declared, Raj Sengupta Grant/research support from: Research grants from UCB, Pfizer, Abbvie and Novartis, Speakers bureau: Received honoraria for giving talks from Abbvie, Biogen, UCB, Novartis, Pfizer

Non-articular Felty's syndrome: An uncommon diagnosis

Felty's syndrome is a triad of rheumatoid arthritis, neutropenia, and splenomegaly. We hereby report an unusual case of non-articular Felty's syndrome and its management along with discussing the importance of appropriately ruling out alternate causes of neutropenia with splenomegaly.

A visual sense of number emerges from the dynamics of a recurrent on-center off-surround neural network

It has been proposed that the ability of humans to quickly perceive numerosity involves a visual sense of number. Different paradigms of enumeration and numerosity comparison have produced a gamut of behavioral and neuroimaging data, but there has been no unified conceptual framework that can explain results across the entire range of numerosity. The current work tries to address the ongoing debate concerning whether the same mechanism operates for enumeration of small and large numbers, through a computational approach. We describe the workings of a single-layered, fully connected network characterized by self-excitation and recurrent inhibition that operates at both subitizing and estimation ranges. We show that such a network can account for classic numerical cognition effects (the distance effect, Fechner׳s law, Weber fraction for numerosity comparison) through the network steady state activation response across different recurrent inhibition values. The model also accounts for fMRI data previously reported for different enumeration related tasks. The model also allows us to generate an estimate of the pattern of reaction times in enumeration tasks. Overall, these findings suggest that a single network architecture can account for both small and large number processing.