axSpA Classification Criteria Research Articles

Spine and Sacroiliac Joint Involvement in Newly Diagnosed Patients With Inflammatory Bowel Disease: Clinical and MRI Findings From a Population-Based Cohort.

In patients with inflammatory bowel disease (IBD), co-occurring spondyloarthritis (SpA) leads to poorer outcomes and impaired quality of life, highlighting the importance of early detection and effective treatment. This is the first study to assess the prevalence and distribution of axial symptoms and magnetic resonance imaging (MRI)-detected involvement of the spine and sacroiliac joints (SIJs) in early IBD. Newly diagnosed patients with IBD from a prospective, population-based cohort were consecutively recruited. Rheumatological interview, clinical, ultrasound, and MRI assessment for SIJ and spine inflammatory and structural lesions were made using validated scoring methods and consensus definitions of axial SpA (axSpA). Of 110 patients (ulcerative colitis: 70, Crohn's disease: 40, mean age of 42 years, and 40% male), 48 (44.9%) reported back and/or buttock pain, and 10 (9.1%) had inflammatory back pain. Seventeen (16.7%) patients had MRI findings indicative of axSpA; only 10 of these patients had axial symptoms. Inflammatory MRI lesions were present in SIJs and the spine of 27 (26.5%) and 30 (30.3%) patients, respectively. The Assessment of SpondyloArthritis International Society classification criteria for axSpA were met in 11 (10%) cases. MRI findings typical of axSpA were associated with peripheral joint and entheseal inflammation detected by ultrasound ( P = 0.04). No differences in clinical or imaging findings were found between patients with ulcerative colitis and Crohn's disease. One-in-6 newly diagnosed patients with IBD had MRI findings indicative of axSpA. As 40% of these patients were asymptomatic, this suggests that axSpA is underdiagnosed in early IBD. Multidisciplinary collaboration is essential to ensure early detection of axial inflammation and to enable optimal therapy preventing future structural damage and disability.

Knowledge, Attitudes, and Practices of Moroccan Community Rheumatologists' Regarding the Management of Non-radiographic Axial Spondyloarthritis: A National Cross-Sectional Study.

Introduction Non-radiographic axial spondyloarthritis (nr-axSpA) is within the spectrum of axial spondyloarthritis (axSpA). The emergence of the nr-axSpA concept, defined by the absence of significant erosive damage to the sacroiliac joints, has prompted numerous initiatives aimed at enhancing the early detection and management of this condition. The aim of the study was to assess the knowledge, attitudes, and practices related to the diagnosis and management of nr-axSpA by rheumatologists in Morocco. Methods We conducted a cross-sectional online survey among the rheumatologist community in Morocco. Rheumatologists received via e-mail a structured Google Forms (Google Inc., Mountainview, CA) questionnaire divided into four sections: sociodemographic data of rheumatologists, knowledge, attitudes, and practices related to the diagnosis and treatment management of nr-axSpA. Results A total of 110 rheumatologists (mean age of 44±13 years, 77.3% females, median professional experience of 12 years (4, 75; 26.25 years)) participated in the survey (response rate of 25%). Most responders reported a diagnosis delay issue in spondyloarthritis(SpA) (93.6%); 70.9% of rheumatologists incorrectly regarded the 2009 Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axSpA as diagnostic criteria. Rheumatologists' awareness of recommended magnetic resonance imaging (MRI) sequences for detecting sacroiliac joint inflammation and structural changes in SpA varied significantly, from 69.1% to 14.5%. Their knowledge of additional subchondral edema cases in these joints, beyond SpA, ranged from 48.2% to 87.3%. Almost all rheumatologists believed that the use of sacroiliac MRI would contribute to the early diagnosis of axSpA (97.3%) but could also lead to false positive diagnoses, according to 47.3% of rheumatologists; 73.6% believed that incorrectly using the 2009 ASAS classification criteria as diagnostic criteria in nr-axSpA could also result in false-positive diagnoses. In their practice, 2009 ASAS classification criteria were used as diagnostic criteria in axSpA by 39.1% of rheumatologists. Of the total participants, 91.8% indicated that they approach nr-axSpA similarly to radiographic axial spondyloarthritis, with disparities in recommendations of biological therapies. Conclusion Our survey provides insight into the current status of nr-axSpA management among Moroccan rheumatologists. It also addresses concerns regarding the risk of false positive diagnoses when using the 2009 ASAS classification criteria for axSpA as diagnostic criteria by rheumatologists and the potential risk of misdiagnosis associated with excessive reliance on MRI, despite its utility for early diagnosis.

Diagnosis and classification of axial spondyloarthritis (axSpA) - the current status

Axial spondyloarthritis (axSpA) is an inflammatory rheumatic disease typically characterized by inflammatory back pain (IBP). The term axSpA has largely replaced the long-used term ankylosing spondylitis (AS). IBP is caused by inflammation in the axial skeleton, with the sacroiliac joints (SIJ) being particularly frequently affected initially. The spine is usually added in later stages, which is then increasingly characterized structurally by the formation of new bone. The overall concept of spondyloarthritis includes other disease manifestations such as uveitis, psoriasis and colitis and comorbidities such as cardiovascular disease and osteoporosis.The ASAS classification criteria for axSpA, in place since 2009, have replaced the 1984 modified New York criteria. In the former, in addition to conventional X-rays, changes in the SIJ detected by magnetic resonance imaging (MRI) and also the detection of HLA B27 have, for the first time, played a role. It is important to note that these are not diagnostic criteria, as they do not exist. This paper outlines 10 points that should be considered when making a diagnosis.

Artificial intelligence for the detection of sacroiliitis on magnetic resonance imaging in patients with axial spondyloarthritis.

Magnetic resonance imaging (MRI) is important for the early detection of axial spondyloarthritis (axSpA). We developed an artificial intelligence (AI) model for detecting sacroiliitis in patients with axSpA using MRI. This study included MRI examinations of patients who underwent semi-coronal MRI scans of the sacroiliac joints owing to chronic back pain with short tau inversion recovery (STIR) sequences between January 2010 and December 2021. Sacroiliitis was defined as a positive MRI finding according to the ASAS classification criteria for axSpA. We developed a two-stage framework. First, the Faster R-CNN network extracted regions of interest (ROIs) to localize the sacroiliac joints. Maximum intensity projection (MIP) of three consecutive slices was used to mimic the reading of two adjacent slices. Second, the VGG-19 network determined the presence of sacroiliitis in localized ROIs. We augmented the positive dataset six-fold. The sacroiliitis classification performance was measured using the sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). The prediction models were evaluated using three-round three-fold cross-validation. A total of 296 participants with 4,746 MRI slices were included in the study. Sacroiliitis was identified in 864 MRI slices of 119 participants. The mean sensitivity, specificity, and AUROC for the detection of sacroiliitis were 0.725 (95% CI, 0.705-0.745), 0.936 (95% CI, 0.924-0.947), and 0.830 (95%CI, 0.792-0.868), respectively, at the image level and 0.947 (95% CI, 0.912-0.982), 0.691 (95% CI, 0.603-0.779), and 0.816 (95% CI, 0.776-0.856), respectively, at the patient level. In the original model, without using MIP and dataset augmentation, the mean sensitivity, specificity, and AUROC were 0.517 (95% CI, 0.493-0.780), 0.944 (95% CI, 0.933-0.955), and 0.731 (95% CI, 0.681-0.780), respectively, at the image level and 0.806 (95% CI, 0.729-0.883), 0.617 (95% CI, 0.523-0.711), and 0.711 (95% CI, 0.660-0.763), respectively, at the patient level. The performance was improved by MIP techniques and data augmentation. An AI model was developed for the detection of sacroiliitis using MRI, compatible with the ASAS criteria for axSpA, with the potential to aid MRI application in a wider clinical setting.

When to start secukinumab treatment in patients with axial spondyloarthropathy: Before or after anti-TNFα treatment?

Introduction and objectivesThis study aimed to evaluate the efficacy of secukinumab (SEC) in axial spondyloarthropathy (axSpA) in anti-TNFα naïve and anti-TNFα experienced patients. It also focused on the duration of SEC treatment and its side effects. Patients and methodsThe patients with axSpA treated with SEC and followed up in our outpatient clinic from May 2018 through October 2021 were included in this study. All patients in the study also fulfilled the ASAS classification criteria for axSpA. Patients were separated into two groups according to whether they received prior anti-TNFα therapy. While anti-TNFα naïve patients comprised group 1, anti-TNFα experienced patients were included in group 2. Pre- and post-treatment BASDAI scores were reported and compared. ResultsEighty-four axSpA patients (42 men; duration of the disease: 86.86±65.35 months in group 1 and 160.65±97.4 months in group 2) were treated with SEC. 45.5% of anti-TNFα naïve patients and 56.5% of anti-TNFα experienced patients were still on SEC therapy in October 2021. Duration of SEC treatment was 12.5±7.9 months in group 1 and 17.19±12 months in group 2 (p=0.098). The differences between pre-and post-treatment BASDAI scores were statistically significant in both groups (p<0.001). While patients in group 1 did not develop any adverse effects, three patients in group 2 experienced alopecia, uveitis, and recurrent pneumonia after SEC treatment. ConclusionOur study's efficacy and safety data on the use of SEC were reassuring in both anti-TNFα naïve and anti-TNFα experienced patients. However, further studies are still needed to determine the appropriate timing to begin SEC treatment.

Axial Pain and Arthritis in Diagnosed Inflammatory Bowel Disease: US National Health and Nutrition Examination Survey Data

ObjectiveTo estimate the nationally representative prevalence of chronic axial pain, inflammatory back pain (IBP), axial spondyloarthritis (axSpA), and peripheral arthritis in persons diagnosed with inflammatory bowel disease (IBD). Patients and MethodsUS National Health and Nutrition Examination Survey (NHANES) data from the 1976-1980 and 2009-2010 survey cycles. ResultsIn NHANES 1976-1980, the chronic axial pain prevalence in participants with diagnosed ulcerative colitis (UC) was 19.5% vs 7.2% in the general population (P<.01). Neck or upper back, lower back, and Amor criteria-based axial pain were also significantly increased (11.2%, 14.5%, and 13.0%, respectively, vs 3%-5% in the general population (P<.01). In those with diagnosed UC, 40% had axial pain onset at an age older than 45 years; 30.2% reported peripheral arthralgias, and 12.2% reported peripheral arthritis. Arthritis findings on examination were uncommon. In NHANES 2009-2010, axial pain in those diagnosed with IBD had similar patterns. ConclusionDespite high rates of chronic axial pain in those with IBD, few cases met the IBP and axSpA classification criteria. This apparent discrepancy is unexplained. However, in IBD, axial pain onset at an age older than 45 years is common; and these may not meet IBP and axSpA age criteria. Also, neck pain was increased in those with IBD but is not included in most IBP and axSpA criteria. Peripheral arthralgias and chronic arthritis symptoms were common, but examination findings were not, suggesting that tenosynovitis or enthesitis is more likely than frank arthritis to occur in patients with UC.

OP0149 RADIOGRAPHIC PROGRESSION FROM NON-RADIOGRAPHIC TO RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: RESULTS FROM A 5-YEAR MULTICOUNTRY PROSPECTIVE OBSERVATIONAL STUDY

BackgroundPatients (pts) with axial spondyloarthritis (axSpA) are classified into radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA) based on the presence or absence of radiographic sacroiliitis. Approximately 20% to 80% of newly diagnosed axSpA pts have nr-axSpA and 8% to 40% progress to r-axSpA over the next 2 to 10 years.ObjectivesTo evaluate progression from nr-axSpA to r-axSpA over 5 years in a prospective multicentre cohort.MethodsPROOF was a global, real-world, prospective, observational study conducted in rheumatology clinical practices in 29 countries across 6 different geographic regions.1 The study enrolled adults with chronic back pain for ≥3 months and onset before 45 years of age. This analysis included pts diagnosed with axSpA who also fulfilled the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA. Study visits occurred at baseline (BL) and yearly thereafter. Baseline and follow-up radiographs of sacroiliac joints (SIJ) were evaluated for pts with initial nr-axSpA diagnosis independently by 2 central readers according to the modified New York criteria. In the case of disagreement on the classification (nr- or r-axSpA), images were adjudicated by a third reader. Radiographic progression from nr-axSpA to r-axSpA over 5 years was evaluated by Kaplan-Meier analysis. Cox proportional hazards regression analyses for time to radiographic progression from nr-axSpA to r-axSpA were conducted. For model 1, ‘imaging arm vs clinical arm’ was used as an independent variable, and for model 2, ‘active inflammation on magnetic resonance imaging highly suggestive of sacroiliitis associated with SpA’ was used. Further, potential predictive factors included in the models were age, gender, back pain duration, number of SpA parameters, smoking status, CRP, good response to NSAIDs, HLA-B27 status, and current use of NSAIDs and TNF inhibitors.ResultsAmong 2633 enrolled pts, 2165 (82%) were diagnosed with axSpA and fulfilled the ASAS classification criteria. Among these, 1612 (74%) were classified as having r-axSpA (1050 [65%]) or nr-axSpA (562 [35%]) by central reading. The majority of nr-axSpA pts (77%) fulfilled the ASAS classification criteria due to positive findings on imaging (plus ≥1 SpA feature) and 23% were classified according to the clinical arm. A total of 246 nr-axSpA pts who had ≥1 follow-up SIJ radiograph were included in this analysis. Among these 246 pts, progression from initial nr-axSpA to r-axSpA at any of the follow-up visits was observed in 40 pts (16%) over 5 years. Mean time to radiographic progression was 2.4 years (ranging from 0.9 to 5.1 years) in descriptive analysis (Kaplan-Meier curve shown in Figure 1). In model 1 of the Cox regression analysis, male gender (hazard ratio [HR]: 3.16 [95% CI: 1.22–8.17]; P=0.0174), fulfilment of the imaging arm (HR: 6.64 [1.37–32.25]; P=0.0188), and good response to NSAIDs, (HR: 4.66 [1.23–17.71]; P=0.0237), were significantly associated with progression to r-axSpA (Figure 1). In model 2, HLA-B27 positivity showed a significant association with progression (HR: 3.99 [1.10–14.49]; P=0.0353; Figure 1).ConclusionIn this study, 16% of nr-axSpA pts progressed to r-axSpA within 5 years. The mean time to disease progression was 2.4 years. Predictors of radiographic progression were male gender, good response to NSAIDs, and fulfilment of the imaging arm as well as HLA-B27 positivity.

AB0789 What drives the BASDAI in pregnant patients with axial spondyloarthritis? A pooled analysis of four European pregnancy registries.

BackgroundThe patient reported Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) includes the six components fatigue, neck, back or hip pain, pain or swelling in other joints, tenderness, morning stiffness severity and duration on a 0-10 scale.ObjectivesTo explore the driving factors for the BASDAI in pregnant patients with axial spondyloarthritis (axSpA).MethodsAnonymized pooled data of the European Network of Pregnancy Registries in Rheumatology (EuNeP) were used. The four participating registries are located in France, Germany, Norway and Switzerland, and collect data of women with child wish, during and after pregnancy prospectively and nationwide on regular time points. For the analysis, women who fulfilled ASAS classification criteria for axSpA and for whom a pregnancy outcome was reported until 12/2019 or 07/2020, depending on the registry, were selected. Mean BASDAI and its components were analysed descriptively.ResultsA total of 332 pregnancies from 304 women with axSpA were eligible. The Norwegian registry contributed half of the pregnancies (50.3%), followed by Germany (26.2%), France (15.4%) and Switzerland (8.1%). Mean maternal age was 31 years, the average disease duration 5 years.Mean BASDAI was 3.0 before conception, 3.4, 3.4 and 3.5 in the 1st, 2nd and 3rd trimester, and 3.4 within 6 months postpartum. The figure shows mean values of the BASDAI and its individual components in the different time periods. Fatigue was higher than the mean score during all phases, and especially elevated in the 1st and 3rd trimester. Furthermore, values for neck, back or hip pain were higher than the mean score, especially from 2nd trimester on. All other components were lower than the mean score.Data were not reported for all pregnancies and all time periods. Availability was highest in the 2nd and 3rd trimester with reported BASDAI in 60% and 62% of the pregnancies, respectively. Lowest reporting was 24% in the preconception period because only a part of the women was also observed before pregnancy.ConclusionThe BASDAI is a validated instrument for assessing disease activity in patients with axSpA. Since the calculation of the score also includes factors that can be influenced by pregnancy, it may only be of limited value for measuring disease activity in pregnancy. This analysis shows that mainly fatigue and back pain in particular have an impact on the mean BASDAI. A limitation of this analysis is that data were not available for all measured time points of the individual pregnancies. Therefore, the results should be confirmed by other studies.Figure 1.Means of BASDAI components before, during and after pregnancy (the table presents means ± standard deviation).AcknowledgementsThis work was supported by a research grant from FOREUM Foundation for Research in Rheumatology.Disclosure of InterestsYvette Meissner Speakers bureau: Pfizer, Anna Moltó Consultant of: UCB and BioGen, Grant/research support from: UCB, Nathalie Costedoat-Chalumeau Grant/research support from: to my institution (UCB), Rebecca Fischer-Betz: None declared, Frauke Förger Speakers bureau: UCB pharma, GSK, Consultant of: UCB pharma, GSK, Roche, Grant/research support from: UCB pharma, GSK, Marianne Wallenius: None declared, Anja Strangfeld Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, Pfizer, Roche, Sanofi, UCB.

Aksiyel Spondiloartrit, Sistemik Lupus Eritematozus, Sjögren Sendromu ve Sekonder Antifosfolipid Sendromunun Birlikte Görüldüğü Olgu Sunumu

Hereby we report a 55-year-old female patient having the association of non-radiographic axial spondyloarthritis (nr-AxSpA), systemic lupus erythematosus (SLE), secondary antiphospholipid antibody syndrome (APS), and Sjögren's Syndrome (SjS). Diagnosis of nr-AxSpA was made based upon the presence inflammatory low-back pain, human leukocyte antigen B27 positivity, and presence of sacroiliitis only in magnetic resonance imaging (MRI). SLE was diagnosed with butterfly-shaped rash on her cheeks, inflammatory arthritis, photosensitivity, erythema involving dorsal inter-joint area of hand fingers, alopecia together with antinuclear antibody (ANA) and anti-dsDNA positivity, low serum complement levels, leucopenia and thrombocytopenia. Additional presence of sicca symptoms, low Schirmer I test, anti SSA/Ro and anti-SSB/La positivity, supported by positive labial salivary gland biopsy led to the diagnosis of SjS. Furthermore, this patient also had miscarriage at 16th week and cerebral vascular disease at 33 years. Besides, IgG and IgM anticardiolipin antibodies were found to be positive twice. Therefore, she was also diagnosed as secondary APS. She fulfilled the relevant classification criteria for AxSpA, SLE, SjS and APS. To our knowledge, this is the first case report showing the association of these four diseases, with different genetic, etiopathogenetic and clinical systemic inflammatory diseases.

The Prevalence of MRI-Defined Sacroiliitis and Classification of Spondyloarthritis in Patients with Acute Anterior Uveitis: A Longitudinal Single-Centre Cohort Study.

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.

Characterising axial psoriatic arthritis: correlation between whole spine MRI abnormalities and clinical, laboratory and radiographic findings

ObjectiveTo describe the prevalence of inflammatory and structural lesions using whole spine MRI in patients with psoriatic disease, and to assess their correlation with clinical features and with axial spondyloarthritis...

Factors Associated With Diagnostic Delay of Axial Spondyloarthritis in Colombian Patients.

The diagnostic delay of axial spondyloarthritis (axSpA) is globally reported to be between 3 and 11 years. Early diagnosis and treatment have long-term benefits for patients and the health care system. Several international studies have evaluated some factors associated with diagnostic delay, but there are no known studies in the Colombian population. This study assesses the factors associated with diagnostic delay of axSpA in a rheumatology center in Bogota, Colombia. This monocentric analytical cross-sectional study was done in a specialized rheumatology center. Patients who fulfilled the 2009 Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axSpA were included. Information was obtained from medical records and a phone call. Bivariate and multivariate analyses were done to assess the associated factors with diagnostic delay. One hundred one patients were included, 54 were women (53.5%). The median diagnostic delay was 2 years (interquartile range, 1-7). The bivariate analysis showed that a younger age at diagnosis (p = 0.042) and previous diagnosis of lumbar degenerative disease (p = 0.029) were associated with a longer diagnostic delay. The logistical regression showed that previous lumbar degenerative disc disease (odds ratio, 2.8; 95% confidence interval, 1.09-7.53) and fibromyalgia (odds ratio, 4.0; 95% confidence interval, 1.2-13.1) diagnosis were both associated with a longer diagnostic delay. Factors associated with a longer diagnostic delay were previous diagnosis of lumbar degenerative disc disease and fibromyalgia. Additional studies are needed so that the reasons for diagnostic delay are understood and early diagnosis and management of axSpA are enabled.

Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study.

Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5-14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown. To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care. Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques. Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness. Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

AB0669 DEPRESSION AND ANXIETY MIGHT NOT BE INCREASED DURING COVID-19 PANDEMIC IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:Anxiety and depression are most common psychiatric disorders in chronic inflammatory rheumatic condition as well as axial spondyloarthritis (axSpA) (1). The prevalence of depression has been reported as 11-64% depending on the criteria used. Also self-reported depression and anxiety were found to be associated with disease activity and function in axSpA (1,2). It is observed that mental health is affected among healthy subjects during the COVID-19 pandemic, but this condition has not been systematically reviewed in axSpA patients.Objectives:We aimed to compare frequency of self-reported depression and anxiety before and during the Covid-19 pandemic in patients with axSpA.Methods:Seventy-six axSpA patients who were evaluated for the presence of depression and anxiety by using Hospital Anxiety and Depression scale (HADs) before pandemic were included in this study. All participants were classified according to the ASAS axSpA classification criteria. Patients were contacted by phone to participate and complete the HADS questionnaire. Demographic and disease related characteristics including BASDAI, BASFI and Patient Acceptable Symptom State (PASS) were recorded during interview. The HADs cut off value was taken as &gt;7 in both groups to define the presence of anxiety or depression. Before and during pandemic period anxiety and depression scores were statistically compared.Results:The demographic and disease related characteristics of axSpA patients with and without anxiety/depression were summarized in Table 1. The frequency of anxiety (43.4% vs %43.4; p&gt;0.05) and depression (46.1% vs 44.7%; p&gt;0.05) were found to be similar before and during pandemic period. Patients with anxiety (HADs&gt;7) and depression (HADs&gt;7) had higher BASDAI and BASFI scores and much less PASS positivity (Table 1). Although the frequency of depression was similar between before and during the pandemic period, symptom severity in depression was slightly increased during the pandemic (Figure 1).Table 1.Patients’ demographics and characteristics according to the presence of anxiety and depressionVariablesPresence of depressionn:35Absence of depressionn:41PPresence of anxiety n:33Absence of anxiety n:43PAge (years) mean ± SD41.8±11.244.1±9.3&gt;0.0542.0±10.943.6±10.0&gt;0.05Male n(%)21(60.0)26(63.4)&gt;0.0518(54.5)29(67.4)&gt;0.05Education time (years) mean ± SD9.6±4.811.0±4.2&gt;0.059.7±5.010.6±4.1&gt;0.05Current smoker n(%)18(51.4)15(36.6)&gt;0.0515(45.5)18(41.9)&gt;0.05Alcohol consumption n(%)12(34.3)12(29.3)&gt;0.0510(30.3)14(32.6)&gt;0.05Current BMI kg/m2 mean ± SD26.0±4.826.8±4.5&gt;0.0526.4±5.026.5±4.3&gt;0.05Sleep time (hours) mean ± SD7.6±1.77.6±1.3&gt;0.057.5±1.67.7±1.4&gt;0.05Current BASDAI mean ± SD2.5±1.61.4±1.6&lt;0.052.7±1.81.3±1.3&lt;0.001Current BASFI mean ± SD2.4±2.11.1±1.3&lt;0.052.4±2.01.2±1.4&lt;0.05PASS positivity n(%)16(45.7)29(70.7)&lt;0.0514(42.4)31(72.1)&lt;0.05Current depression and anxiety scores were correlated with disease activity (HADs Depression vs BASDAI r:0.530, p&lt;0.001; HADs Anxiety vs BASDAI r:0.500, p&lt;0.001) and function (HADs-Depression vs BASFI r:0.519, p&lt;0.001; HADs-Anxiety vs BASFI r:0.391, p&lt;0.001). These relationships were also observed in the pre-pandemic period (HADs-Depression vs BASFI r:0.326, p&lt;0.05; HADs-Anxiety vs BASDAI r:0.342, p&lt;0.05).Conclusion:Depression and anxiety symptoms seems to be comparable before and after the COVID-19 pandemic. Regardless of this period, the presence of both depression and anxiety are associated with disease activity, function and less patient acceptable symptom state.

Performance of Different Criteria Sets for Inflammatory Back Pain in Radiographic and Nonradiographic Axial Spondyloarthritis

Introduction: It is important to recognise inflammatory back pain (IBP) for early diagnosis of ankylosing spondylitis (AS). The aims of this study were to develop a valid, reliable Bengali IBP tool and to assess the performance of different IBP criteria sets, including Calin, Berlin set 8a and 7b, and new Assessment of SpondyloArthritis International Society (ASAS) expert criteria, in radiographic axial spondyloarthritis (axSpA) and nonradiographic axSpA. Method: This case-control study was performed in three phases. The first phase involved development of an IBP tool by adding the fifth parameter of ASAS expert criteria to the National Health and Nutrition Examination Survey (NHANES) 2009–2010 arthritis questionnaires; the second phase assessed reliability by test-retest statistics among 87 participants at a 5-day interval. Finally, according to the imaging arm of ASAS axSpA classification criteria, 50 patients with axSpA were included as cases while 50 patients with chronic mechanical back pain (MBP) were included as a control. Results: The presence of IBP with SpA versus patients with MBP, detected by Calin criteria, were 76.0% versus 10.0%, by Berlin 8a were 72.0% versus 6.0%, by Berlin 7b were 58.0% versus 12.0%, and by ASAS were 64.0% versus 18.0%, respectively. Results suggested the Calin criteria set has the highest sensitivity (76.0%) and Berlin set 8a has the highest specificity (78.9%) in the differentiation of IBP from MBP. Conclusion: The performance of the new ASAS criteria was analogous to the other existing criteria sets. The highest positive likelihood ratio and odds ratio were found for Berlin set 8a criteria. The Berlin set 8a criteria can still be used in primary care practice at the first screening because of high sensitivity.

Predictive Value of Active Sacroiliitis in MRI for Flare Among Chinese Patients with Axial Spondyloarthritis in Remission.

IntroductionIn recent axSpAx patients with remission lasting at least 3 months and later followed-up monthly for a median of 8 months, we compared the predictive value of baseline MRI of sacroiliac joints and constructed a nomogram model for predicting flare.MethodsThis study included 251 patients with axial spondyloarthritis, according to the ASAS axSpA classification criteria, who achieved Low Disease Activity (ASDAS) and underwent MRI examination. A total of 144 patients from the First Affiliated Hospital of Xiamen University were used as the nomogram training set; 107 from the First Affiliated Hospital of Fujian Medical University were for external validation.ResultsThe median time of relapse was 8.705 months (95% CI 8.215–9.195) and 7.781 months (95% CI 7.075–8.486) for MRI-positive patients and 9.8 months (95% CI 9.273–10.474) for MRI negative patients, respectively. Both active sacroiliitis on MRI (HR 1.792, 95% CI 1.230–2.611) and anti-TNF-α treatments (HR 0.507, 95% CI 0.349–0.736) were significantly associated with disease flares. Gender, disease duration, HLA-B27, MRI, and anti-TNF-α treatment were selected as predictors of the nomogram. The areas under the ROC curve (AUROCs) of the 1-year remission probability in the training and validation groups were 0.71 and 0.729, respectively. Nomogram prediction models present better AUROCs, C-indices, and decision curve analysis cure than the clinical experience model.ConclusionsActive sacroiliitis in MRI requires weighting in order to estimate remission and disease flares, when axSpA patients achieve low disease activity. The simple nomogram might be able to discriminate and calibrate in clinical practice.Trial registrationClinicalTrials, NCT03425812, Registered 8 February 2018, https://clinicaltrials.govSupplementary InformationThe online version contains supplementary material available at 10.1007/s40744-021-00279-y.

Exploring the Prevalence and Factors Associated With Fatigue in Axial Spondyloarthritis in an Asian Cohort in Singapore.

Aim: To evaluate the prevalence of fatigue and the factors associated with fatigue among patients with axial spondyloarthritis (axSpA) within an Asian population.Method: We used the baseline data from a clinic registry in a tertiary referral center. All patients fulfilled the 2009 Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA. Severe fatigue was defined as Bath Ankylosing Spondylitis Disease Activity Index-fatigue (BASDAI-fatigue) ≥5/10 and vitality domain of Short Form-36 Health Survey (SF-36 VT) ≤10th percentile of the general population.Results: We included 262 consecutive patients with axSpA (79% men, 82.4% Chinese). The mean (standard deviation, SD) age and duration of disease were 41.7 (13.7) and 10.1 (8.3) years, respectively. 145 (55.3%) and 52 (31.1%) patients reported severe fatigue by the BASDAI-fatigue and SF-36 VT criteria, respectively. Patients with severe fatigue had worse scores across all disease activity assessments and disease impact measures compared to those without severe fatigue. Using principal component analyses, disease activity and impact were associated with BASDAI-fatigue, while disease activity and impact, and disease chronicity were associated with SF-36 VT. In the univariable analyses, all disease activity assessments and disease impact measures correlated with both BASDAI-fatigue and SF-36 VT. In the multivariable analyses, BASDAI-axial pain, BASFI, BAS-G, and ethnicity were associated with BASDAI-fatigue, while ASQoL and BASDAI-morning stiffness were associated with SF-36 VT.Conclusion: Fatigue is prevalent amongst patients with axSpA in Asia and is associated with disease activity, disease impact as well as patient related factors.

Axial spondyloarthritis: concept, construct, classification and implications for therapy.

The axial spondyloarthritis (axSpA) disease concept has undergone substantial change from when the entity ankylosing spondylitis was defined by the modified New York criteria in 1984. Developments in imaging, therapy and genetics have all contributed to changing the concept of axSpA from one of erosions in the sacroiliac joints to a spectrum of disease with and without changes evident on plain radiographs. Changes to the previously held concept and construct of the disease have also necessitated new classification criteria. The use of MRI, primarily of the sacroiliac joints, has substantially altered the diagnosis and differential diagnosis of axSpA. Manyin the axSpA community believe that the current classification criteria lack specificity, and the CLASSIC study is underway to examine this area. Although much about the evolving axSpA disease concept is universally agreed, there remains disagreement about operationalizing aspects of it, such as the requirement for the objective demonstration of axial inflammation for the classification of axSpA. New imaging technologies, biomarkers and genetics data will probably necessitate ongoing revision of axSpA classification criteria. Advances in our knowledge of the biology of axSpA will settle some differences in opinion as to how the disease concept is applied to the classification and diagnosis of patients.

Understanding the paradigm of non-radiographic axial spondyloarthritis.

The concept of axial spondyloarthritis (axSpA) encompasses both non-radiographic (nr-axSpA) and traditional radiographic axSpA (r-axSpA) forms. The former was conceived following the establishment of the ASAS classification criteria for axSpA, which for the first time included the use of magnetic resonance imaging of the sacroiliac joints. This facilitated the classification of patients with axSpA who did not present substantial structural damage. This conception of nr-axSpA revolutionized the classical understanding of axSpA opening new doors for research and broadening the scope of treatment to the entire spectrum of axSpA. In this sense, epidemiologic patterns of the disease were viewed anew, and early diagnosis became a primary objective in the management of the disease. However, despite these advances, this new axSpA subtype led to some concerns within the scientific community. These issues have been addressed by several studies that set out to clarify the concept of nr-axSpA. In this review, we summarize the findings of the most relevant studies including nr-axSpA and then discuss recent advances in understanding disease clinical patterns, burden of disease, and treatment effects. Current scientific research has shown subtle differences between nr-axSpA and r-axSpA. In the near future, these advances will allow for better management of individual patients across the axSpA spectrum.

Assessing rheumatologists' attitudes and utilization of classification criteria for ankylosing spondylitis and axial spondyloarthritis: a global effort.

This study aims to assess rheumatologists' perceptions, utilization patterns, and attitudes towards the modified New York (mNY) criteria for ankylosing spondylitis (AS) and Assessment of SpondyloArthritis International Society (ASAS) criteria for axial spondyloarthritis (axSpA). Members of the national rheumatology societies in five countries (United States of America (USA), Canada, India, Turkey, and Brazil) were invited to participate in a survey containing questions regarding rheumatologists' familiarity, and use of AS and axSpA classification criteria in daily practice, perceived specificity of spondyloarthritis features in making the diagnosis, patterns of imaging tests performed in daily practice, and their opinion about the need for modification of current classification criteria. The responses were analyzed by gender, age, years in practice, as well as by country of practice. Descriptive statistics, t test, and chi-square test were used for comparison of groups. Approximately 6% rheumatologists (478 out of 8021 professional association members) from five countries completed the survey. The country-specific response rates were Brazil 4%, USA 4.3%, India 11%, Canada 14%, and Turkey 29%, though the overall contributions from individual countries were USA 47%, India 14.9%, Brazil 13.8%, Turkey 12.8%, and Canada 8.8%. The mean age of respondents was 50years (± 11.8), 31% were females and 90% spent majority (> 75%) of their time in clinical practice. The mNY and ASAS criteria were regularly used in clinical practice by 44 and 66% of responders, respectively. Those reporting "always" using ASAS criteria were more likely to be women (p = 0.006), and within 5years of completing rheumatology training. Vast majority (74%) regarded Inflammatory Back Pain (IBP) as a specific feature for axSpA. Majority (50 and 60%, respectively) regarded uveitis and dactylitis as "very specific" features helping them make the diagnosis of axSpA, whereas heel enthesitis, peripheral inflammatory arthritis, and response to NSAIDs were considered "somewhat specific" by 50% of the responders. Less than half (47%) of the responders used the mNY grading for X-ray of SI joints. In the case of normal X-ray of SI joint, the use of MRI was more frequent than CT scan (83.6 vs. 10.9%) in assessing for sacroiliitis. If sacroiliitis was not seen on X-rays, the likelihood of ordering MRI was significantly higher among rheumatologists completing training within < 15years versus > 25years prior (90 vs. 75%, p = 0.007). Overall, 70% thought that ASAS criteria were adequately specific for clinical trials. However, 42% respondents still felt a need to modify ASAS classification criteria for axSpA. Also, 46% respondents felt that mNY criteria should be modified. In the absence of diagnostic criteria, majority of rheumatologists are using the classification criteria for diagnosis of axSpA. Though axSpA classification criteria are perceived to be specific for clinical trials, 40% rheumatologists feel the need to modify these criteria. Key Points • This study informs how rheumatologists in five countries spread over four different continents diagnose axSpA in clinical practice. • Since majority rheumatologists among survey respondents across the countries use ASAS criteria for diagnosis of axSpA, more specific criteria may be required to avoid overdiagnosis. • MRI is commonly used to rule out sacroiliitis in case of normal X-ray of sacroiliac joints.