Review of phase 2/3 trials in polymyalgia rheumatica and giant cell arteritis.

INTRODUCTION: GCA (giant cell arteritis) and PMR (polymyalgia rheumatica) are two overlapping inflammatory rheumatic conditions that are seen exclusively in older adults, sharing some common features. GCA is a clinical syndrome characterized by inflammation of the medium and large arteries, with both cranial and extracranial symptoms. PMR is a clinical syndrome characterized by stiffness in the neck, shoulder, and pelvic girdle muscles. Both are associated with constitutional symptoms. AREAS COVERED: In this review, we assess the established and upcoming treatments for GCA and PMR. We review the current treatment landscape, completed trials, and upcoming trials in these conditions, to identify new and promising therapies. EXPERT OPINION: Early use of glucocorticoids (GC) remains integral to the immediate management of PMR and GCA but being aware of patient co-morbidities that may influence treatment toxicity is paramount. As such GC sparing agents are required in the treatment of PMR. Currently there are limited treatment options available for PMR and GCA, and significant unmet needs remain. Newer mechanisms of action, and hence therapeutic options being studied include CD4 T cell co-stimulation blockade, IL-17 inhibition, IL-12/23 inhibition, GM-CSF inhibition, IL-1ß inhibition, TNF-α antagonist and Jak inhibition, among others, which will be discussed in this review.

Embroidery Triboelectric Nanogenerator for Energy Harvesting.

Triboelectric nanogenerators (TENGs) are devices that efficiently transform mechanical energy into electrical energy by utilizing the triboelectric effect and electrostatic induction. Embroidery triboelectric nanogenerators (ETENGs) offer a distinct prospect to incorporate energy harvesting capabilities into textile-based products. This research work introduces an embroidered triboelectric nanogenerator that is made using polyester and nylon 66 yarn. The ETENG is developed by using different embroidery parameters and its characteristics are obtained using a specialized tapping and friction device. Nine ETENGs were made, each with different stitch lengths and line spacings for the polyester yarn. Friction and tapping tests were performed to assess the electrical outputs, which included measurements of short circuit current, open circuit voltage, and capacitor charging. One sample wearable embroidered energy harvester collected 307.5 µJ (24.8 V) of energy under a 1.5 Hz sliding motion over 300 s and 72 µJ (12 V) of energy through human walking over 120 s. Another ETENG sample generated 4.5 µJ (3 V) into a 1 µF capacitor using a tapping device with a 2 Hz frequency and a 50 mm separation distance over a duration of 520 s. Measurement of the current was also performed at different pressures to check the effect of pressure and validate the different options of the triboelectric/electrostatic characterization device. In summary, this research explains the influence of embroidery parameters on the performance of ETENG (Embroidery Triboelectric Nanogenerator) and provides valuable information for energy harvesting applications.

A Novel Homomorphic Approach for Preserving Privacy of Patient Data in Telemedicine.

Globally, the surge in disease and urgency in maintaining social distancing has reawakened the use of telemedicine/telehealth. Amid the global health crisis, the world adopted the culture of online consultancy. Thus, there is a need to revamp the conventional model of the telemedicine system as per the current challenges and requirements. Security and privacy of data are main aspects to be considered in this era. Data-driven organizations also require compliance with regulatory bodies, such as HIPAA, PHI, and GDPR. These regulatory compliance bodies must ensure user data privacy by implementing necessary security measures. Patients and doctors are now connected to the cloud to access medical records, e.g., voice recordings of clinical sessions. Voice data reside in the cloud and can be compromised. While searching voice data, a patient's critical data can be leaked, exposed to cloud service providers, and spoofed by hackers. Secure, searchable encryption is a requirement for telemedicine systems for secure voice and phoneme searching. This research proposes the secure searching of phonemes from audio recordings using fully homomorphic encryption over the cloud. It utilizes IBM's homomorphic encryption library (HElib) and achieves indistinguishability. Testing and implementation were done on audio datasets of different sizes while varying the security parameters. The analysis includes a thorough security analysis along with leakage profiling. The proposed scheme achieved higher levels of security and privacy, especially when the security parameters increased. However, in use cases where higher levels of security were not desirous, one may rely on a reduction in the security parameters.

Granular Data Access Control with a Patient-Centric Policy Update for Healthcare.

Healthcare is a multi-actor environment that requires independent actors to have a different view of the same data, hence leading to different access rights. Ciphertext Policy-Attribute-based Encryption (CP-ABE) provides a one-to-many access control mechanism by defining an attribute's policy over ciphertext. Although, all users satisfying the policy are given access to the same data, this limits its usage in the provision of hierarchical access control and in situations where different users/actors need to have granular access of the data. Moreover, most of the existing CP-ABE schemes either provide static access control or in certain cases the policy update is computationally intensive involving all non-revoked users to actively participate. Aiming to tackle both the challenges, this paper proposes a patient-centric multi message CP-ABE scheme with efficient policy update. Firstly, a general overview of the system architecture implementing the proposed access control mechanism is presented. Thereafter, for enforcing access control a concrete cryptographic construction is proposed and implemented/tested over the physiological data gathered from a healthcare sensor: shimmer sensor. The experiment results reveal that the proposed construction has constant computational cost in both encryption and decryption operations and generates constant size ciphertext for both the original policy and its update parameters. Moreover, the scheme is proven to be selectively secure in the random oracle model under the q-Bilinear Diffie Hellman Exponent (q-BDHE) assumption. Performance analysis of the scheme depicts promising results for practical real-world healthcare applications.

Digitalisation provisions for controlling depression in developing countries: Short review.

Depression is a global health issue which is associated with disability, absenteeism, decreased productivity and high suicide rates. It is the fourth most common cause of disability globally and by the year 2020 it will be the second leading cause of disease burden. In Pakistan, the prevalence of depression is 45.9%. A unique and promising method for addressing the issue is mobile health (m-health). It refers to the utilisation of mobile technology to support various aspects of healthcare. Electronic record, SMS, internet, wearable devices and mobile applications are some of the digitalisation approaches used to bridge the treatment gap in depression through assuring privacy of patients, improving accessibility, reducing taboos related to depression, save cost for patients and reduce hospital burden and consultation time; these will be accessible in remote areas as well. Therefore, this short review is aimed to highlight the m-health forecasting for controlling depression and positional use in developing countries.

Risk factors leading to pulmonary exacerbation in patients with cystic fibrosis: A systematic review.

OBJECTIVE: To ascertain major risk factors associated with pulmonary exacerbation and pulmonary function decline in cystic fibrosis. METHODS: The systematic review was conducted at Aga Khan University, Karachi, in September 2018, and comprised electronic search of PubMed, Ovid, Science Direct and Cumulative Index of Nursing and Allied Health Literature databases of studies conducted from January 1990 to September 2018 which were categorised into 3 sets; 1990-98, 1999-2007 and 2008-18. Studies included for review focussed on articles with pulmonary exacerbation as the health outcome indicator, and had diagnosis of cystic fibrosis as the inclusion criteria, while risk factors were the exposure terms used in the search process. References in bibliographies of the included studies were also systematically searched for relevant documents. RESULTS: Of the 60 studies obtained, 31(51.7%) were selected; 2(6.45%) from 1990-98, 7(22.58%) from 1999-2007 and 22(70.96%) from 2008-18. Overall, 17(54.83%) were cohort studies, 7(22.5%) were cross-sectional studies, 3(9.6%) were case-control studies, 3(9.6%) were randomised controlled trials and 1(3.2%) was systematic review and meta-analysis. In terms of major risk factors, genetic mutations were cited by 4(12.9%) studies, infections and inflammatory biomarkers by 15(48.4%), nutritional deficiencies by 9(29%) and geographical and socioeconomic status by 3(9.6%) studies. CONCLUSIONS: Early identification and recognition of risk factors associated with pulmonary exacerbation can have an explicit impact on its management, leading to decreased morbidity and mortality burden in cystic fibrosis cases.

Multicentre, randomised, open-label, parallel-group study evaluating the efficacy and safety of ixekizumab versus adalimumab in patients with psoriatic arthritis naïve to biological disease-modifying antirheumatic drug: final results by week 52.

OBJECTIVES: SPIRIT head-to-head (H2H) is a 52-week (Wk) trial comparing ixekizumab (IXE) with adalimumab (ADA) for simultaneous American College of Rheumatology (ACR)50 and Psoriasis Area and Severity Index (PASI)100 responses in 566 patients (distributed evenly across both groups) with psoriatic arthritis (PsA). IXE was superior to ADA for this primary end point at Wk24. We aimed to determine the final efficacy and safety results through Wk52 including a prespecified subgroup analysis of concomitant conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) use. METHODS: SPIRIT-H2H is a Wk52 multicentre, open-label, blinded-assessor study comparing IXE and ADA in bionaïve patients with PsA. Patients were randomised 1:1 to IXE or ADA with stratification by concomitant csDMARD use and presence of moderate-to-severe plaque psoriasis. Prespecified end points at Wk24 and Wk52 included musculoskeletal, psoriasis, quality-of life outcomes, subgroup analyses and safety. RESULTS: A significantly higher proportion of patients treated with IXE versus ADA simultaneously achieved ACR50 and PASI100 (39% vs 26%, p<0.001), PASI100 (64% vs 41%, p<0.001) at Wk52. Efficacy of IXE and ADA was similar at Wk52 for ACR50 (49.8% vs 49.8%, p=0.924), treat-to-target outcomes, enthesitis and dactylitis resolution. Responses to IXE were consistent irrespective of concomitant csDMARD use. Significantly more patients on IXE monotherapy versus ADA monotherapy had simultaneous ACR50 and PASI100 (38% vs 19%, p=0.007), and PASI100 responses (66% vs 35%, p<0.001) at Wk52. There were no new safety findings for IXE or ADA. CONCLUSIONS: IXE provided significantly greater simultaneous joint and skin improvement than ADA through Wk52 in bionaïve patients with PsA. IXE showed better efficacy on psoriasis and performed at least as well as ADA on musculoskeletal manifestations. IXE efficacy was consistent irrespective of concomitant csDMARD use. TRIAL REGISTRATION NUMBER: NCT03151551.

A head-to-head comparison of the efficacy and safety of ixekizumab and adalimumab in biological-naïve patients with active psoriatic arthritis: 24-week results of a randomised, open-label, blinded-assessor trial.

OBJECTIVES: To compare efficacy and safety of ixekizumab (IXE) to adalimumab (ADA) in biological disease-modifying antirheumatic drug-naïve patients with both active psoriatic arthritis (PsA) and skin disease and inadequate response to conventional synthetic disease-modifying antirheumatic drug (csDMARDs). METHODS: Patients with active PsA were randomised (1:1) to approved dosing of IXE or ADA in an open-label, head-to-head, blinded assessor clinical trial. The primary objective was to evaluate whether IXE was superior to ADA at week 24 for simultaneous achievement of a ≥50% improvement from baseline in the American College of Rheumatology criteria (ACR50) and a 100% improvement from baseline in the Psoriasis Area and Severity Index (PASI100). Major secondary objectives, also at week 24, were to evaluate whether IXE was: (1) non-inferior to ADA for achievement of ACR50 and (2) superior to ADA for PASI100 response. Additional PsA, skin, treat-to-target and quality-of-life outcome measures were assessed at week 24. RESULTS: The primary efficacy endpoint was met (IXE: 36%, ADA: 28%; p=0.036). IXE was non-inferior for ACR50 response (IXE: 51%, ADA: 47%; treatment difference: 3.9%) and superior for PASI100 response (IXE: 60%, ADA: 47%; p=0.001). IXE had greater response versus ADA in additional PsA, skin, nail, treat-to-target and quality-of-life outcomes. Serious adverse events were reported in 8.5% (ADA) and 3.5% (IXE) of patients. CONCLUSIONS: IXE was superior to ADA in achievement of simultaneous improvement of joint and skin disease (ACR50 and PASI100) in patients with PsA and inadequate response to csDMARDs. Safety and tolerability for both biologicals were aligned with established safety profiles.

Secukinumab provides sustained low rates of radiographic progression in psoriatic arthritis: 52-week results from a phase 3 study, FUTURE 5.

OBJECTIVE: To evaluate the effect of secukinumab on radiographic progression through 52 weeks in patients with PsA from the FUTURE 5 study. METHODS: Patients with active PsA, stratified by prior anti-TNF use (naïve or inadequate response), were randomized to s.c. secukinumab 300 mg load (300 mg), 150 mg load (150 mg), 150 mg no load regimens or placebo at baseline, at weeks 1, 2 and 3 and every 4 weeks starting at week 4. Radiographic progression was assessed by change in van der Heijde-modified total Sharp score (vdH-mTSS; mean of two readers). Statistical analysis used a linear mixed-effects model (random slope) at weeks 24 and 52, and observed data at week 52. Assessments at week 52 included additional efficacy endpoints (non-responders imputation and mixed-effects models for repeated measures) and safety. RESULTS: The majority (86.6%) of patients completed 52 weeks of treatment. The proportion of patients with no radiographic progression (change from baseline in vdH-mTSS ⩽0.5) was 91.8, 85.2 and 87.2% in 300, 150 and 150 mg no load groups, respectively, at week 52. The change in vdH-mTSS from baseline to week 52 using random slope [mean change (s.e.)] was -0.18 (0.17), 0.11 (0.18) and -0.20 (0.18) in 300, 150 and 150 mg no load groups, respectively; the corresponding observed data [mean change (s.d.)] was -0.09 (1.02), 0.13 (1.39) and 0.21 (1.15). Clinical efficacy endpoints were sustained, and no new or unexpected safety signals were reported through 52 weeks. CONCLUSION: Secukinumab 300 and 150 mg with or without s.c. loading regimen provided sustained low rates of radiographic progression through 52 weeks of treatment. TRIAL REGISTRATION: ClinicalTrials.gov, http://clinicaltrials.gov, NCT02404350.

Axial Spondyloarthritis: Overcoming the Barriers to Early Diagnosis-an Early Inflammatory Back Pain Service.

PURPOSE OF REVIEW: To discuss the challenges to early diagnosis of axial spondyloarthritis (axSpA) and present the impact an early inflammatory back pain service (EIBPS) had on diagnostic delay in the UK. RECENT FINDINGS: Diagnostic delay in axSpA varies greatly worldwide, and has continued in the UK at an average of 8.5 years. Education, public awareness, and accessibility to inflammatory back pain (IBP) pathways are some of the key barriers to achieving a prompt diagnosis. A recent national inquiry has highlighted insufficiencies in the availability of specialist axSpA services and limited provision of education and training to first contact practitioners and allied healthcare providers. We demonstrate diagnostic delay in axSpA can be successfully reduced to 3 years when an early inflammatory back pain service is embedded within a rheumatology department alongside a local educational and awareness campaign. Sharing these experiences and outcomes will enable other departments to engage in best practice and achieve similar results, facilitating a timely and accurate diagnosis.

Person Re-Identification Using Deep Modeling of Temporally Correlated Inertial Motion Patterns.

Person re-identification (re-ID) is among the essential components that play an integral role in constituting an automated surveillance environment. Majorly, the problem is tackled using data acquired from vision sensors using appearance-based features, which are strongly dependent on visual cues such as color, texture, etc., consequently limiting the precise re-identification of an individual. To overcome such strong dependence on visual features, many researchers have tackled the re-identification problem using human gait, which is believed to be unique and provide a distinctive biometric signature that is particularly suitable for re-ID in uncontrolled environments. However, image-based gait analysis often fails to extract quality measurements of an individual's motion patterns owing to problems related to variations in viewpoint, illumination (daylight), clothing, worn accessories, etc. To this end, in contrast to relying on image-based motion measurement, this paper demonstrates the potential to re-identify an individual using inertial measurements units (IMU) based on two common sensors, namely gyroscope and accelerometer. The experiment was carried out over data acquired using smartphones and wearable IMUs from a total of 86 randomly selected individuals including 49 males and 37 females between the ages of 17 and 72 years. The data signals were first segmented into single steps and strides, which were separately fed to train a sequential deep recurrent neural network to capture implicit arbitrary long-term temporal dependencies. The experimental setup was devised in a fashion to train the network on all the subjects using data related to half of the step and stride sequences only while the inference was performed on the remaining half for the purpose of re-identification. The obtained experimental results demonstrate the potential to reliably and accurately re-identify an individual based on one's inertial sensor data.

Determinants of occupational hazards knowledge and safety practices among textile workers in Karachi, Pakistan: a cross sectional study.

OBJECTIVE: To determine the factors associated with good knowledge and safe practices regarding occupational hazards among textile workers. METHODS: The cross-sectional study was conducted in Karachi from September 2015 to February 2016, and comprised male workers from seven textile mills. A 45-item structured questionnaire was developed and pretested in Urdu, the local language. One part of the questionnaire comprised 31 items related to good knowledge, and the other part comprised 14 items related to safe practices. Data was analysed using SPSS 19. RESULTS: Of the 300 subjects, 123(41%) were aged 18-27 years, 183(63%) were educated, 184(61.3%) worked more than eight hours daily, 170(57%) were employed in the weaving section and 164(55%) as machine operators. Besides, 231(77%) had good knowledge, and 62(21%) reported safe practices. Educated workers were more likely (p<0.05), and machine operators were less likely (p<0.05) to have good knowledge, while educated workers, those in the spinning section and those working less than 8-hours daily (p<0.05) were more likely to report safe practices. CONCLUSIONS: There was a high knowledge level, but a wide gap in adopting safety practices, which indicates need for focused interventions targeting high-risk workers and regulation of working hours.

Kangaroo mother care: opportunities and implications for rural Pakistan.

Neonatal mortality comprises 40% of total under-5 mortality, globally. Kangaroo mother care (KMC) is one of the most cost-effective interventions to reduce neonatal mortality. KMC does not require highend equipment, intensive care facilities or technical knowledge. A recent meta-analysis reported that KMC may reduce neonatal mortality in preterm and low birth weight neonates up to 36%. A review of enablers and barriers of KMC suggests that KMC can be integrated in maternal health care system by giving awareness, involving family and giving ownership of the intervention to the community. If supported with minimal incentives it would reduce the cost of health care substantially, reduce patient burden on hospitals by reducing hospital stay in postnatal period. It will reduce financial burden, time strain and help eliminate social taboos regarding preterm and low birth weight neonates. Hospital and community based KMC interventions should be tested in Pakistan .

Secukinumab improves active psoriatic arthritis symptoms and inhibits radiographic progression: primary results from the randomised, double-blind, phase III FUTURE 5 study.

OBJECTIVES: To evaluate the effect of subcutaneous (s.c.) secukinumab, an interleukin-17A inhibitor, on clinical signs and symptoms and radiographic progression in patients with psoriatic arthritis (PsA). METHODS: Adults (n=996) with active PsA were randomised 2:2:2:3 to s.c. secukinumab 300 mg or 150 mg with loading dose (LD), 150 mg without LD or placebo. All groups received secukinumab or placebo at baseline, weeks 1, 2 and 3 and then every 4 weeks from week 4. The primary endpoint was the proportion of patients achieving an American College of Rheumatology 20 (ACR20) response at week 16. RESULTS: Significantly more patients achieved an ACR20 response at week 16 with secukinumab 300 mg with LD (62.6%), 150 mg with LD (55.5%) or 150 mg without LD (59.5%) than placebo (27.4%) (p<0.0001 for all; non-responder imputation). Radiographic progression, as measured by van der Heijde-modified total Sharp score, was significantly inhibited at week 24 in all secukinumab arms versus placebo (p<0.01 for 300 mg with LD and 150 mg without LD and p<0.05 for 150 mg with LD; linear extrapolation). Adverse event rates at week 24 were similar across treatment arms: 63.1% (300 mg with LD), 62.7% (150 mg with LD), 61.1% (150 mg without LD) and 62.0% (placebo). No deaths or new safety signals were reported. CONCLUSION: S.c. secukinumab 300 mg and 150 mg with and without LD significantly improved clinical signs and symptoms and inhibited radiographic structural progression versus placebo at week 24 in patients with PsA. TRIAL REGISTRATION NUMBER: NCT02404350; Results.

Therapies in ankylosing spondylitis-from clinical trials to clinical practice.

Until recently, the therapeutic options for patients suffering from active AS comprised NSAIDs and TNF inhibitor therapy. Although these are effective in a significant proportion of patients, not all patients respond and some are intolerant to these therapies. Therefore, there is a clear unmet treatment need in AS patients. This article reviews the evidence for targets currently being studied in AS. This includes the IL-12/23 inhibitor ustekinumab, the pan-Janus kinase inhibitor tofacitinib and the anti-IL-17A antibody secukinumab.

Securing health sensing using integrated circuit metric.

Convergence of technologies from several domains of computing and healthcare have aided in the creation of devices that can help health professionals in monitoring their patients remotely. An increase in networked healthcare devices has resulted in incidents related to data theft, medical identity theft and insurance fraud. In this paper, we discuss the design and implementation of a secure lightweight wearable health sensing system. The proposed system is based on an emerging security technology called Integrated Circuit Metric (ICMetric) that extracts the inherent features of a device to generate a unique device identification. In this paper, we provide details of how the physical characteristics of a health sensor can be used for the generation of hardware "fingerprints". The obtained fingerprints are used to deliver security services like authentication, confidentiality, secure admission and symmetric key generation. The generated symmetric key is used to securely communicate the health records and data of the patient. Based on experimental results and the security analysis of the proposed scheme, it is apparent that the proposed system enables high levels of security for health monitoring in resource optimized manner.

Intra-articular hylastan versus steroid for knee osteoarthritis.

PURPOSE: To assess the efficacy and safety of one and two intra-articular (IA) injections of the new viscosupplement, hylastan, compared with a single IA corticosteroid injection for pain due to knee osteoarthritis (OA). Hylastan is a high-molecular-weight hyaluronan derivative prepared from bacterial fermented sodium hyaluronate that was developed to remain in the joint for longer than most other viscosupplements. METHODS: This 6-month, double-blind, randomized, parallel group, multicenter trial enrolled patients aged ≥40 years who met American College of Rheumatology criteria for knee OA and had continued pain despite conservative treatment. Patients were randomized 1:1:1 to one of three arms: 2 × 4 mL hylastan (n = 129; arthrocentesis then IA hylastan Day 0, same treatment Week 2); 1 × 4 mL hylastan (n = 130; arthrocentesis then IA hylastan Day 0, arthrocentesis only Week 2); steroid (n = 132; arthrocentesis then IA methylprednisolone acetate 40 mg Day 0, arthrocentesis only Week 2). Participants and evaluators were blinded to treatment. The primary clinical outcome measure was change from baseline in WOMAC A pain score over all postbaseline visits to Week 26. RESULTS: Statistically significant pain reduction was observed in all three arms, with similar mean (95 % CI) changes in WOMAC A: 2 × 4 mL hylastan -0.9 (-1.0, -0.7); 1 × 4 mL hylastan -0.8 (-0.9, -0.7); steroid -0.9 (-1.0, -0.8); all P < 0.0001 versus baseline. Changes in secondary outcomes (OMERACT-OARSI and WOMAC A responder rates, patient/clinical observer global assessments, and WOMAC A1 walking pain) were similar in all three arms. Target knee adverse events were comparable for all treatments. CONCLUSIONS: Both IA hylastan injection regimens were effective in relieving pain with an acceptable safety profile. IA hylastan did not show a difference versus IA corticosteroid; therefore, the hypothesis of superior pain relief was not met. Further research is needed to compare the efficacy and safety of hylastan with other viscosupplements.

A Survey Exploring Inflammatory Back Pain in Patients With Inflammatory Bowel Disease.

Background Diagnostic delay of axial spondyloarthritis (axSpA) is a widely recognized issue worldwide, providing a great burden for patients with this disease. AxSpA is present in a significant proportion of patients with inflammatory bowel disease (IBD). This UK study primarily aims to identify the presence of inflammatory back pain (IBP) in patients attending IBD clinic. Further aims of this study include investigating if participants had received further referrals and diagnoses for their IBP and considering factors contributing to diagnostic delay. Methods Patients were recruited from a Royal Free London NHS Trust hospital's IBD clinic. Each participant completed a 23-question survey. The Berlin criteria were applied to the questions to investigate the presence of IBP. Further questions were asked about their IBD diagnosis and treatment, the healthcare professionals they had seen for their back pain, and other extra-articular features associated with axSpA. Results Seventy-five patients completed the online survey sent out via email. Forty percent (n = 30) of participants were female and 60% (n = 45) were male. Sixty-one percent (n = 36) of participants from the colitis clinic reported they had back pain, and 41% of the participants reported back pain for over three months. Of these, 39% (12) of participants fulfilled the Berlin criteria for IBP. Of patients experiencing back pain for over three months, we found that 10% (3) fulfilled the Berlin criteria but had not received a diagnosis for their IBP. All patients who had fulfilled the Berlin criteria but had not received a diagnosis for their IBP had seen their general practitioner (GP) and an allied healthcare professional, but not a rheumatologist. Conclusions This study highlights the presence of possibly undiagnosed axSpA in patients with IBD. The reasons for the diagnostic delay of axSpA are multifactorial. We consider specific patient characteristics, lack of awareness and education of the condition, and issues in the referral process. There is a need to improve education and awareness of axSpA, reconsider referral processes, and consider new initiatives such as joint specialty clinics to identify and treat axSpA on time.