Healthcare professionals' perceptions of working on lifestyle management for patients with early rheumatoid arthritis - a qualitative study.

AIM: To explore HPs' perceptions of working on lifestyle management for patients with early rheumatoid arthritis (RA). METHODS: In this qualitative study, individual interviews were conducted with 20 HPs. Qualitative content analysis was used, and three categories and six subcategories were identified. RESULTS: HPs' perceptions of working on lifestyle management for patients with early RA revealed a need for commitment from different levels. This included commitment from healthcare managers and organizations prioritizing work on lifestyle management and providing competence development for HPs. Commitment within the team regarding coordination of interdisciplinary teamwork and development of a structured lifestyle management approach, and commitment to involving patients in lifestyle management, by facilitating patient engagement and a person-centred approach. CONCLUSIONS: HPs' perceptions of working on lifestyle management for patients with early RA revealed that commitment from healthcare managers, organizations, and the interdisciplinary team was essential to facilitate collaboration, patient involvement, and a person-centred approach.

How good is the agreement between clinical diagnoses and classification criteria fulfilment in axial spondyloarthritis? Results from the SPARTAKUS cohort.

OBJECTIVES: To study the agreement between clinical axial spondyloarthritis (axSpA) diagnoses and fulfilment of the Assessment of SpondyloArthritis international Society (ASAS) axSpA and modified New York (mNY) classification criteria, and to compare disease/health status between axSpA subtypes. METHOD: Patients with prevalent, clinical axSpA attending a rheumatology clinic were enrolled in a cross-sectional study. Assessments included physical evaluation, laboratory testing, questionnaires, and appropriate imaging, allowing classification. Standard axSpA outcome measures were compared between patients fulfilling mNY/radiographic versus non-radiographic axSpA (r-axSpA/nr-axSpA) criteria. RESULTS: Of 239 consecutively included patients, 141 fulfilled ASAS r-axSpA and/or mNY criteria, while 57 fulfilled nr-axSpA criteria. The agreement between r-axSpA and mNY criteria fulfilment was 94%. The positive predictive value (PPV) of a clinical ankylosing spondylitis (AS) diagnosis for mNY criteria fulfilment was 71%; the PPV of an undifferentiated axSpA (u-axSpA) diagnosis for fulfilment of nr-axSpA criteria was 30% and 40% for mNY criteria. Patients with r-axSpA/AS were older, more often men, and had longer disease duration, more uveitis, and worse spinal mobility than nr-axSpA patients, who had more enthesitis and dactylitis. CONCLUSION: We found an overall good concordance between clinical axSpA diagnoses and classification criteria fulfilment, with 83% fulfilling ASAS axSpA and/or mNY criteria. Regarding axSpA subtypes, the concordance was weaker, and although the ICD-10 code for AS correctly identified patients meeting mNY criteria in 71% of cases, one-third of mNY-positive patients lacked an AS diagnosis. Moreover, clinical u-axSpA diagnoses could not serve as a proxy to identify nr-axSpA, highlighting the importance of thorough classification in research on axSpA subtypes.

Elevated fecal levels of the inflammatory biomarker calprotectin in early systemic sclerosis.

Knowledge on gastrointestinal manifestations in early systemic sclerosis (SSc) is limited. We have investigated gastrointestinal inflammation in SSc at the time of diagnosis using the inflammatory biomarker Fecal calprotectin (F-cal). Consecutive patients with suspected SSc were characterized in relation to the 2013 classification criteria for SSc and classified as SSc or SSc-like disease. F-cal levels were measured with a polyclonal ELISA (Calpro A/S, Lysaker, Norway) and levels above 50 µg/g were considered elevated. F-cal levels were compared to those of control subjects without rheumatic disease. Of 137 patients with suspected SSc, 92 were classified as SSc and 45 as SSc-like disease. Median (interquartile range) disease duration among the SSc participants was 2.5 (1.2, 4.6) years. A substantial proportion of participants classified as SSc (35/92, 38%) and SSc-like disease (14/45, 31%) exhibited elevated F-cal compared to the control group (3/41, 7.3%; p < 0.001 and p = 0.007, respectively). Elevated F-cal was associated with proton pump inhibitor usage (OR 7.14; 95% CI 2.56-29.93; p < 0.001). We conclude that elevated F-cal is present in a subgroup of patients with SSc at the time of diagnosis, suggesting that that GI inflammation may be present in this patient group early in the disease course. F-cal did not exhibit potential to differentiate SSc from SSc-like disease.

A combination of two or more unhealthy lifestyle factors is associated with impaired physical and mental health in patients with spondyloarthritis: a cross-sectional study.

BACKGROUND: There is increasing knowledge of how individual lifestyle factors affect patients with spondyloarthritis, while studies exploring the combination of unhealthy lifestyle factors are lacking. Thus, our aim was to study the frequency of two or more unhealthy lifestyle factors and their associations with physical and mental health in patients with spondyloarthritis (SpA). METHODS: A population-based postal survey involving questions on lifestyle factors was completed by 1793 patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), and undifferentiated spondyloarthritis (USpA). Self-reported physical activity, body mass index, and tobacco use were respectively dichotomized as "healthy" or "unhealthy", summarized for each patient and stratified into four groups (0-3; 0 = no unhealthy lifestyle factors). Group comparisons were performed with Chi-squared tests, and associations with physical and mental health outcomes were performed with analysis of covariance and logistic regression analysis. RESULTS: Out of 1426 patients (52% women) with complete information for all studied lifestyle factors, 43% reported ≥ two unhealthy lifestyle factors-more frequently patients with PsA (48%) than AS (39%) or USpA (38%)-and with no difference between women and men (p = 0.399). Two or more unhealthy lifestyle factors were associated with worse health-related quality of life, disease activity, physical function, pain, fatigue, anxiety, and depression, adjusted for age and SpA-subgroup. If an unhealthy level of physical activity was one of the two unhealthy lifestyle factors, patients reported worse health outcomes. CONCLUSION: Reporting two or more unhealthy lifestyle factors were associated with worse physical and mental health in patients with SpA. This highlights the need to screen for a combination of unhealthy lifestyle factors and offer individualized coordinated interventions, and tailored coaching to support behavioral change, in order to promote sustainable health.

Gut dysbiosis associated with worse disease activity and physical function in axial spondyloarthritis.

BACKGROUND: Based on clinical and genetic associations, axial spondyloarthritis (axSpA) and inflammatory bowel disease (IBD) are suspected to have a linked pathogenesis. Gut dysbiosis, intrinsic to IBD, has also been observed in axSpA. It is, however, not established to what degree gut dysbiosis is associated with axSpA disease severity. The objective of this study was to compare gut dysbiosis frequency between controls, non-radiographic axial spondyloarthritis (nr-axSpA), and ankylosing spondylitis (AS) patients and investigate whether gut dysbiosis is cross-sectionally associated with axSpA disease activity, physical function, mobility, or pain. METHODS: Gut dysbiosis was assessed by 16SrRNA analysis of feces from 44/88 nr-axSpA/AS patients (ASAS/mNY criteria) without inflammatory bowel disease (IBD) and 46 controls without IBD or rheumatic disease. The GA-map™ Dysbiosis Test was used, grading gut microbiota aberrations on a 1-5 scale, where ≥3 denotes dysbiosis. Proportions with dysbiosis were compared between the groups. Furthermore, standard axSpA measures of disease activity, function, mobility, and pain were compared between patients (nr-axSpA and AS combined) with and without dysbiosis, univariately, and adjusted for relevant confounders (ANCOVA). RESULTS: Gut dysbiosis was more frequent in AS than controls (36% versus 17%, p=0.023), while nr-axSpA (25% dysbiosis) did not differ significantly from either AS or controls. Univariately, most axSpA measures were significantly worse in patients with dysbiosis versus those without: ASDAS-CRP between-group difference 0.6 (95% CI 0.2-0.9); BASDAI 1.6 (0.8-2.4); evaluator's global disease activity assessment (Likert scale 0-4) 0.3 (0.1-0.5), BASFI 1.5 (0.6-2.4), and VAS pain (cm) 1.3 (0.4-2.2). Differences remained significant after adjustment for demographics, lifestyle factors, treatments, gut inflammation (fecal calprotectin ≥50 mg/kg), and gut symptoms, except for VAS pain. BASMI and CRP were not associated with dysbiosis. CONCLUSION: Gut dysbiosis, more frequent in AS patients than controls, is associated with worse axSpA disease activity and physical function, seemingly irrespective of both gut inflammation and treatments. This provides further evidence for an important link between disturbances in gastrointestinal homeostasis and axSpA.

Chronic Pain and Assessment of Pain Sensitivity in Patients With Axial Spondyloarthritis: Results From the SPARTAKUS Cohort.

OBJECTIVE: To study differences in pain reports between patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (nr-axSpA), and to assess how pain sensitivity measures associate with disease and health outcomes. METHODS: Consecutive patients with axial SpA (axSpA) were enrolled in the population-based SPARTAKUS cohort (2015-2017) and classified as AS (n = 120) or nr-axSpA (n = 55). Pain was assessed with questionnaires (intensity/duration/distribution) and computerized cuff pressure algometry to measure pain sensitivity (pain threshold/pain tolerance/temporal summation of pain). Linear regression models were used to compare pain measures between patients with AS and nr-axSpA, and to assess associations between pain sensitivity measures and disease and health outcomes. RESULTS: Of 175 patients with axSpA, 43% reported chronic widespread pain, with no significant differences in any questionnaire-derived or algometry-assessed pain measures between patients with AS and nr-axSpA. Lower pain tolerance was associated with longer symptom duration, worse Ankylosing Spondylitis Disease Activity Score using C-reactive protein (ASDAS-CRP), Bath Ankylosing Spondylitis Functional Index, and Bath Ankylosing Spondylitis Metrology Index (BASMI), more pain regions, unacceptable pain, worse Maastricht AS Enthesitis Score (MASES), fatigue, anxiety, and health-related quality of life. Further, lower pain threshold was associated with worse ASDAS-CRP and MASES, whereas higher temporal summation was associated with longer symptom duration, unacceptable pain, and worse BASMI. CONCLUSION: Chronic pain is common in axSpA, with no observed differences in any pain measures between patients with AS and nr-axSpA. Further, higher pain sensitivity is associated with having worse disease and health outcomes. The results indicate that patients with AS and nr-axSpA, in line with most clinical characteristics, have a similar pain burden, and they highlight large unmet needs regarding individualized pain management, regardless of axSpA subgroup.

Elevated faecal calprotectin is linked to worse disease status in axial spondyloarthritis: results from the SPARTAKUS cohort.

OBJECTIVES: To examine faecal calprotectin (F-calprotectin) levels and presence of anti-Saccharomyces cerevisiae antibodies (ASCA) and their associations with disease subtype and current status in axial SpA (axSpA). METHODS: F-calprotectin and ASCA in serum were compared between consecutive patients with a clinical axSpA diagnosis, classified as non-radiographic axSpA (nr-axSpA; n = 40) or AS (n = 90), and with healthy controls (n = 35). Furthermore, standard axSpA outcome measures were compared between axSpA patients (nr-axSpA and AS combined) with elevated vs normal F-calprotectin, ASCA IgA and IgG, respectively. RESULTS: Elevated F-calprotectin (⩾50 mg/kg) was observed in 27% of nr-axSpA patients, 38% of AS patients and 6% of controls. F-calprotectin was significantly higher in AS vs nr-axSpA [AS: geometric mean 41 (95% CI 32, 54) mg/kg; nr-axSpA: 24 (95% CI 16, 38) mg/kg; P = 0.037], and in each axSpA subtype vs controls. Overall, worse disease activity and physical function scores were observed among axSpA patients with elevated vs normal F-calprotectin levels, with significant differences regarding patient's visual analogue scale for global health, ASDAS using CRP, and BASFI (adjusted for age, sex, NSAID use, anti-rheumatic treatments, and CRP). ASCA titres and seropositivity (⩾10 U/ml) were similar in nr-axSpA (IgA/IgG-seropositivity: 8%/26%) and AS (7%/28%), and clinical outcome measures did not differ between patients with elevated vs normal ASCA IgA or IgG, respectively. Compared with controls (IgA/IgG-seropositivity: 0%/17%), ASCA IgA was significantly higher in both axSpA subtypes, and IgG was significantly higher in the AS group. CONCLUSION: In patients with axSpA, gut inflammation measured by elevated F-calprotectin is associated with worse disease activity and physical function, and may be a marker of more severe disease.

Prevalence of chronic widespread pain in a population-based cohort of patients with spondyloarthritis - a cross-sectional study.

BACKGROUND: Chronic pain, regional or widespread, is a frequent and multidimensional symptom in arthritis. There is still limited information on chronic pain in spondyloarthritis, which is important to recognize for adequate diagnosis and treatment. Our objective was to study differences in prevalence of chronic widespread pain in two spondyloarthritis subgroups: ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (USpA). METHODS: A population-based postal survey involving questions on the duration, distribution, and intensity of pain was answered by 940 patients with AS (ICD-10 M45.9) or USpA (ICD-10 M46.1-0, M46.8-9). The patients were categorized as having chronic widespread pain, chronic regional pain, or no chronic pain, and prevalence estimates for the pain groups were calculated, including age- and sex-adjusted prevalence. RESULTS: The prevalence of chronic widespread pain was 45.3% in AS vs. 49.3% in USpA, and that of chronic regional pain was 17.7% vs. 21.9% (p = 0.033). More women than men reported having chronic widespread pain (54.1% vs. 41.2%, p ≤ 0.001), while the sex distribution for chronic regional pain was equal. Reports of pain intensity were equal in AS and USpA, with no significant difference in pain intensity between women and men who had chronic regional pain or chronic widespread pain. In the multiple logistic regression analysis, chronic widespread pain was associated to female sex, being an ever-smoker, and having a higher body mass index, controlled for SpA subgroup and disease duration. CONCLUSIONS: The prevalence of chronic widespread pain in patients with AS and USpA is high, and with a female predominance, but with no difference in pain intensity between women and men. Chronic pain can complicate the clinical evaluation in patients with SpA, and highlights the need for a thorough clinical examination, including evaluation of inflammation and an accurate pain analysis, to individualize non-pharmacological and pharmacological treatment decisions.

Spinal Mobility in Axial Spondyloarthritis: A Cross-Sectional Clinical Study.

OBJECTIVE: Research concerning spinal mobility in axial spondyloarthritis (axSpA) has focused on ankylosing spondylitis (AS), and data on the clinical diagnosis of undifferentiated spondyloarthritis (USpA) are limited. The objective was to study differences in spinal mobility between axSpA subgroups AS and USpA, including gender differences. METHODS: A total of 183 patients with axSpA from a rheumatology clinic were included in the study. The earliest recorded spinal mobility measures (cervical rotation/flexion/extension/lateral flexion, tragus-to-wall distance, vital capacity, chest expansion, thoracic flexion, thoracolumbar flexion, lateral spinal flexion, lumbar flexion and intermalleolar distance) were obtained by specialized physiotherapists. Differences between subgroups were analysed using analysis of covariance, controlled for gender and disease duration. RESULTS: In the USpA group (n = 57), the mean [standard deviation (SD)] age was 41.6 (11.4) years, and disease duration was 13 (10.6) years, with 54% men. In the AS group (n = 126), the mean (SD) age was 48.4 (13.5) years, and disease duration 24.6 (13.3) years, with 77% men. Spinal mobility was less restricted in USpA versus AS patients (p ≤ 0.05), with a median (interquartile range) tragus-to-wall distance of 11 (10-12) cm versus 13 (11.3-18.5) cm; thoracolumbar flexion 9 (7-10) cm versus 6.5 (4-9) cm; lateral spinal flexion 29 (25-36) cm versus 21.3 (12-31) cm; lumbar flexion 4.5 (3.5-5.0) cm versus 3.5 (2.0-4.5) cm and intermalleolar distance 113 (102-121) cm versus 101 (86-114) cm. There were no differences between the subgroups in cervical mobility, vital capacity, chest expansion or thoracic flexion, and there were few gender differences, besides anthropometric measures. CONCLUSION: Patients with USpA and AS had similar cervical and chest mobility, while thoracic and lumbar mobility were more severely restricted in AS. There were few gender differences in either subgroup. Further studies, to understand the full impact of USpA on spinal mobility, are needed. Copyright © 2016 John Wiley & Sons, Ltd.