Validity and reliability of the ten-item Connor-Davidson Resilience Scale (CD-RISC10) instrument in patients with axial spondyloarthritis (axSpA) in Singapore.

We aimed to assess the validity and reliability of the ten-item Connor-Davidson Resilience Scale (CD-RISC10) in patients with axial spondyloarthritis (axSpA) in Singapore. We used cross-sectional data from 108 patients with axSpA recruited from a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2017 to 2018. Analyses were guided by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) framework. Face validity was assessed through cognitive debriefing interviews (CDIs). Internal consistency was assessed through Cronbach's alpha. Test-retest reliability was assessed through intraclass correlation (ICC). Measurement error was assessed through smallest detectable change (SDC). Construct validity was assessed through six a priori hypotheses through correlation of the CD-RISC10 score with other patient-reported outcome measures. Structural validity was assessed using confirmatory factor analysis (CFA). Fit indices evaluated were root-mean-square error of approximation (RMSEA), comparative fit index (CFI), Tucker-Lewis index (TFI), and standardized root-mean-squared residual (SRMR). Ten patients completed the CDIs and face validity was supported. Among 108 patients (median age: 37(21-77), 81.5% males, 93.5% Chinese), the CD-RISC10 demonstrated good internal consistency (Cronbach's alpha = 0.94), and excellent test-retest reliability [ICC = 0.964 (95% CI 0.937-0.980)]. SDC was calculated as 1.88. Construct validity was established by meeting five out of the six a priori hypotheses. Structural validity was supported as CFA confirmed a one-factor model, with adequate fit statistics after adding three covariances (RMSEA = 0.077; CFI = 0.975; TLI = 0.964; SRMR = 0.036). This study supports the CD-RISC10 as a valid and reliable measure of resilience for use in patients with axSpA.

Factors Associated With Initiation of Biologics in Patients With Axial Spondyloarthritis in an Urban Asian City: A PRESPOND Study.

OBJECTIVE: The aim of this study was to examine if patients' sociodemographic, clinical characteristics, and patient-reported outcomes were associated with biologics initiation in patients with axial spondyloarthritis in Singapore. METHODS: Data from a dedicated registry from a tertiary referral center in Singapore from January 2011 to July 2016 were used. Initiation of first biologics was the main outcome of interest. Logistic regression analyses were used to explore the association of various factors on biologics initiation. RESULTS: Of 189 eligible patients (aged 37.7 ± 13.3 years; 76.2% were males), 30 (15.9 %) were started on biologics during follow-up. In the multivariable analysis model, age (odds ratio [OR]; 0.93; 95% confidence interval [CI], 0.89-0.98; p < 0.01), mental component summary score of Short-Form 36 Health Survey (OR, 0.18; 95% CI, 0.03-0.89; p = 0.04), erythrocyte sedimentation rate (OR, 1.02; 95% CI, 1.00-1.04; p = 0.02), presence of peptic ulcer disease (OR, 10.4; 95% CI, 2.21-48.8; p < 0.01), and lack of good response to nonsteroidal anti-inflammatory drugs (OR, 4.44; 95% CI, 1.63-12.1; p < 0.01) were found to be associated with biologics initiation. CONCLUSIONS: Age, erythrocyte sedimentation rate, mental component summary score, comorbidities of peptic ulcer disease, and responsiveness to nonsteroidal anti-inflammatory drugs were associated with biologics initiation. It is essential that clinicians recognize these factors in order to optimize therapy.

The impact of axial spondyloarthritis on quality of life (QoL): a comparison with the impact of moderate to end-stage chronic kidney disease on QoL.

PURPOSE: The purpose of the study was to assess the impact of axial spondyloarthritis (axSpA) on patients' quality of life (QoL) compared to patients with moderate to end-stage chronic kidney disease (CKD). METHODS: We conducted secondary analysis of QoL data obtained from patients with axSpA and CKD from 2011 to 2014. QoL was assessed using the SF-36 version 2 and KDQoL-SF for patients with axSpA and CKD, respectively. Patients with CKD were subcategorized to CKD-pre-dialysis, hemodialysis (CKD-HD) and peritoneal dialysis (CKD-PD). Linear regression was used to compare QoL between patients with axSpA and CKD after adjusting for age, gender, ethnicity, education level, and marital status. RESULTS: A total of 765 patients (mean age 54.6, 63.0% males, 69.0% Chinese) were analyzed, of which 188 (24.5%) had axSpA. Patients with axSpA had poorer SF-36 bodily pain (BP) scores (axSpA: reference; CKD-pre-dialysis ß: 11.04, p < 0.001; CKD-HD ß: 9.52, p < 0.001; CKD-PD ß: 10.35, p < 0.001) and higher general health scores (axSpA: reference; CKD-pre-dialysis ß: - 7.87, p < 0.001; CKD-HD ß: - 7.14, p < 0.001, CKD-PD ß: - 7.25, p < 0.001) as compared to patients with CKD. Generally, patients with axSpA had poorer SF-36 scores than patients with CKD-pre-dialysis and similar SF-36 scores compared to patients with CKD-HD or CKD-PD. CONCLUSIONS: The burden of axSpA on QoL is not trivial and is comparable to patients with CKD-HD or CKD-PD.

Adaptation of Chinese and English versions of the Ankylosing Spondylitis quality of life (ASQoL) scale for use in Singapore.

BACKGROUND: To cross-culturally adapt and validate the Singapore Chinese and Singapore English versions of the Ankylosing Spondylitis Quality of Life (ASQoL) scales. METHODS: Translation of the ASQoL into Singapore Chinese and English was performed by professional and lay translation panels. Field-testing for face and content validity was performed by interviewing ten Chinese speaking and ten English speaking axial spondyloarthritis (AxSpA) patients. AxSpA patients (either Chinese or English speaking) were invited to take part in validation surveys. The Health Assessment Questionnaire (HAQ), Short Form Health Survey (SF-36), Bath Indices, and other measures of disease activity were used as comparator scales for convergent validity. A separate sample of AxSpA patients were invited to participate in a test-retest postal study, with 2 weeks between administrations. RESULTS: The cross-sectional study included 183 patients (77% males, 82% English speaking), with a mean (SD) age of 39.4 (13.7) years. The ASQoL had excellent internal consistency (Cronbach's alpha = 0.88), and correlated moderately with all the comparator scales. The ASQoL was able to distinguish between patients grouped by disease activity and perceived general health. The ASQoL fulfilled the Rasch model analysis for fit, reliability and unidimensionality requirements. No significant differential item functioning was noted for gender, age below or above 50 years, and language of administration. Test-retest reliability was good (r = 0.81). CONCLUSIONS: The ASQoL was adapted into Singapore Chinese and English language versions, and shown to be culturally relevant, valid and reliable when used with combined samples of AxSpA patients who speak either Chinese or English.

Validity and reliability of the Short Form 36 Health Surveys (SF-36) among patients with spondyloarthritis in Singapore.

The Short Form 36 Health Survey (SF-36) is a popular health-related quality of life (HrQoL) tool. However, few studies have assessed its psychometric properties in patients with spondyloarthritis (SpA). We therefore aimed to assess the reliability and validity of the SF-36 in patients with SpA in Singapore. Cross-sectional data from a registry of 196 SpA patients recruited from a dedicated tertiary referral clinic in Singapore from 2011 to 2014 was used. Analyses were guided by the COnsensus-based Standards for the selection of health Measurement INstruments framework. Internal consistency reliability was assessed using Cronbach's alpha. Construct validity was assessed through 33 a priori hypotheses by correlations of the eight subscales and two summary scores of SF-36 with other health outcomes. Known-group construct validity was assessed by comparison of the means of the subscales and summary scores of the SF-36 of SpA patients and the general population of Singapore using student's t tests. Among 196 patients (155 males (79.0 %), median (range) age: 36 (17-70), 166 Chinese (84.6 %)), SF-36 scales showed high internal consistency ranging from 0.88 to 0.90. Convergent construct validity was supported as shown by fulfillment of all hypotheses. Divergent construct validity was supported, as SF-36 MCS was not associated with PGA, pain and HAQ. Known-group construct validity showed SpA patients had lower scores of 3.8-12.5 when compared to the general population at p < 0.001. This study supports the SF-36 as a valid and reliable measure of HrQoL for use in patients with SpA at a single time point.

Validity and reliability of EQ-5D-5L among patients with axial spondyloarthritis in Singapore.

OBJECTIVE: This study aims to evaluate the reliability and validity of EuroQOL-5 Dimensions-5 Levels (EQ-5D-5L) among patients with axial spondyloarthritis (SpA) in Singapore. METHODS: A cross-sectional study was conducted involving patients with axial SpA in an Asian tertiary hospital from 2017 to 2018. This study followed the COnsensus-based Standards for selection of health Measurement Instruments framework. Construct validity was evaluated by testing 22 a priori hypotheses with other patient-reported outcomes measures. Cronbach's alpha was used to estimate the internal consistency of the EQ-5D-5L, while its test-retest reliability was assessed using weighted kappa and the intraclass correlation coefficient (ICC). The measurement error was assessed by analyzing minimal detectable change (MDC). RESULTS: The median age of included patients (n=118) was 35 years (interquartile range: 28, 49). Ninety-six (81.4%) patients were male, while 112 (94.9%) patients were of Chinese ethnicity. The EQ-5D-5L demonstrated good internal consistency with a Cronbach's alpha of 0.79. The test-retest reliability of the EQ-5D-5L was good with a weighted kappa of ≥0.61 for mobility, self-care, usual activities, and anxiety/depression; the ICC was 0.92 and 0.99 for the EQ-5D-5L index and visual analog scale (VAS) scores, respectively. The weighted kappa for the EQ-5D-5L pain/discomfort was moderate [0.53, 95% confidence interval: 0.41-0.60]. The MDC for EQ-5D-5L index and VAS scores was 0.06 and 4.5, respectively. Convergent validity was supported as all hypotheses were confirmed in the results. CONCLUSION: This study supports EQ-5D-5L as a valid and reliable instrument for assessing health-related quality of life among patients with axial SpA in Singapore.

Validity and reliability of Work Productivity and Activity Impairment among patients with axial spondyloarthritis in Singapore.

OBJECTIVES: To assess the validity and reliability of the Work Productivity and Activity Impairment (WPAI) questionnaire in patients with axSpA. METHODS: English-speaking patients seen at a dedicated axSpA clinic in a Singapore tertiary referral hospital were recruited from 2017 to 2019. Content validity of the WPAI was assessed through cognitive debriefing interviews (CDIs). Construct validity was assessed by a priori hypotheses regarding the correlations of the WPAI outcomes (absenteeism, presenteeism, overall work productivity loss, and activity impairment) with Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Patient Global Score (BAS-G), patient global assessment (PGA) and pain scores. Known group validity was assessed relative to disease activity. Test-retest reliability was assessed by intraclass correlation coefficients (ICC) in patients without treatment change 2 weeks apart. RESULTS: Cognitive debriefing interviews conducted with 10 patients (22-46 years old, 50% male) supported the content validity of the WPAI. We analyzed cross-sectional data from 168 patients (mean [SD] age 41.0 [14.4], 79.8% male). Construct validity was established by meeting 100% of the hypotheses. Presenteeism, overall work productivity loss, and activity impairment demonstrated strong correlations with BASFI, BAS-G, PGA, and pain (rs  > .6). The WPAI was able to distinguish patients grouped by disease activity. Test-retest reliability conducted with 50 patients ranged from moderate to good for all the four outcomes (absenteeism: ICC = 0.54; presenteeism: ICC = 0.76; activity impairment: ICC = 0.79; overall work productivity loss: ICC = 0.83; all P < .01). CONCLUSIONS: This study supports the content validity, construct validity, and test-retest reliability of the WPAI in patients with axSpA.

Singapore chapter of rheumatologists' updated consensus statement on the eligibility for government subsidization of biologic and targeted therapy for the treatment of psoriatic arthritis.

AIM: There have been major advances in biologic treatment options for psoriatic arthritis (PsA) since the publication of the 2015 consensus recommendations by the Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore, for government-assisted funding, thus warranting a revision of this guideline. METHODS: Recent trials and nine published guidelines on the use of biologic therapy for PsA were reviewed. Based on the synthesized evidence, a task force panel (TFP), consisting of 10 practicing rheumatologists in Singapore, rated the statements pertaining to the use of biologic therapy, using a modified Delphi approach. Consensus was obtained if >70% agreed on a statement. RESULTS: The TFP agreed on 10 recommendations pertaining to the initiation, choice and continuation of biologic therapy. A biologic is indicated in patients with PsA: (a) with at least three swollen and tender joints, digits or entheses; and (b) who have failed at least two conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) strategies for a minimum of 3 months each. Any approved drug class including tumor necrosis factor inhibitors, interleukin-17 inhibitors (IL-17i), IL-12/23i or targeted synthetic DMARDs may be considered as first-line treatment, and continued only if a response is achieved by 6 months. CONCLUSION: These recommendations developed through a formal consensus method may be useful to guide funding considerations for appropriate and equitable use of biologic therapy for eligible patients with PsA.

Update on recommendations for eligibility of government subsidization of biologic disease-modifying antirheumatic drugs for the treatment of axial spondyloarthritis in Singapore.

AIMS: The field of axial spondyloarthritis (axSpA) has undergone significant changes recently in particular with disease classification, assessment of disease activity and increased treatment options for biologics. In order to reflect these developments, we aimed to update the local consensus recommendations for subsidization of biologics. METHODS: A modified Delphi approach was used. Six published guidelines from major rheumatology societies and healthcare authorities on axSpA were reviewed. Findings were synthesized and used in formulating updated recommendation statements. Recommendations were rated by 10 practicing rheumatologists in Singapore. Consensus was reached if there was more than 70% agreement or disagreement. RESULTS: Ten statements achieved consensus. Patients may be considered for subsidization of biologic therapy if they fulfill the Assessment of Spondyloarthritis International Society or modified New York criteria, with persistently active disease (defined either by Ankylosing Spondylitis Disease Activity Score ≥ 2.1 or Bath Spondylitis Disease Activity Index ≥ 4), despite 4 weeks of full-dose non-steroidal anti-inflammatory drugs and regular exercise. Either tumor necrosis factor inhibitors or interleukin 17 inhibitors may be used as first-line therapy, and should be continued if adequate response is achieved at 6 months. CONCLUSION: Recommendation statements were formulated through a formal consensus process by local experts with a view to assist relevant authorities in funding considerations and for use in clinical practice.

Singapore Chapter of Rheumatologists updated consensus statement on the eligibility for government subsidization of biologic and targeted-synthetic therapy for the treatment of rheumatoid arthritis.

INTRODUCTION: Approximately 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional-synthetic disease-modifying anti-rheumatic drugs (csDMARDs). However, widespread use of biologic DMARDs (bDMARDs) and targeted-synthetic (tsDMARDs) is limited by cost. We formulated updated recommendations for eligibility criteria for government-assisted funding of bDMARDs/tsDMARDs for RA patients in Singapore. MATERIALS AND METHODS: Published guidelines regarding use of bDMARD and tsDMARDs were reviewed. We excluded those without a systematic literature review, formal consensus process or evidence grading. Separately, unpublished national reimbursement guidelines were included. RESULTS: Eleven recommendations regarding choice of disease activity measure, initiation, order of selection and continuation of bDMARD/tsDMARDs were formulated. A bDMARD/tsDMARD is indicated if a patient has: (a) at least moderately active RA with a Disease Activity Score in 28 joints/erythrocyte sedimentation rate (DAS28-ESR) score of ≥3.2; (b) failed ≥2 csDMARD strategies, 1 of which must be a combination; (c) received an adequate dose regimen of ≥3 months for each strategy. For the first-line bDMARD/tsDMARD, either tumor necrosis factor inhibitors (TNFi), non-TNFi (abatacept, tocilizumab, rituximab), or tsDMARDs, may be considered. If a first-line TNFi fails, options include another TNFi, non-TNFi biologic or tsDMARDs. If a first-line non-TNFi biologic or tsDMARD fails, options include TNFi or another non-TNF biologic or tsDMARD. For continued bDMARD/tsDMARD subsidization, a patient must have a documented DAS28-ESR every 3 months and at least a moderate European League Against Rheumatism response by 6 months. CONCLUSION: These recommendations are useful for guiding funding decisions, making bDMARD/tsDMARDs usage accessible and equitable in RA patients who fail csDMARDs.

Comparison of ankylosing spondylitis and non-radiographic axial spondyloarthritis in a multi-ethnic Asian population of Singapore.

OBJECTIVES: To compare clinical characteristics, disease activity, patient-reported outcomes and associated comorbidities between patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthitis (nr-axSpA) in a multi-ethnic Asian population of Singapore. METHODS: We used data from the PREcision medicine in SPONdyloarthritis for Better Outcomes and Disease Remission (PRESPOND) registry in Singapore General Hospital. All patients fulfilled 2009 Assessment in AS International Working Group classification criteria for axial SpA (axSpA). Of these, all AS patients fulfilled the 1984 modified New York criteria. Baseline characteristics, medications, disease activity, patient-reported outcomes and inflammatory markers were recorded using standardized questionnaires. RESULTS: Two hundred and sixty-two axSpA patients (82% Chinese, 79% male) were included. Mean age (SD) at diagnosis was 32.4 (13.1) years, which was similar between AS and nr-axSpA patients. AS patients were older (mean age 42.7 [13.5] vs 37.4 [13.8] years, P = 0.02), had longer disease duration (mean disease duration 10.9 [8.7] vs 6.4 [4.8] years, P < 0.01), higher Bath Ankylosing Spondylitis Metrology Index (BASMI) (mean BASMI 3.1 [2.3] vs 1.5 [1.5], P < 0.01), more frequently human leukocyte antigen (HLA)-B27 positive (82% vs 68%, P = 0.03), associated with uveitis (33% vs 17%, P = 0.03), and hypertensive (17% vs 0%, P < 0.01) compared to nr-axSpA, respectively. Nr-axSpA patients had higher Bath Ankylosing Spondylitis Global Score (BAS-G) (mean BAS-G 46.9 [16.8] vs 38.6 [20.6], P < 0.01), Bath Ankylosing Spondylitis Disease Activity Index (mean [SD] 4.2 [1.6] vs 3.5 [1.9], P = 0.02) and AS quality of life (ASQoL) (mean ASQoL 4.9 [4.8] vs 3.5 [4.1], P = 0.04) scores compared to AS patients respectively at baseline. Patient global assessment, Bath Ankylosing Spondylitis Functional Index, AS Disease Activity Score - C-reactive protein (CRP), Health Assessment Questionnaire, Short-Form 36 physical component summary and mental component summary were similar in both groups at baseline, as were medications used and mean erythrocyte sedimentation rate and CRP. CONCLUSIONS: In our multi-ethnic Asian cohort, patients with AS are more likely to be HLA-B27 positive, have uveitis, hypertensive, and have poorer spinal mobility, while nr-axSpA patients tend to experience poorer well-being and quality of life.

Are extra-spinal symptoms associated with quality of life in patients with axial spondyloarthritis? A 1-year follow-up study.

To assess the extent to which a history of extra-spinal symptoms (including peripheral arthritis, heel enthesitis, or dactylitis) (HPED) is associated with quality of life (QoL) in patients with axial spondyloarthritis (axSpA) at baseline and 1-year follow-up. We analyzed data from 138 patients with axSpA from a tertiary referral center in Singapore, seen between 2011 and 2015. Demographic, clinical variables, and patient-reported outcomes [Ankylosing Spondylitis Quality of Life (ASQoL) and SF-36] at baseline and 1-year follow-up were collected. We used linear mixed models to assess the association of HPED with QoL at baseline and 1 year post-baseline. Among 138 patients (mean age 39.3 years, 74.6% males, 87.6% Chinese, disease duration 7.4 years), at baseline, HPED was associated with poorer QoL for 3 of 8 SF-36 domains [role physical (RP) scores ß - 8.38, p < 0.05; social functioning (SF) scores ß - 6.74, p < 0.05; role emotional (RE) scores ß - 9.37, p < 0.01] and SF-36 Physical Component Summary (PCS) (ß - 4.52, p < 0.01) scores, but not ASQoL scores. At 1 year post-baseline, HPED was associated with poorer ASQoL (ß 1.61, p < 0.05) scores, SF-36 PCS (ß - 5.61, p < 0.01) scores, and three out of eight SF-36 domains (physical functioning (PF) ß - 9.60, p < 0.01; RP ß - 12.17, p < 0.01; RE ß - 7.87, p < 0.05) scores. HPED was associated with QoL in patients with axSpA. After 1-year, patients with HPED have poorer QoL especially for physical health domains than patients without HPED.

Validity and reliability of the Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in patients with axial spondyloarthritis (axSpA) in Singapore.

INTRODUCTION: The Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) are commonly used instruments for measuring disease activity. However, few studies have assessed their psychometric properties in patients with axial spondyloarthritis (axSpA). We aimed to assess the validity and reliability of ASDAS-CRP and BASDAI in patients with axSpA in Singapore. METHODS: Cross-sectional data from 280 patients with axSpA from a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2011 to 2019 were used. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed through 12 a priori hypotheses by correlation of overall ASDAS-CRP and BASDAI score with other patient-reported outcomes measures (PROMs). Structural validity was evaluated via confirmatory factor analysis using maximum-likelihood method, where Comparative Fit Index (CFI) >0.95, Tucker-Lewis Index (TLI) >0.95, Root Mean Square Error of Approximation (RMSEA) <0.06 and Standardized Root Mean Residuals (SRMR) <0.08 were indicative of good fit. RESULTS: Among 280 patients (78.2% Male; 92.5% Chinese), ASDAS-CRP showed poor internal consistency of 0.33, while BASDAI showed high internal consistency of 0.87. Convergent and divergent construct validity were demonstrated by fulfillment of 11 out of 12 a priori hypotheses when ASDAS-CRP and BASDAI were compared with other PROMs. Our proposed ASDAS-CRP and BASDAI model showed good fit for a 1-factor structure respectively (CFI = 0.993, TLI = 0.984, RMSEA = 0.036, SRMR = 0.026 for ASDAS-CRP; CFI = 0.993, TLI = 0.985, RMSEA = 0.057, SRMR = 0.022 for BASDAI), demonstrating structural validity. CONCLUSION: This study supports the use of both ASDAS-CRP and BASDAI in measuring disease activity in patients with axSpA in Singapore.

A qualitative study of quality of life domains and subdomains relevant to patients with spondyloarthritis.

AIMS: To identify quality of life (QoL) domains and subdomains relevant to patients with different spondyloarthritis (SpA) subtypes in Singapore, and to assess how identified QoL domains and subdomains map onto currently used patient-reported outcome measures (PROMs). METHODS: Nine focus group discussions (FGDs), including two previously conducted FGDs from the Updating the Psoriatic Arthritis Core Domain Set Study, were conducted with patients with SpA in Singapore. The FGDs were organized by SpA subtype and language spoken. All FGDs were audio-taped, transcribed verbatim. After thematic analysis through open and axial coding, the domains were organized using the World Health Organization Quality of Life (WHOQOL) framework. Identified QoL domains and subdomains were mapped to currently used PROMs. RESULTS: The nine FGDs included 51 patients. In total, 27 domains and 92 subdomains were identified and then organized within the 7 broad categories of the WHOQOL framework. Patients in Singapore were more concerned about "financial resources, " "work satisfaction" and "positive feelings" while less concerned about "freedom, physical safety and security" than patients in Western countries. "Home environment" and "work satisfaction" emerged as unique QoL domains relevant to patients with axial SpA (axSpA). PROMs for psoriatic arthritis (PsA) can capture both identified domains of PsA and axSpA. CONCLUSIONS: A wide range of QoL domains and subdomains are relevant to SpA patients in Singapore, and there appears to be minimal differences in their relative importance between SpA subtypes. This study supports the development and validation of common QoL-specific PROMs for usage in SpA.

The mediating role of pain and function in the association between stiffness and quality of life in patients with axial spondyloarthritis.

OBJECTIVE: The relationship between stiffness and quality of life (QoL) remains unclear. We therefore aimed to examine the role of pain and function in linking stiffness and QoL in patients with axSpA. METHODS: We used cross-sectional data from a registry of axSpA patients in a tertiary referral centre to assess the links among stiffness, pain and function on QoL. Path analysis was used to analyse the associations between these domains, pursuing four hypotheses: H1 - More stiffness is associated with poor QoL; H2 - More pain and decreased function are associated with poor QoL; H3 - More stiffness is associated with more pain and decreased function; H4 - The linkage between stiffness and QoL is mediated by function and pain. RESULTS: Data from 221 patients (Mean age 38.5, 79.0% males and 83.1% Chinese) were analyzed. Our mediation model achieved good fit (χ2 (10) = 7.06, p = 0.719, CFI= 1.00 TLI = 1.00, RMSEA < 0.001). Results supported all 4 hypotheses (p < 0.001): More stiffness, more pain, decreased function were associated with poor QoL. Function was associated directly with QoL. Stiffness was associated with QoL through both pain and function. CONCLUSION: Optimization of QoL in patients with stiffness in axSpA requires effective control of both function and pain. Physiotherapy, exercises and medications may improve the QoL in these patients.

A systematic review of the association of obesity with the outcomes of inflammatory rheumatic diseases.

This was a systematic review of the literature on the association between obesity and the outcome of inflammatory rheumatic diseases. We conducted a literature search using PubMed®, Embase and PsycINFO®. Articles were classified into three categories based on the effects of obesity on the outcomes of inflammatory rheumatic diseases. The subject population, country, type of studies, number of patients, measurement of obesity and outcomes assessed were presented. Quality was appraised using Kmet et al's criteria. 4,331 articles were screened and 60 were relevant to the objective. Obesity had a negative, positive and neutral association with outcomes of inflammatory rheumatic diseases in 38 (63.3%) studies with 57,612 subjects, 11 (18.3%) studies with 3,866 subjects, and 11 (18.3%) studies with 3,834 subjects, respectively. In most studies, the disease population had been diagnosed with rheumatoid arthritis (RA). Tumour necrosis factor-α inhibitors were mostly associated with negative outcomes. More studies examining subjects outside Europe and North America and diseases other than RA are warranted.

A systematic review of the factors associated with the initiation of biologicals in patients with rheumatological conditions.

OBJECTIVES: Biologicals play a crucial role in managing some of the rheumatological diseases, thus it is important for clinicians, healthcare institutions and policy-makers to understand why biologicals are initiated or refused so as to make better decisions to improve patients' disease outcomes. Although there have been many studies investigating factors associated with the initiation of biologicals for patients with rheumatological conditions, there have been no systematic reviews that provide a comprehensive summary. We aim to provide a summary of factors associated with biologicals' initiation for patients with rheumatological conditions. METHODS: We performed a literature search in PubMed, Embase and PsycINFO. We identified and screened studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Factors were presented according to patient, disease-related, therapy-related, healthcare team-related and system in-place factors. RESULTS: A total 1755 articles were reviewed and 24 articles were found to be relevant to our objective. Forty four factors reviewed were placed into five main categories: patient factors (n=13); disease-related factors (n=11); therapy-related factors (n=7); healthcare team-related factors (n=4) and system in-place-related factors (n=9). The factors studied by the published papers found to be associated with decisions to initiate biologicals varied widely. CONCLUSION: Forty two factors of five different categories were found to be associated with biologicals' initiation for patients with rheumatological conditions. Clinicians need to be mindful of the complex nature of these factors to optimise therapy of patients with rheumatological conditions. Healthcare institutions and policy- makers ought to be aware of any potential barriers to successful biologicals' treatment and address them accordingly.

Validity and reliability of the Assessment of Spondyloarthritis International Society Health Index in English-speaking patients with axial spondyloarthritis in Singapore.

OBJECTIVES: To assess the validity and reliability of the Assessment of Spondyloarthritis International Society Health Index (ASAS HI) among patients with axial spondyloarthritis (axSpA) in Singapore. METHODS: We collected data from English-speaking patients with axSpA seen at a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2017 to 2018. Face validity of the English version of ASAS HI was assessed through cognitive debriefing interviews (CDIs). Structural validity was assessed with confirmatory factor analysis. Convergent construct validity was assessed with 12 a priori hypotheses about the magnitude and direction of correlations between the ASAS HI summary score and other patient-reported outcome measures. Internal consistency was assessed using Cronbach's alpha. Test-retest reliability was assessed by intraclass correlation coefficient (ICC). Measurement error was assessed by analyzing smallest detectable change (SDC). RESULTS: Ten patients (age range 22-46 years, 50% male) participated in CDIs and face validity was supported. Among 108 patients (median age: 37 [21-77], 80.6% males), unidimensionality was confirmed (comparative fit index = 0.960, Tucker-Lewis Index = 0.952, root mean square error of approximation = 0.038, standardized root mean residuals = 0.068, model Chi-square test P = 0.1251) in the 17-item ASAS HI. The ASAS HI showed good internal consistency of 0.83 and excellent test-retest reliability (ICC = 0.95; 95% CI 0.91-0.98) when baseline was compared with week 2. SDC was 1.02. Convergent validity was supported as hypotheses were confirmed in 100% of the results. CONCLUSIONS: This study supports the ASAS HI as a valid and reliable measure of health status for use in patients with axSpA in Singapore.

Traditional Chinese medicine (TCM) collaborative care for patients with axial spondyloarthritis (AcuSpA): protocol for a pragmatic randomized controlled trial.

BACKGROUND: Axial spondyloarthritis (AxSpA) is a chronic disease which results in fatigue, pain, and reduced quality of life (QoL). Traditional Chinese medicine (TCM), especially acupuncture, has shown promise in managing pain. Although a TCM collaborative model of care (TCMCMC) has been studied in cancer, there are no randomized controlled trials investigating TCM in AxSpA. Therefore, we will conduct a pragmatic trial to determine the clinical effectiveness, safety, and cost-effectiveness of TCMCMC for patients with AxSpA. We define TCMCMC as standard TCM history taking and physical examination, acupuncture, and TCM non-pharmacological advice and communications with rheumatologists in addition to usual rheumatologic care. The purpose of this paper is to describe the rationale for and methodology of this trial. METHODS/DESIGN: This pragmatic randomized controlled trial will recruit 160 patients who are diagnosed with AxSpA and have inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). Simple randomization to usual rheumatologic care or the intervention (TCMCMC) with a 1:1 allocation ratio will be used. Ten 30-min acupuncture sessions will be provided to patients assigned to the TCMCMC arm. All participants will continue to receive usual rheumatologic care. The primary endpoint - spinal pain - will be evaluated at week 6. Secondary endpoints include clinical, quality of life, and economic outcome measures. Patients will be followed up for up to 52 weeks, and adverse events will be documented. DISCUSSION: This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of a TCMCMC for patients with AxSpA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03420404 . Registered on 14 February 2018.

A rare cause of reversible unilateral third nerve palsy.

CASE REPORT: A 59-year-old Chinese male presented in January 2007 with acute left retro-orbital headache, diplopia and left partial ptosis. Isolated left third nerve palsy was diagnosed. Imaging studies and cerebral angiography excluded a posterior communicating artery aneurysm. Anti-nuclear (titre 1/800, speckled pattern), anti-PR3, anti-Ro and anti-La antibodies were present. Sjogren's syndrome (SS) was considered in view of positive anti-Ro and La antibodies, and was confirmed with focal lymphocytic infiltrates on labial salivary gland biopsy and a positive Schirmer's test (6 mm of tear flow over 5 min). Immunosuppressive therapy was started 2 months after his initial presentation and within 2 weeks, the patient experienced an almost complete recovery of both ptosis and diplopia. He has been on tapering doses of prednisolone since and his condition remains stable. CONCLUSION: This patient has cranial neuropathy secondary to Sjogren's syndrome. The rapid reversibility of the oculomotor nerve palsy with immunosuppression suggests lymphocytic infiltration or autoantibodies as the cause rather than a vasculitic process, which would have led to irreversible or slowly, partially reversible ischaemic damage.