Factors Associated With Treatment Pathways in Early Axial Spondyloarthritis: A Multistate Analysis of the 10-Year Follow-Up of the DESIR Cohort.

OBJECTIVE: Current recommendations for the management of patients with axial spondyloarthritis (axSpA) emphasize the need of an individualized strategy in therapeutic decision-making. The study objectives were to describe therapeutic strategies observed in axSpA, and to assess the factors associated with treatment intensification over time. METHODS: We included patients with axSpA from the French prospective cohort DESIR (Devenir des Spondylarthropathies Indifférenciées Récentes), with a scheduled 10-year follow-up. A multistate model with 4 ordered treatment states (no treatment, nonsteroidal antiinflammatory drugs [NSAIDs], conventional synthetic disease-modifying antirheumatic drugs [csDMARDs], and tumor necrosis factor inhibitors [TNFi]) was defined, with 6 possible transitions. Restricted mean sojourn times in each state were estimated. Then, predictors of those transitions were assessed by multivariable Cox models. RESULTS: A total of 686/708 (96.9%) patients who had > 1 visit were analyzed. At cohort entry, 199 (29%) were untreated, 427 (62.2%) were receiving NSAIDs, 60 (8.7%) csDMARDs, and none were receiving TNFi. Over the follow-up period, patients mostly (46.4% of the time) received NSAIDs, followed by TNFi (24.4% of the time). The presence of sacroiliitis on radiographs, inflammatory bowel disease, and articular index were jointly associated with the transition to NSAIDs. Longer duration in the previous state often decreased the hazard of the transition to csDMARDs or TNFi. Worse disease activity outcomes increased the hazard of most transitions. CONCLUSION: To our knowledge, this was the first study using a multistate model to easily represent different treatment states, detailing the transitions across them and their associated factors. Different time profiles for the management of patients with axSpA were identified, including in those abstaining from treatment up to a significant proportion of patients treated with csDMARDs.

Arthroplasty after septic arthritis of the native hip and knee: retrospective analysis of 49 joints.

Background: Arthroplasty after septic arthritis (SA) treatment raises diagnostic and therapeutic questions. The main objective was to evaluate infection-free survival of patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) post-SA. Other objectives were to describe the population's characteristics, surgical strategies, results of preoperative examinations and cultures of intraoperative samples taken at implantation, and postoperative antibiotic therapy. Methods: This is a retrospective, observational, monocenter study, from January 2005 to May 2019, including all patients undergoing TKA or THA with prior or ongoing SA in the same joint. Infection-free survival was analyzed and reported. Results: Forty-seven patients, 29 men, 49 joints operated on (30 knees, 19 hips), were included. Median SA-to-arthroplasty interval was 32 [1-216] weeks. It was < 2  years for 43 joints and < 6  months for 19 joints. Six patients underwent arthroplasty while still on SA treatment. One-stage arthroplasty was done for 43 joints and two-stage arthroplasty for 6 joints. Eight (16 %) cultures of intraoperative specimens were positive. Median durations of postoperative antibiotic therapy were 10 d for sterile cultures and 82 d for those that were positive. At 2 years, infection-free survival rate was 95.9 % ( ± 0.02 ). After a median follow-up of 47 [18-142] months, no SA relapse was observed, but five patients developed new periprosthetic joint infections (PJIs) with a different microorganism. Conclusion: Arthroplasty may be a post-SA option, even within a short period of time. One-stage arthroplasty can be done if synovectomy is thorough, intraoperative samples are taken and antibiotics are administered until those culture results become available. We observed no SA relapse, but new PJIs occurred.

Disease activity outcome measures are only available in half of the electronic medical files of patients with axial spondyloarthritis followed in an outpatient clinic: the results of an audit of a tertiary-care rheumatology department.

Current recommendations for management of patients with axial spondyloarthritis (axSpA) include regular collection of validated disease activity outcomes. This study aimed at evaluating the proportion of patients for whom validated outcome measures were available on their electronic medical reports (EMR), and the factors associated with the presence of such information on the EMR. We performed a cross-sectional monocentric observational study, including patients with an axSpA diagnosis who attended an outpatient visit between February, 2018 and February, 2019. Patients (demographics, disease characteristics, treatment) and physician characteristics (age, gender) and the disease activity outcome measures (BASDAI, CRP and ASDAS, and the items allowing to calculate them) were retrieved from the EMR. The proportion of patients in which disease activity outcome measures were available in the EMR was calculated, and the association between the presence of such outcomes and patients and physician's characteristics was evaluated. 320 EMR of axSpA patients seen in the outpatient clinic were examined. Among them, 131 (41%) and 123 (38.4%) had a BASDAI + CRP and an ASDAS reported, respectively, but at least one was available in 178 (55.6%) of the EMR. The most frequently reported disease activity items were duration of morning stiffness (n = 230, 72%) and CRP (n = 224, 70%). Only previous participation on a systematic holistic review was independently associated with a reported disease activity outcome. Thus, implementation of recommendations with regard to regularly collecting disease activity outcome measures is not optimal. The participation in educational programs including self-assessment educational programs might be a key to improve such implementation.