Search

Objective To describe the development of an Environmental contextual factors (EF) Item Set (EFIS) accompanying the disease specific Assessment of SpondyloArthritis international Society Health Index (ASAS HI). Method First, a candidate item pool was developed by linking items from existing questionnaires to 13 EF previously selected for the International Classification of Functioning, Disability and Health (ICF) /ASAS Core Set. Second, using data from two international surveys, which contained the EF item pool as well as the items from the ASAS HI, the number of EF items was reduced based on the correlation between the item and the ASAS HI sum score combined with expert opinion. Third, the final English EFIS was translated into 15 languages and cross-culturally validated. Results The initial item pool contained 53 EF addressing four ICF EF chapters: products and technology (e1), support and relationship (e3), attitudes (e4) and health services (e5). Based on 1754 responses of axial spondyloarthritis patients in an international survey, 44 of 53 initial items were removed based on low correlations to the ASAS HI or redundancy combined with expert opinion. Nine items of the initial item pool (range correlation 0.21–0.49) form the final EFIS. The EFIS was translated into 15 languages and field tested in 24 countries. Conclusions An EFIS is available complementing the ASAS HI and helps to interpret the ASAS HI results by gaining an understanding of the interaction between a health condition and contextual factors. The EFIS emphasizes the importance of support and relationships, as well as attitudes of the patient and health services in relation to self-reported health.

BACKGROUND: The current core outcome set for ankylosing spondylitis (AS) has had only minor adaptations since its development 20 years ago. Considering the significant advances in this field during the preceding decades, an update of this core set is necessary.OBJECTIVE: To update the ASAS-OMERACT core outcome set for AS into the ASAS-OMERACT core outcome set for axial spondyloarthritis (axSpA).METHODS: Following OMERACT and COMET guidelines, an international working group representing key stakeholders (patients, rheumatologists, health professionals, pharmaceutical industry and drug regulatory agency representatives) defined the core domain set for axSpA. The development process consisted of: i) Identifying candidate domains using a systematic literature review and qualitative studies; ii) Selection of the most relevant domains for different stakeholders through a 3-round Delphi survey involving axSpA patients and axSpA experts; iii) Consensus and voting by ASAS; iv) Endorsement by OMERACT. Two scenarios are considered based on the type of therapy investigated in the trial: symptom modifying therapies and disease modifying therapies.RESULTS: The updated core outcome set for axSpA includes 7 mandatory domains for all trials (disease activity, pain, morning stiffness, fatigue, physical function, overall functioning and health, and adverse events including death). There are 3 additional domains (extra-musculoskeletal manifestations, peripheral manifestations and structural damage) that are mandatory for disease modifying therapies and important but optional for symptom modifying therapies. Finally, 3 other domains (spinal mobility, sleep, and work and employment) are defined as important but optional domains for all trials.CONCLUSION: The ASAS-OMERACT core domain set for AS has been updated into the ASAS-OMERACT core domain set for axSpA. The next step is the selection of instruments for each domain.

Objectives The primary objective was to compare the clinical characteristics of SpA patients with and without root joint disease (RJD+ and RJD–). The secondary objectives were to compare the prevalence of RJD across various SpA subtypes and in different world regions, and to compare the SpA axial severity and SpA burden between RJD+ and RJD–. Methods This is a post hoc analysis of the Assessment of Spondyloarthritis International Society PerSpA study (PERipheral involvement in SpondyloArthritis), which included 4465 patients with SpA [axial (axSpA), peripheral (pSpA), PsA, IBD, reactive and juvenile] according to the rheumatologist’s diagnosis. RJD was defined as the ‘ever’ presence of hip or shoulder involvement related to SpA, according to the rheumatologist. Patient characteristics were compared between RJD+ and RJD–. Multivariable stepwise binary logistic regression analyses were conducted to identify factors associated with ‘RJD’, ‘hip’ and ‘shoulder’ involvement. Results RJD was significantly associated with the SpA main diagnosis (highest in pSpA), a higher prevalence of HLA-B27 positivity, enthesitis, tender and swollen joints, CRP, conventional synthetic DMARDs, loss of lumbar lordosis and occiput-wall distance >0. RJD was more prevalent in Asia, and occurred in 1503 patients (33.7%), with more hip (24.2%) than shoulder (13.2%) involvement. Hip involvement had a distinct phenotype, similar to axSpA (including younger age at onset, HLA-B27 positivity), whereas shoulder involvement was associated with features of pSpA (including older age at onset). Conclusion RJD+ SpA patients had a distinctive clinical phenotype compared with RJD–. Hip involvement, based on the rheumatologist’s diagnosis, was more prevalent than shoulder involvement and was clinically distinct.

Objectives: The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges. Methods: Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified. Results: Twenty-three rheumatologists from MEAC identified unmet needs in patients’ education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician’s visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix. Conclusion: Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.

To study the association of smoking status and the level of seropositivity in RA patients from COMORA Cohort. A post hoc analysis of COMORA database included 3439 RA patients was performed. Current smokers or recently quitted ( 3 years (Group I vs. II) regarding their seropositivity status (high positive, low positive and negative) for Rheumatoid Factor (RF) or Anti-citrullinated antibodies (ACPA). A further comparison was made between current smokers (Group III) and never smoked patients (Group IV). Analysis was also done on the individual country level for the 17 countries included in the COMORA study. Out of 3439 RA patients, 705 (20.5%) were smokers (group I), and 2734 (79.5%) were non-smokers (group II). Significantly more patients in group I, 442 (62.7%), had high levels of seropositivity than those in group II, 1556 (56.9%), [P = 0.006, OR 1.27 (95% CI, 1.07–1.5)]. More current smoker patients (group III—286 out of 456 “62.7%”) had high levels of seropositivity than never smoked patients (group IV—1236 out of 2191 “56.4%”), with significant difference [P = 0.013, OR 1.3 (95% CI, 1.06–1.6)]. In 11 countries, higher proportions of patients with high level of seropositivity in group I was found, with statistical significance in four countries. Smoking was associated with higher level of seropositivity in patients with RA in this post hoc analysis, both on a global level and in certain individual countries. As smoking is a modifiable risk factor, studying the effects of quitting smoking on level of seropositivity and other disease parameters is warranted.

Aim of the work To study the effect of education on rheumatoid disease in a cohort of Egyptian patients. Patients and methods This study included 1022 consecutive rheumatoid arthritis (RA) patients recruited from several rheumatology clinics of public and private sectors from Cairo, Kafr Elsheik and Fayoum governorates. Their mean age was 45.1 ± 12.4 years and mean disease duration was 85.9 ± 73 months. Patients were divided into groups according to their educational level (university degree/high school/illiterate) and were compared regarding their disease activity score (DAS28) and modified health assessment questionnaire (mHAQ) as a measure of the functional status. Results The mean age of patients was 45.1 ± 12.4 years, they were 854 females and 168 males and disease duration of 85.9 ± 73 months. 106 (10.4%) were smokers and 333 (32.6%) were employed. 342 (33.5%) were illiterate, 455 (44.5%) were non-university-educated and 225 (22%) university educated. Educated patients showed significant lower disease activity (p = 0.001), swollen joint count (p = 0.044), tender joint count (p = 0.001), doctors global assessment (p = 0.001), erythrocyte sedimentation rate (p = 0.003) and visual analogue scale (p = 0.001). Educated patients had significantly received more biologic therapy (p = 0.001) and attended regular follow-up (p = 0.001). They showed better functional status with significantly lower MHAQ and had significant higher percentage of employment (p = 0.001). Rheumatoid patients with a university degree had significantly lower diseases activity and better functional indices compared to those without. Further regression analysis showed that university education is a predictor for low disease activity. Conclusion Rheumatoid disease is influenced by education among Egyptians. Higher educated patients had lower disease activity and better functional outcome, and university education predicts low disease activity among Egyptian RA patients.

BackgroundTelehealth use is increasing and will undeniably continue to play a role beyond the COVID-19 era. Best practice guidelines (BPG) for telehealth add credibility, standardize approaches, facilitate reimbursement, and decrease liability.ObjectivesTo develop BPG for the use of Telehealth In Rheumatology in the Arab region, to identify the top barriers and facilitators of telehealth in the Arab region, and to provide rheumatologists with a practical toolkit for the implementation of telehealth.MethodsGuidelines were drafted by a core steering committee from the Arab League of Associations for Rheumatology (ArLAR) after performing a literature search. A multidisciplinary task force (TF), including 18 rheumatologists, 2 patients, and 2 regulators from 15 Arab countries, assessed the BPG using 3 rounds of anonymous online voting by modified Delphi process. The voting on barriers and facilitators was performed through one voting round. The toolkit was developed based on available literature and discussions during the Delphi rounds.ResultsFour General Principles and twelve Statements were formulated. All statements reached >80% consensus. A teleconsultation was specifically defined for the purpose of these guidelines. The concept of choice in telehealth was highlighted, emphasizing patient confidentiality, medical information security, rheumatologist’s clinical judgment, and local jurisdictional regulations. The top barrier for telehealth was the concern about the quality of care. The toolkit emphasized technical aspects of teleconsultation and proposed a triage system.ConclusionsThe ArLAR BPG provides rheumatologists with a series of strategies about the most reliable, productive, and rational approaches to apply telehealth.Article SummaryStrengths and limitations of this studyBest practice guidelines (BPG) the use of Telehealth In Rheumatology in the Arab region were developed herein under the umbrella of the Arab League of Associations for Rheumatology (ArLAR)A teleconsultation was specifically defined for the purpose of these guidelinesThe concept of choice in telehealth was highlighted, emphasizing patient confidentiality, medical information security, rheumatologist’s clinical judgment, and local jurisdictional regulationsThe top barrier for telehealth was the concern about the quality of careThe ArLAR BPG provides rheumatologists with a series of strategies about the most reliable, productive, and rational approaches to apply telehealth in the rheumatology clinic

Little is known about the prevalence, phenotype, and burden of peripheral spondyloarthritis (pSpA). The objective of the study is to compare the phenotype and burden of disease of pure pSpA to that of pure psoriatic arthritis (PsA), pure axial SpA (axSpA), and combined forms of SpA.This is a post hoc analysis of 4,185 patients from the cross-sectional ASAS-Peripheral involvement in SpA (PerSpA) study. Patients were approached in 2 ways: the first approach was based on the rheumatologist's diagnosis (diagnostic approach) and the second one was based on the fulfillment of ASAS or CASPAR classification criteria (classification criteria approach). Demographics, disease phenotype, and burden were compared among pure pSpA, PsA, axSpA, and the combined forms.The proportion of pSpA was 31.5% of SpA using the classification criteria approach and 10.3% using the diagnostic approach. pSpA was pure (i.e. without axSpA or PsA) in 16.8% of pSpA using the criteria, and in 62.3% using the diagnostic approach. Using classification criteria and diagnostic approach, respectively, pure pSpA patients had a high prevalence of peripheral joint disease (86 and 96%), synovitis (76 and 91%), and enthesitis (57 and 55%), a positive HLA-B27 in 65 and 59%, a high C-Reactive Protein level in 51% and inflammatory back pain in 52 and 42%. However, compared to pure PsA and pure axSpA, they had a significantly higher disease burden, but lower use of biologics using both approaches.The proportion of pSpA varies when using the classification criteria or the diagnostic approach. pSpA occurred in a pure form less frequently than PsA and axSpA and had intermediate features but a higher disease burden.The PerSpA main study has been conducted under the umbrella of ASAS thanks to unrestricted grants from PFIZER, LILLY, ABBVIE, NOVARTIS, UCB, JANSSEN, MERCK.

BackgroundTofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We performed a comprehensive review of phase 3 studies of tofacitinib 5 mg twice daily (BID) (approved dose in many countries) in patients with moderate to severe RA and inadequate response to pri

ObjectivesTo characterise peripheral musculoskeletal involvement in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), across the world.MethodsCross-sectional study with 24 participating countries. Patients with a diagnosis of axial SpA (axSpA), peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The investigators were asked which diagnosis out of a list of six (axSpA, PsA, pSpA, inflammatory bowel disease-associated SpA, reactive arthritis or juvenile SpA (Juv-SpA)) fitted the patient best. Peripheral manifestations (ie, peripheral joint disease, enthesitis, dactylitis and root joint disease), their localisation and treatments were evaluated.ResultsA total of 4465 patients were included (61% men, mean age 44.5 years) from four geographic areas: Latin America (n=538), Europe plus North America (n=1677), Asia (n=975) and the Middle East plus North Africa (n=1275). Of those, 78% had ever suffered from at least one peripheral musculoskeletal manifestation; 57% had peripheral joint disease, 44% had enthesitis and 15% had dactylitis. Latin American had far more often peripheral joint disease (80%) than patients from other areas. Patients with PsA had predominantly upper limb and small joint involvement (52%).Hip and shoulder involvement was found in 34% of patients. The prevalence of enthesitis ranged between 41% in patients with axSpA and 65% in patients with Juv-SpA. Dactylitis was most frequent among patients with PsA (37%).ConclusionThese results suggest that all peripheral features can be found in all subtypes of SpA, and that differences are quantitative rather than qualitative. In a high proportion of patients, axial and peripheral manifestations coincided. These findings reconfirm SpA clinical subtypes are descendants of the same underlying disease, called SpA.

To evaluate the perceptions of patients with rheumatoid arthritis (RA) about self-assessment of their disease activity after watching an educational video. Consecutive patients with RA consulting their rheumatologist in six Middle Eastern Countries were invited to watch an educational video developed to teach self-assessment using Disease Activity Score (DAS-28). Then, a rheumatology nurse conducted a semi-structured interview and collected the patients’ perception about the understanding of the video, feasibility, capability and confidence in performing self-assessment using Likert-type items. The degree of confidence with self-assessment was correlated to the patients’ socio-demographic characteristics. Sixty-two patients were included and had an overall positive reaction to the video. It was easy to understand in 96% and helped facilitate self-assessment in 92% of cases. Self-assessment was considered totally feasible in 74%, and 66% of patients were capable of always doing it, with a confidence of 60% (always) to 34% (sometimes). Confidence was associated with a higher educational level. Nevertheless, 77% of patients felt that the self-assessment would not fully replace the physician’s visit. Open-ended questions identified five themes: better understanding of the disease, easier communication with the rheumatologist, less consultation time, difficulty with the scoring part and importance of practice. Patients with RA felt that self-assessment was feasible and helpful in understanding RA, improving communication with the rheumatologist and shortening the visit time. Supplementary Information The online version contains supplementary material available at 10.1007/s00296-021-04799-2.

To study the association of smoking status and the level of seropositivity in RA patients from COMORA Cohort. A post hoc analysis of COMORA database included 3439 RA patients was performed. Current smokers or recently quitted ( 3 years) were initially compared to those who never smoked or stopped 3 years (Group I vs. II) regarding their seropositivity status (high positive, low positive and negative) for Rheumatoid Factor (RF) or Anti-citrullinated antibodies (ACPA). A further comparison was made between current smokers (Group III) and never smoked patients (Group IV). Analysis was also done on the individual country level for the 17 countries included in the COMORA study. Out of 3439 RA patients, 705 (20.5%) were smokers (group I), and 2734 (79.5%) were non-smokers (group II). Significantly more patients in group I, 442 (62.7%), had high levels of seropositivity than those in group II, 1556 (56.9%), [P = 0.006, OR 1.27 (95% CI, 1.07-1.5)]. More current smoker patients (group III-286 out of 456 "62.7%") had high levels of seropositivity than never smoked patients (group IV-1236 out of 2191 "56.4%"), with significant difference [P = 0.013, OR 1.3 (95% CI, 1.06-1.6)]. In 11 countries, higher proportions of patients with high level of seropositivity in group I was found, with statistical significance in four countries. Smoking was associated with higher level of seropositivity in patients with RA in this post hoc analysis, both on a global level and in certain individual countries. As smoking is a modifiable risk factor, studying the effects of quitting smoking on level of seropositivity and other disease parameters is warranted.

ObjectivesTo evaluate construct validity, interpretability, reliability and responsiveness as well as determination of cut-off points for good and poor health within the original English version and the 18 translations of the disease-specific Assessment of Spondyloarthritis international Society Health Index (ASAS HI) in 23 countries worldwide in patients with spondyloarthritis (SpA).MethodsA representative sample of patients with SpA fulfilling the ASAS classification criteria for axial (axSpA) or peripheral SpA was used. The construct validity of the ASAS HI was tested using Spearman correlation with several standard health outcomes for axSpA. Test–retest reliability was assessed by intraclass correlation coefficients (ICCs) in patients with stable disease (interval 4–7 days). In patients who required an escalation of therapy because of high disease activity, responsiveness was tested after 2–24weeks using standardised response mean (SRM).ResultsAmong the 1548 patients, 64.9% were men, with a mean (SD) age 42.0 (13.4) years. Construct validity ranged from low (age: 0.10) to high (Bath AnkylosingSpondylitisFunctioning Index: 0.71). Internal consistency was high (Cronbach’s α of 0.93). The reliability among 578 patients was good (ICC=0.87 (95% CI 0.84 to 0.89)). Responsiveness among 246 patients was moderate-large (SRM=−0.44 for non-steroidal anti-inflammatory drugs, −0.69 for conventional synthetic disease-modifying antirheumatic drug and −0.85 for tumour necrosis factor inhibitor). The smallest detectable change was 3.0. Values ≤5.0 have balanced specificity to distinguish good health as opposed to moderate health, and values ≥12.0 are specific to represent poor health as opposed to moderate health.ConclusionsThe ASAS HI proved to be valid, reliable and responsive. It can be used to evaluate the impact of SpA and its treatment on functioning and health. Furthermore, comparison of disease impact between populations is possible.

Introduction Les patients avec un diagnostic clinique de spondyloarthrite (SpA) (en incluant le rhumatisme psoriasique – Rhpso) peuvent avoir des symptomes principalement peripheriques ou principalement axiaux. Cependant, des chevauchements entre ces symptomes sont frequents et ils n’existent pas de sous-groupes clairement definis. L’objectif de cette etude a ete d’identifier des groupes des manifestations musculosquelettiques peripheriques selon leur localisation anatomique dans le spectre des SpA (en incluant le Rhpso). Patients et methodes Etude transversale et internationale avec 24 pays participants. Des patients consecutifs avec un diagnostic de SpA axiale (axSpA), SpA peripherique (pSpA), rhumatisme psoriasique (Rhpso), SpA associe a maladie inflammatoire de l’intestin (SpA-MICI), arthrite reactive (ReA) et SpA juvenile ont ete eligibles. Une analyse de cluster pour chaque manifestation peripherique musculosquelettique (affection articulaire peripherique, enthesite et dactylite) a ete realisee en utilisant des donnees sur la localisation anatomique de ces symptomes observes a n’importe quel moment de la maladie. La distribution de ces manifestations peripheriques et les caracteristiques cliniques ont ete comparees entre les differents clusters. Resultats Un total de 4465 patients ont ete inclus. Trois clusters ont ete trouves selon la localisation de l’affection articulaire, nommes « arthrite rare (a) », « principalement membres inferieurs (b) » et « principalement mains (c) ». Les patients du groupe « a » avaient, en comparaison avec les groupes « b » et « c », une prevalence plus importante d’hommes (63,9 % vs 51,3 % vs 41,5 %), de HLA-B27 (79,8 % vs 48,2 % vs 34,8 %) et de diagnostic de axSpA (67,2 % vs 20,9 % vs 23,7 %), mais une prevalence plus basse de psoriasis (23,2 % vs 67,8 % vs 59,6 %) et de diagnostic de Rhpso (17,2 % vs 61,7 % vs 58,5 %). Entre les clusters « b » et « c », l’uveite etait plus frequente chez le premier (15,7 % vs 8,7 %), tandis que la maladie inflammatoire de l’intestin etait plus frequente chez le deuxieme (3,5 % vs 6,7 %). Concernant la localisation de l’enthesite, nous avons trouve aussi 3 clusters, nommes « enthesite du talon (d) », « enthesite axiale (e) » et « polyenthesite (f) ». Les patients du cluster « f » avaient une frequence plus eleve de fibromyalgie concomitante (41,3 % vs 17,4 % vs 31,3 %), de psoriasis (48,3 % vs 28,4 % vs 23,4 %) et de Rhpso (40,8 % vs 22,7 % vs 21,5 %) en comparaison avec les groupes « d » et « e », mais une prevalence moindre d’hommes (40 % vs 61,9 % vs 56,2 %) et de diagnostic d’axSpA (37,5 % vs 61,4 % vs 64,1 %). Finalement, nous avons trouve 3 clusters selon la localisation des dactylites : « absence de dactylite (g) », « principalement orteils (h) » et « principalement doigts (i) ». Le groupe « g » a montre, en comparaison avec les groupes « h » et « i », la plus grande prevalence d’hommes (61,4 % vs 51,4 % vs 52,9 %), de HLA-B27 (66,6 % vs 52,5 % vs 50,0 %) et de diagnostic d’axSpA (62,6 % vs 20 % vs 11,8 %), mais la plus basse frequence de psoriasis (26,9 % vs 68,6 % vs 79,4 %) et de diagnostic de Rhpso (21,5 % vs 65,7 % vs 52,9 %). Conclusion Cette etude suggere la presence de groupes heterogenes d’affection peripherique chez des patients atteints de SpA (et Rhpso) sans groupes clairement definis, ce qui confirme un clair chevauchement entre les differents sous-types de SpA.

Clinical practice guidelines can assist rheumatologists in the proper prescription of newer treatment for rheumatoid arthritis (RA). The objective of this paper is to report on the recommendations for the management of patients with RA in the Eastern Mediterranean region. We adapted the 2015 American College of Rheumatology guidelines in two separate waves. We used the adolopment methodology, and followed the 18 steps of the “Guidelines 2.0” comprehensive checklist for guideline development. For each question, we updated the original guidelines’ evidence synthesis, and we developed an Evidence Profile (EP) and an Evidence to Decision (EtD) table. In the first wave, we adoloped eight out of the 15 original questions on early RA. The strength changed for five of these recommendations from strong to conditional, due to one or more of the following factors: cost, impact on health equities, the balance of benefits, and harms and acceptability. In the second wave, we adoloped eight out of the original 44 questions on established RA. The strength changed for two of these recommendations from strong to conditional, in both cases due to cost, impact on health equities, balance of benefits and harms, and acceptability. The panel also developed a good practice recommendation. We successfully adoloped 16 recommendations for the management of early and established RA in the Eastern Mediterranean region. The process proved feasible and sensitive to contextual factors.

Introduction La distribution des manifestations peripheriques musculosquelettiques chez tous les sous-types de spondyloarthrite (SpA) et leurs caracteristiques ont ete peu etudiees. De plus, tres peu d’etudes ont evalue la distribution des manifestations peripheriques selon la region geographique. L’objectif de cette etude a ete de comparer la prevalence, les caracteristiques et les traitements des manifestations musculosquelettiques peripheriques chez les patients atteints de tous sous-types possibles de SpA ainsi que leur distribution selon la region geographique. Patients et methodes Etude transversale avec 24 pays participants. Des patients consecutifs avec un diagnostic de SpA axiale (axSpA), SpA peripherique (pSpA), rhumatisme psoriasique (Rhpso), SpA associe a maladie inflammatoire de l’intestin (SpA-MICI), arthrite reactive (ReA) et SpA juvenile etaient eligibles pour l’etude. La prevalence des manifestations peripheriques (affection articulaire peripherique, enthesite, dactylite, tarsite et affection des articulations racines) leur localisation et leur traitement ont ete evalues, ainsi que leur distribution dans les differentes regions du monde. Resultats Un total de 4465 patients (61 % hommes, âge moyenne 45 ans) ont ete inclus appartenant a quatre regions : Amerique Latine (n = 538), Europe et Amerique du Nord (n = 1677), Asie (n = 975), Moyen-Orient et Afrique du Nord (n = 1275). La prevalence des diagnostics etait axSpA (60,9 %), Rhpso (23,1 %), pSpA (9,7 %), SpA-MICI (2,5 %), ReA (1,3 %), et Juv-SpA (1,3 %). Parmi la totalite des patients, 78,3 % avaient eu au moins une manifestation peripherique ; 56,9 % au moins une affection articulaire peripherique, 44,3 % une enthesite, 33,7 % une affection des articulations racines, 15,3 % une dactylite et 7,7 % une tarsite. Les patients d’Amerique Latine avaient la prevalence la plus haute d’affection articulaire peripherique (79,9 %), d’enthesite (68,8 %), de dactylite (25,5 %) et de tarsite (23,6 %), tandis que la prevalence d’affection des articulations des racines des membres etait plus elevee chez les patients d’Asie (57,4 %). L’affection articulaire peripherique etait plus frequente chez les patients avec pSpA (94,7 %) et moins souvent chez les patients avec axSpA (36,0 %). Les patients atteints de Rhpso avaient plus souvent une atteinte polyarticulaire (58,9 %) tandis que les axSpA avaient une atteinte surtout mono-articulaire (20,1 %). L’atteinte des petites articulations des membres superieurs etait plus souvent observee chez les patients avec Rhpso (52,0 %) tandis que l’atteinte des grosses articulations des membres inferieurs etait plus souvent chez les MICI-SpA (55,9 %) et pSpA (51,2 %). Parmi les patients avec atteinte des articulations proximales, la hanche etait surtout observee dans les axSpA (86 %) tandis que l’epaule etait plus frequente au cours du Rhpso (60,9 %). Les patients atteints de axSpA avaient la prevalence la plus basse d’enthesite (40,9 %) et de dactylite (6,0 %) ; cependant, les dactylites etaient plus souvent localises aux pieds au cours de la axSpA et aux mains au cours des ReA et SpA-MICI. Conclusion Cette etude suggere que toutes ces manifestations musculosquelettiques peripheriques peuvent etre trouvees dans tous les sous-types de SpA (en incluant le Rhpso), avec seulement des differences quantitatives. Ces resultats confirment le chevauchement entre les differentes entites et suggerent que la probabilite de trouver ces manifestations depend de la maladie sous-jacente. En plus, ces resultats confirment la grande variabilite dans l’expression de la maladie entre pays.

The aims of this study are to present the results of Egyptian RA patients included in COMORA cohort and compare it to general COMORA cohort, concerning prevalence of comorbidities, and level of application of recommendations related to detection/prevention of comorbidities. Three-hundred eight Egyptian RA patients included in the cross-sectional, observational, multi-center, international study "COMORA", were compared to the total number of 3612 RA patients. The CRF of COMORA was used in all patients. CRF collects demographic and disease characteristics, comorbidities, risk factors, and compliance with recommendations regarding management of comorbidities. Data were analyzed according to COMORA protocol. Egyptian RA patients were significantly younger, had more active disease, and were more functionally disabled. They showed more frequent use of NSAIDs, methotrexate and steroids and significantly lower use of bDMARDs when compared to non-Egyptians. Egyptian patients had the highest ever HCV prevalence, while depression, hypertension, smoking and dyslipidemia were less prevalent in Egyptians. Prevalence of malignancy risk factors was highly deficient among Egyptians; primarily due to lack of screening. Further, following recommendations for monitoring comorbidities is significantly deficient among Egyptian patients. Egyptian patients had more active disease and more functional impairment than the rest of the COMORA cohort; with lower use of bDMARDs, that is possibly related to the economic situation. Also, there is a clear gap in screening and monitoring comorbidities. Awareness among Egyptian healthcare providers (and possibly similar third-world countries) to detect and manage RA-related comorbidities is required.

In the original version of this article the first name of the co-author was incorrectly spelled as "Khaled A. Alnaqbi". The correct spelling should have been "Khalid A. Alnaqbi". This is now presented correctly in this article.

Background Using a treatment target in rheumatoid arthritis (RA), such as DAS-28 and involving patients in their disease management can improve prognosis. Objectives To develop and implement an educational video that instructs patients with RA for self-assessment of disease activity using DAS-28. Methods Step 1:Initiation. Rheumatologists from some Middle Eastern Arab countries were invited to participate in this study. International experts and societies were contacted to access pre-existing educational material. Step 2: Development. Different material sources were synthetized and translated into Arabic and validated by the rheumatologists. The educational video was shot by a professional team with a real patient and a rheumatologist on set. Step 3. Validation. The final products (leaflets and video) were validated by the rheumatologists and tested with patients (figure 1). Obstacles were noted at the various study levels. Results 23 rheumatologists from 7 Middle Eastern Arab countries participated in the study. A one-page educational leaflet was developed in Arabic and English languages. An educational video presenting the treat-to-target concept and the basics of DAS performance was produced in Arabic language with English subtitles. Obstacles at the rheumatologist, patient, cultural and logistic levels were identified and the potential solutions were addressed by the study team. Conclusions Collaboration between several countries sharing the same language and similar cultural backgrounds was possible and able to produce an educational video aiming at the empowerment of RA patients for the self-assessment of their disease activity. The video will serve for future studies in the Arabic-speaking countries and will be available later for clinical use according to the rheumatologist’s clinical judgment. References [1] Smolenet al. Ann Rheum Dis2015;0:1–13. [2] Gossec, et al. Arthritis Rheumatol2016;68(suppl 10). [3] Studenic, et al. 2012;64(9):2814–23. www.nras.org.uk and www.das-score.nl Acknowledgements Professor Maxime Dougados, Paris. Disclosure of Interest None declared

Aim To review the published studies that dose down and then discontinue biologic therapy in patients with rheumatoid arthritis (RA), particularly concerning the criteria for such dosing and the impact on clinical outcomes. Methods Published studies conducted in patients with RA that sequentially decreased the dose and then discontinued therapy were included if one or more of the following biologic disease modifying antirheumatic drugs (bDMARDs) was evaluated: abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab or tocilizumab. Results Five studies qualified for inclusion. The populations of patients with RA were heterogeneous among the studies; patients were required to have low disease activity (LDA) or to be in remission prior to dose titration. Approximately 25-65% of patients successfully decreased and in some cases, discontinued the bDMARD. However, the flare rate was higher than for the patients who remained on a standard dose. The only variable that predicted relapse in more than one study was down-titration of the bDMARD dose. Conclusion In patients who have achieved LDA or remission, down-titration and discontinuation of bDMARD therapy may be attempted, with careful monitoring. However, it is likely that some patients will flare, and it is not known how to predict these patients.

Aim of the work To evaluate frequency and causes of discontinuation of methotrexate (MTX) in a group of Egyptian patients and to identify factors that may increase the incidence of its discontinuation. Patients and methods One hundred and fifty seven rheumatoid arthritis (RA) patients with disease duration of at least one year, using or were using methotrexate, were included in this study. All patients were subjected to full history taking including the cause of discontinuation of methotrexate, full detailed clinical examination, laboratory assessment, X-ray hands and assessment of disease activity score (28 joints) (DAS 28) for all RA patients. Patients were divided into two groups according to the current status of MTX use, to identify factors which may increase the incidence of MTX discontinuation. Results Forty six (29.3%) of the patients stopped MTX due to different causes, hepatic and gastrointestinal side effects were the most common causes of discontinuation, representing together 69.5% of causes of discontinuation. We found significant statistical difference between the two groups regarding disease duration, erythrocyte sedimentation rate (ESR), corticosteroid and non steroidal-anti-inflammatory drug (NSAID) use. Conclusion MTX is a safe and effective drug for RA patients and usually well tolerated, however the use of NSAIDs and corticosteroid may be associated with increased risk of discontinuation of methotrexate especially in patients with long standing disease.

BackgroundIncreased risk of some comorbidities has been reported in spondyloarthritis (SpA). Recommendations for detection/management of some of these comorbidities have been proposed, and it is known that a gap exists between these and their implementation in practice.ObjectiveTo evaluate (1) the prevalence of comorbidities and risk factors in different countries worldwide, (2) the gap between available recommendations and daily practice for management of these comorbidities and (3) the prevalence of previously unknown risk factors detected as a result of the present initiative.MethodsCross-sectional international study with 22 participating countries (from four continents), including 3984 patients with SpA according to the rheumatologist.Statistical analysisThe prevalence of comorbidities (cardiovascular, infection, cancer, osteoporosis and gastrointestinal) and risk factors; percentage of patients optimally monitored for comorbidities according to available recommendations and percentage of patients for whom a risk factor was detected due to this study.ResultsThe most frequent comorbidities were osteoporosis (13%) and gastroduodenal ulcer (11%). The most frequent risk factors were hypertension (34%), smoking (29%) and hypercholesterolaemia (27%). Substantial intercountry variability was observed for screening of comorbidities (eg, for LDL cholesterol measurement: from 8% (Taiwan) to 98% (Germany)). Systematic evaluation (eg, blood pressure (BP), cholesterol) during this study unveiled previously unknown risk factors (eg, elevated BP (14%)), emphasising the suboptimal monitoring of comorbidities.ConclusionsA high prevalence of comorbidities in SpA has been shown. Rigorous application of systematic evaluation of comorbidities may permit earlier detection, which may ultimately result in an improved outcome of patients with SpA.

This study was designed to highlight the relation of tumor necrosis factor-α (TNF-α) to neuropsychiatric lupus (NPLE) manifestations. The relation of TNF-α to the type of single photon emission computed tomography (SPECT) findings in this context was also studied. Twenty-one systemic lupus erythematosus (SLE) females, mean age 27.57 ± 9.89 years, and twenty age-matched normal females (controls), were subjected to TNF-α assessment. Different clinical and neuropsychiatric manifestations were evaluated. SPECT was carried out for all patients. The results showed that the mean TNF-α level (pg/ml) was significantly raised in patients compared with controls (167.8 ± 102.5 versus 64 ± 50.2, respectively, P0.005). Thirteen patients (69.1%) had NPLE manifestations. NPLE patients had a significantly higher mean TNF-α than patients without NPLE (203 ± 102.8 versus 109 ± 47.3, respectively, P0.03). Positive SPECT findings were found in 18 lupus patients (85.7%), including all 13 patients with NPLE (100% sensitivity), with a multiple focal pattern of hypoperfusion being the most frequent type (9/13), followed by diffuse (3/13), and then single focal pattern (1/13). The mean TNF-α was significantly higher in patients with multiple focal pattern (P0.001). In conclusion, results of this work support the hypothesis that TNF-α could be involved in the pathogenesis of NPLE, and hence, it could be speculated that the evolving anti-TNF therapy can play a potential role in the management of this disease.

Background: Patients with rheumatoid arthritis (RA) are at increased risk of developing comorbid conditions.\ud \ud Objectives: To evaluate the prevalence of comorbidities and compare their management in RA patients from different countries worldwide.\ud \ud Methods Study design: international, cross-sectional. Patients: consecutive RA patients. Data collected: demographics, disease characteristics (activity, severity, treatment), comorbidities (cardiovascular, infections, cancer, gastrointestinal, pulmonary, osteoporosis and psychiatric disorders).\ud \ud Results: Of 4586 patients recruited in 17 participating countries, 3920 were analysed (age, 56±13 years; disease duration, 10±9 years (mean±SD); female gender, 82%; DAS28 (Disease Activity Score using 28 joints)–erythrocyte sedimentation rate, 3.7±1.6 (mean±SD); Health Assessment Questionnaire, 1.0±0.7 (mean±SD); past or current methotrexate use, 89%; past or current use of biological agents, 39%. The most frequently associated diseases (past or current) were: depression, 15%; asthma, 6.6%; cardiovascular events (myocardial infarction, stroke), 6%; solid malignancies (excluding basal cell carcinoma), 4.5%; chronic obstructive pulmonary disease, 3.5%. High intercountry variability was observed for both the prevalence of comorbidities and the proportion of subjects complying with recommendations for preventing and managing comorbidities. The systematic evaluation of comorbidities in this study detected abnormalities in vital signs, such as elevated blood pressure in 11.2%, and identified conditions that manifest as laboratory test abnormalities, such as hyperglycaemia in 3.3% and hyperlipidaemia in 8.3%.\ud \ud Conclusions: Among RA patients, there is a high prevalence of comorbidities and their risk factors. In this multinational sample, variability among countries was wide, not only in prevalence but also in compliance with recommendations for preventing and managing these comorbidities. Systematic measurement of vital signs and laboratory testing detects otherwise unrecognised comorbid conditions.

NTRODUCTION:The Assessments of SpondyloArthritis international society Health Index (ASAS HI) measures functioning and health in patients with spondyloarthritis (SpA) across 17 aspects of health and 9 environmental factors (EF). The objective was to translate and adapt the original English version of the ASAS HI, including the EF Item Set, cross-culturally into 15 languages.METHODS:Translation and cross-cultural adaptation has been carried out following the forward-backward procedure. In the cognitive debriefing, 10 patients/country across a broad spectrum of sociodemographic background, were included.RESULTS:The ASAS HI and the EF Item Set were translated into Arabic, Chinese, Croatian, Dutch, French, German, Greek, Hungarian, Italian, Korean, Portuguese, Russian, Spanish, Thai and Turkish. Some difficulties were experienced with translation of the contextual factors indicating that these concepts may be more culturally-dependent. A total of 215 patients with axial SpA across 23 countries (62.3% men, mean (SD) age 42.4 (13.9) years) participated in the field test. Cognitive debriefing showed that items of the ASAS HI and EF Item Set are clear, relevant and comprehensive. All versions were accepted with minor modifications with respect to item wording and response option. The wording of three items had to be adapted to improve clarity. As a result of cognitive debriefing, a new response option 'not applicable' was added to two items of the ASAS HI to improve appropriateness.DISCUSSION:This study showed that the items of the ASAS HI including the EFs were readily adaptable throughout all countries, indicating that the concepts covered were comprehensive, clear and meaningful in different cultures.