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OBJECTIVE: . To compare the screening performance of the Psoriasis Epidemiology Screening Tool (PEST), Psoriatic Arthritis Screening and Evaluation (PASE) and Early Arthritis for Psoriatic Patients (EARP) questionnaires for detecting PsA among psoriasis patients in a primary care setting.METHODS: In a cross-sectional study, 473 primary care psoriasis patients at risk for PsA completed the PEST, PASE and EARP questionnaires and were clinically evaluated by a trained research nurse. A PsA case was defined by a rheumatologist according to the CASPAR criteria. Sensitivity and specificity were determined for the PEST and EARP cut-offs (⩾3) and the PASE cut-offs (⩾44 and ⩾47).RESULTS: PsA was diagnosed in 53 patients. The PEST had a sensitivity of 0.68 and a specificity of 0.71. The PASE was validated for two different cut-offs. The cut-off of 47 led to a sensitivity of 0.59 and a specificity of 0.66, whereas the lower cut-off of 44 led to a sensitivity of 0.66 and a specificity of 0.57. For the EARP we found a sensitivity of 0.87 with a specificity of 0.34.CONCLUSION: The PEST questionnaire has the most favourable trade-off between sensitivity and specificity to screen for PsA. However, as the prevalence of psoriasis and PsA is fairly low in primary care, screening only psoriasis patients with musculoskeletal complaints may be a better allocation of resources.

textabstractObjective To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care. Methods We conducted a cross-sectional study in adult primary care patients with psoriasis. Responding patients reporting pain in joints, entheses, or the lower back were interviewed by telephone to determine eligibility and, if eligible, were invited for clinical evaluation. During clinical evaluation, skin, nails, joints, and entheses were assessed. Additionally, ultrasound of the enthesis was performed by an independent trained examiner if a patient had at least 1 tender enthesis (determined by the Leeds Enthesitis Index and the Maastricht Ankylosing Spondylitis Enthesitis Score). Patients who fulfilled the Classification of Psoriatic Arthritis (CASPAR) Study Group criteria were classified as having PsA. Results We invited 2,564 psoriasis patients from databases of 97 participating general practitioners. Of 1,673 responders (65.2%), 841 (50.3%) were willing to participate. A total of 823 patients (32.1%) reported having musculoskeletal symptoms; 659 of these patients were determined to be eligible, 524 of whom were clinically evaluated. We identified 64 cases of established PsA and another 17 cases of newly diagnosed PsA, leading to a prevalence of 3.2% (95% confidence interval [95% CI] 2.5-3.9) among psoriasis patients in primary care. This prevalence would increase to 4.6% (95% CI 3.8-5.4) if PsA cases based on enthesitis were also taken into account. Conclusion Among psoriasis patients in primary care, the prevalence of PsA is conservatively estimated to be 3.2%, increasing to 4.6% if enthesitis is taken into account. The prevalence of musculoskeletal symptoms among psoriasis patients is comparable with the prevalence of musculoskeletal symptoms in the general population.

Part of the psoriasis patients with musculoskeletal complaints will have inflammation of the entheses. Entheseal inflammation is difficult to assess by clinical examination only. Therefore, we aimed to determine the frequency of clinically relevant ultrasound inflammation at the most commonly assessed entheses (MASEI; Madrid Sonographic Enthesis Index) in primary care psoriasis patients with one or more tender entheses.Adult primary care psoriasis patients with musculoskeletal complaints (tender enthesis or arthritis at physical examination) had an ultrasound examination of seven entheses according to the MASEI. Clinically relevant ultrasound inflammation was defined as active inflammation on ultrasound in combination with at least one clinical feature at the same enthesis. Active ultrasound inflammation contained positive power Doppler signal or in case of the plantar aponeurosis increased thickness. Structural changes entailed calcifications, enthesophytes, increased thickness, hypoechogeneicity indicating irregular fibre structure and erosions. Clinically, an enthesis was scored positive by a tender enthesis at clinical examination, reported pain in the history or self-reported pain in the questionnaires.Of 542 primary care psoriasis patient, 111 patients had tender entheses and/or arthritis. These patients were both clinically and ultrasonographically evaluated. Active ultrasound inflammation accompanied with pain or tenderness at the enthesis was found in 36% of the patients (n=40). Most common were inflammation at the knee (n=11) and at the plantar aponeurosis (n=10). Structural changes were observed in 95% of the psoriasis patients independent of their clinical manifestation.We found concurrent presence of ultrasound inflammatory changes and clinical symptoms in 36% of the primary care psoriasis patients who had tenderness at one or more entheseal sites.

To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care.We conducted a cross-sectional study in adult primary care patients with psoriasis. Responding patients reporting pain in joints, entheses, or the lower back were interviewed by telephone to determine eligibility and, if eligible, were invited for clinical evaluation. During clinical evaluation, skin, nails, joints, and entheses were assessed. Additionally, ultrasound of the enthesis was performed by an independent trained examiner if a patient had at least 1 tender enthesis (determined by the Leeds Enthesitis Index and the Maastricht Ankylosing Spondylitis Enthesitis Score). Patients who fulfilled the Classification of Psoriatic Arthritis (CASPAR) Study Group criteria were classified as having PsA.We invited 2,564 psoriasis patients from databases of 97 participating general practitioners. Of 1,673 responders (65.2%), 841 (50.3%) were willing to participate. A total of 823 patients (32.1%) reported having musculoskeletal symptoms; 659 of these patients were determined to be eligible, 524 of whom were clinically evaluated. We identified 64 cases of established PsA and another 17 cases of newly diagnosed PsA, leading to a prevalence of 3.2% (95% confidence interval [95% CI] 2.5-3.9) among psoriasis patients in primary care. This prevalence would increase to 4.6% (95% CI 3.8-5.4) if PsA cases based on enthesitis were also taken into account.Among psoriasis patients in primary care, the prevalence of PsA is conservatively estimated to be 3.2%, increasing to 4.6% if enthesitis is taken into account. The prevalence of musculoskeletal symptoms among psoriasis patients is comparable with the prevalence of musculoskeletal symptoms in the general population.

BACKGROUND AND AIMS: Inflammatory bowel disease [IBD] is a chronic disease which affects up to 0.5% of the population. Various extraintestinal manifestations occur, among which are rheumatic manifestations, grouped together under the name spondyloarthritis. The objective of this systematic review and meta-analysis was to give a systematic overview of the prevalence and incidence of spondyloarthritis in patients with inflammatory bowel disease.METHODS: We systematically searched Embase, Pubmed, OvidSP, Scopus, and Web-of-Science databases from inception to August 2016. All articles that addressed the prevalence or incidence of the different features of spondyloarthritis in adult inflammatory bowel disease patients were included. Methodological quality was assessed using a modified quality assessment tool developed for prevalence studies.RESULTS: A total of 71 studies were included, reporting on the prevalence of sacroiliitis, ankylosing spondylitis, arthritis, enthesitis, and dactylitis. Pooled prevalences were calculated for sacroiliitis (10%; 95% confidence interval [CI] 8-12%), ankylosing spondylitis [3%; 95% CI 2-4%], and arthritis [13%; 95% CI 12-15%]. Geographical area, setting and use of different criteria contribute to the large heterogeneity. Few estimates were available for enthesitis [prevalence range from 1% to 54%] and dactylitis [prevalence range from 0% to 6%]. Only three incidence studies were identified, which report cumulative incidences from 5 to 30 years.CONCLUSIONS: Spondyloarthritis occurs in up to 13% of patients with IBD. Ankylosing spondylitis is the least common [3%] followed by sacroiliitis [10%] and peripheral arthritis [13%].

Background Patients with psoriasis (PSO) and inflammatory bowel disease (IBD) are at risk for developing spondyloarthritis (SpA). To overcome diagnostic delay, physicians treating patients with these conditions should be aware of this increased risk to minimize doctors9 delay in referring patients to specialized care. However, as patients9 delay could also be an issue, patients themselves should also be aware of their risk to develop SpA. Since the need to empower patients in order to effectively manage their disease has recently been included in several guidelines for rheumatic diseases, involving patients in their disease becomes more and more important. Objectives To assess whether patients with PSO or IBD are aware of the risk of developing SpA and if so how they became aware. Methods A cross-sectional study was set up including PSO and IBD patients between 18 and 55 years of age. Patients were invited to participate either by their GP or by the patient organizations for PSO and IBD. Patients willing to participate completed a set of questionnaires regarding their disease, level of awareness and presence of musculoskeletal complaints. Results 552 PSO patients completed the questionnaires, of which 43.1% indicated to be aware of the possibility of developing a rheumatic condition already before the study-invitation. Of these 238 patients, 34% indicated to have gained this knowledge by themselves. Another 13.5% was informed by their GP and 24.4% by their medical specialist, while 18.5% learned from family or neighbors. Of the IBD patients, 344 completed the questionnaires, of which 41.9% was aware of the possibility of developing a rheumatic condition before the invitation for the study. The majority of patients was informed by their medical specialist (40.3%) or gained this knowledge by themselves (39.6%). Only 1.4% was informed by their GP and 9.7% learned from family or neighbors. For both PSO and IBD, patients who were recruited via the patient organizations were significantly more aware than patients recruited via the GPs. Conclusions Less than half of the patients with psoriasis or IBD are aware of the possibility of developing a rheumatic condition. If patients are aware, the majority gained this knowledge by themselves and 60% were not informed by a medical professional. More awareness could be achieved if medical professionals like the GP or the medical specialist would have more knowledge about symptoms of SpA and are trained in informing their patients about the increased risk of developing SpA. Public awareness campaigns to inform patients at risk could also be beneficial in minimizing patients9 delay. Patient organizations could play a role in this awareness campaigns, since they already seem to inform their patients well. Acknowledgement This survey is part of initiative to develop a communication platform which was financially supported by AbbVie. Disclosure of Interest None declared

Background Various screening tools have been developed and validated over the years in order to enhance early recognition of psoriatic arthritis (PsA) among psoriasis patients, but their performance remains suboptimal. In 2014 the CONTEST-group developed a new screening tool consisting of the most discriminating questions from 3 existing tools (PEST, PASE, TOPAS) which was externally validated in 2 psoriasis cohorts from dermatology. Validation in a primary care setting has yet to be performed. Objectives To externally validate the CONTEST questionnaire in psoriasis patients in primary care. Methods Data from the SENSOR study was used, a cross-sectional study in adult psoriasis patients with regular spells of musculoskeletal complaints from primary care. In this study, patients completed the PEST and PASE screening-questionnaires before clinical evaluation. Within CONTEST 3 TOPAS questions are used that were not included in our study. These questions were therefore replaced by similar questions: ToPAS 2A was replaced by PEST 3, ToPAS 2B by nail assessment by a dermatologist and ToPAS 7 by data from the manikin in the PEST. We calculated sensitivity, specificity and area under the curve (AUC) for the CONTEST with a cutoff of 4, as well as the CONTEST-w (weighted version, cutoff of 8) and the CONTEST-jt (including the PEST manikin, cutoff of 5). Performance was also calculated selecting the patients in the same way as the CONTEST study, i.e. only inviting patients with a positive PEST and/or PASE questionnaire for clinical evaluation. As a reference standard we used a clinical diagnosis of PsA made by a rheumatologist and enthesitis confirmed by ultrasound (presence of Power Doppler). Results from our dataset were compared with data from the development cohort and with the performance of the PEST. Results For this analysis 473 psoriasis patients at risk for PsA were available. Compared with the development cohort sensitivity was considerably lower in our dataset (0.30–0.51) than in the development of the CONTEST (0.86). Specificity was higher in our dataset (0.75–0.87) compared with the CONTEST development (0.35–0.48). While AUCs were around 0.7 for all three versions, comparable with the AUCs found in the development of CONTEST. Comparing these results with the performance of the PEST in our population, it shows that the sensitivity is lower for the CONTEST (0.30–0.51) than for the PEST (0.68), while the specificity is slightly higher (0.75–0.87 vs 0.71). Conclusions External validation of the CONTEST questionnaire in primary care psoriasis patients with regular spells of musculoskeletal symptoms resulted in lower sensitivity and higher specificity compared to the development cohort, while AUCs were comparable. When only selecting patients with at least one positive screeningtool, the sensitivity slightly increases while the specificity slightly decreases. However, the performance of the CONTEST questionnaires does not seem to exceed the performance of the PEST in a primary care setting. Acknowledgement This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Background Inflammatory Bowel Disease (IBD) is a chronic disease that affects up to 0.5% of the population, comprising both Crohn9s Disease (CD) and ulcerative colitis (UC). Various extra-intestinal manifestations can occur, among which spondyloarthritis (SpA). SpA can manifest with both axial and peripheral manifestations, but prevalence estimates of these manifestations differ widely. Objectives To provide a pooled estimate of the prevalence of axial and peripheral manifestations of SpA in patients with IBD and to identify factors that might influence the prevalence estimates. Methods We systematically searched Embase, Pubmed, OvidSP, Scopus and Web-of-science databases from inception to May 2014. All articles addressing the prevalence of axial and/or peripheral manifestations of spondyloarthritis in adult IBD patients were included. Risk of bias was assessed using a quality assessment tool including items on selection bias, non-response bias, sample size and misclassification of SpA diagnosis. Results Out of 4846 studies, 60 studies were included. Sample size varied from 9 to 4454. Methodological quality of the included studies was moderate, with only a slight majority scoring positively on the individual items of the quality assessment tool. With regard to axial manifestations, the pooled prevalence of sacroiliitis was 0.11 (95% CI 0.08–0.014), whereas the pooled prevalence for ankylosing spondylitis was 0.03 (95% CI 0.03–0.04). For peripheral arthritis the pooled prevalence was 0.14 (95% CI 0.12–0.16). Few estimates were available for the prevalence of enthesitis (range from 0.01 to 0.54) and dactylitis (range from 0 to 0.04). For both axial and peripheral manifestations, the prevalence was higher in patients with CD than in patients with UC. Heterogeneity between studies was large, which might be explained by methodological quality as well as difference in geographic area, clinical setting and the use of criteria for case ascertainment as shown in figure 1 for the prevalence of SI and AS. Conclusions Spondyloarthritis is a common extraintestinal manifestation in IBD. Peripheral arthritis is slightly more common with a pooled prevalence of 0.14 than axial manifestations as sacroiliitis (pooled prevalence 0.11) and ankylosing spondylitis (pooled prevalence 0.03). For both axial and peripheral manifestations, the prevalence is higher in patients with CD than in patients with UC. Disclosure of Interest None declared

Background Over the last couple of years early arthritis clinics provided quick access for patients with inflammatory arthritis. However, although early access to specialized care is now available, adequate referrals are also required to shorten the doctors9 delay. Therefore, general practitioners (GPs), the ones who refer, should be aware of symptoms distinguishing between inflammatory and non-inflammatory disease in patients at risk for spondyloarthritis (SpA). Objectives To describe GP9s ability to recognize symptoms suggestive of spondyloarthritis. Methods The AppSpA study was set up, a cross-sectional study focusing on awareness and knowledge of SpA in GPs and patients at risk for SpA. For the present study a single survey was developed and send out to GPs in various regions of the Netherlands. This survey was based on a study by Jois et al, which looked into recognition of symptoms of inflammatory back pain. Since we were also interested in the ability of GPs to recognize peripheral manifestations of SpA, we added some extra questions. Results 183 of the 950 GPs completed the survey, leading to a participation rate of 19.3%. Of the participating GPs the mean age was 47.2 years (SD 10.3) and 47.5% were male. Mean time working as a GP was 15.4 years (SD 13.5). Almost all GPs (94.5%) indicated to be familiar with the term SpA, but 55.5% associated it only with axial manifestations. Up to one third of the GPs associated the term SpA with psoriatic arthritis (23.7%) and Inflammatory Bowel Disease (33.5%). With regard to the recognition of signs of inflammatory pain, especially morning stiffness and pain relieve by NSAIDs were recognized (Table 1), whereas pain improvement with exercise was recognized in less than 25% of cases. When we focus on the peripheral manifestations of SpA; out of six signs for inflammatory peripheral disease, only 43.2% of GPs recognized at least three of these symptoms. For the eight axial signs, 60.6% recognized at least four symptoms. If GPs thought about inflammatory symptoms, the majority asked for the presence of psoriasis (83.6%) and inflammatory bowel disease (72.1%). GPs less often ask about other SpA related symptoms such as uveitis (61.8%), enthesitis (19.1%) and dactylitis (19.1%). Conclusions Overall, recognition of inflammatory disease by GPs is suboptimal, where GPs are more aware of axial manifestations compared to peripheral manifestations. The recognition of these signs and symptoms of SpA in primary care needs improvement in order to facilitate the necessary referrals to rheumatologists. Acknowledgement This survey is part of initiative to develop a communication platform which was financially supported by AbbVie. Disclosure of Interest None declared

Background Psoriatic Arthritis (PsA) is a progressive inflammatory joint disease that can lead to severe joint damage. New treatment strategies can be very effective in early stages of the disease [1]. This requires early recognition of the symptoms to be PsA. Several screening tools have been developed to enhance early recognition [1-4]. However, most were developed in secondary care [2,3], while early recognition should ideally take place in primary care. Objectives To evaluate the screening performance of the PEST [4], PASE [2,5] and EARP [3] to identify psoriatic arthritis among primary care psoriasis patients with recurrent spells musculoskeletal complaints (MSC). Methods We conducted a cross-sectional study in adult primary care patients with psoriasis who reported recurrent MSC spells. Patients were selected by ICPC code S91 for psoriasis and the presence of recurrent spells of MSC (joints, enthesis or low back pain) was determined by telephone interview. Patients completed the PEST, PASE & EARP questionnaires before clinical evaluation by a trained research nurse. Assessments included PASI, LEI/MASES, 66/68-joint count and the presence of nail-psoriasis. When patients reported a painful enthesis on LEI/MASES, an ultrasound of the entheses was performed. A PsA case fulfilled the CASPAR criteria. Sensitivity and specificity were determined for the PEST and EARP cut off ≥3 and PASE cut off ≥44 as well as ≥47. Results 473 psoriasis patients participated with a mean ± SD age of 55.7±13.9 years and 50.9% being male. Median PASI score was 2.3 (IQR 1-4) and 71 patients (15.0%) had nail abnormalities related to psoriasis. We found 17 new cases of PsA (3.6%) as diagnosed by a rheumatologist. Moreover, we found 36 cases of enthesitis, confirmed by ultrasound. The majority of these refrained from further evaluation by a rheumatologist, however most of them would classify as PsA according to the CASPAR criteria. Looking into all cases, including enthesitis, the EARP had a sensitivity of 87% and a specificity of 33%, for the PEST this was 68% and 71%. The PASE had a sensitivity of 66% and a specificity of 55% at the cut off of ≥44 and 59% and 64% at the cut off of≥47 (Table 2). Similar figures were observed if only axial manifestations and arthritis were taken into account. Conclusions Modest sensitivity was observed for the PEST and PASE with an acceptable specificity for the PEST, while the EARP had high sensitivity and low specificity, which is undesirable for screening. The performance of all screening tools was lower than previously reported in secondary care settings [1-4]. References Coates LC, et al. BMC Musculoskelet Disord, 2013. Husni ME, et al. J Am Acad Dermatol, 2007. Tinazzi I, et al. Rheumatology (Oxford), 2012. Ibrahim GH, et al. Clin Exp Rheumatol, 2009. Dominguez, PL, et al. Arch Dermatol Res, 2009. Acknowledgements This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Background Psoriasis patients with enthesitis can classify as psoriatic arthritis since the introduction of the CASPAR classification criteria in 2006. However, clinical assessment of the entheses could be challenging. In addition, the presence of a tender enthesis is not necessarily indicative for underlying inflammatory disease as it could be related to overuse, metabolic disease or ageing. Therefore, we need a better way to identify the inflammatory component of entheseal involvement in psoriasis. To detect these inflammatory components in the entheses, ultrasound (US) examination can be used to identify inflammatory disease at the entheses. Objectives Our aims were to determine the prevalence of US abnormalities among psoriasis patients in primary care and to determine the concordance of clinical and US information at individual entheseal sites. Methods Adult patients with psoriasis were invited to participate in the SENSOR study. Patients who reported pain in joints, entheses or the lower back were eligible for clinical evaluation. If physical examination indicated a painful enthesis on the LEI/MASES or if arthritis was present, US examination of the entheses was performed. The six entheses of the Madrid Sonographic Enthesis Index (MASEI) and the lateral epicondyle tendon insertion (elbow) were evaluated according to the MASEI scoring system. Enthesitis was defined as US inflammation (positive power Doppler (PD) signal or a thickened enthesis of the plantar fascia) in combination with one clinical feature at the same enthesis. Structural changes detected by ultrasound were calcifications, increased thickness, irregular fibre structure and erosions. Results Of 524 patients who participated in the SENSOR study, 111 patients were assessed both by physical examination and by US. In 106 (95%) patients we detected US abnormalities. In 56 (50%) patients we found structural changes without indication for inflammatory disease. In 50 (45%) patients we found US abnormalities indicating inflammatory disease at the enthesis (positive PD: n=35; thickened plantar fascia: n=15). When we combined the US data with the clinical information, 36% of US inflammatory disease were confirmed [Figure 1]. Conclusions We found US abnormalities in 95% of the primary care psoriasis patients with musculoskeletal complaints, which is a combination of both structural and inflammatory US components. In 45% of primary care psoriasis patients we observed US inflammatory disease, which was confirmed in 36% of the patients by clinical information. Acknowledgements This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Background Over 25% of the new consultations in primary care is due to musculoskeletal complaints (MSC)(1). In patient with psoriasis, the underlying diagnosis could be psoriatic arthritis (PsA). Prevalence figures of PsA in psoriasis patients vary widely (6-42%) and data in primary care is scarce (2, 3) Objectives To estimate the prevalence of MSC and PsA in primary care patients with psoriasis. Methods We conducted a cross-sectional study in adult primary care patients with psoriasis. Patients were identified from GP records by ICPC code S91 for psoriasis. Responding patients reporting pain in joints, entheses or the lower back were checked on eligibility by a telephone interview and invited for clinical evaluation. Ultrasonoghraphy (US) of the enthesis was performed if a patient had at least one tender enthesis (LEI/MASES) by an independent trained examiner. Patients were referred to a rheumatologist if clinical evaluation suggested the presence of arthritis or axial disease or ultrasonography of the enthesis showed positive Power Doppler (PD) signal. A PsA case was defined by opinion of the rheumatologist or fulfilling the CASPAR criteria with PD signal in an enthesis on US. Results 2564 psoriasis (PsO) patients from 97 GPs were invited. Of the 1673 responders (65.2%), 841 (50.3%) were willing to participate. 823 (32.1%) patients reported suffering from MSC of which eventually 524 were eligible and clinically evaluated. We identified 81 cases of PsA (Figure 1), of which 17 (21%) were newly diagnosed, leading to a prevalence of 3.2% (95%CI 2.5%>3.9%) among primary care psoriasis patients, assuming no additional cases of PsA among the non-responders. Besides these cases, we also identified 36 patients with enthesitis confirmed by ultrasound, which would increase the prevalence of PsA towards 4.6% (95% CI 3.8%>5.4%). Conclusions Among psoriasis patients in primary care the prevalence of PsA is estimated to be 3.2%, which would increase towards 4.6% if you take the enthesitis cases into account. Moreover, 21% of the cases was newly diagnosed. We hereby assumed that no additional cases would be observed in the non-responders. The prevalence of MSC is estimated to be 32.1%, which is comparable with the prevalence in general population (1). References van der Linden MW et al., NIVEL/RIVM2004. Ibrahim G. et al, Arthritis Rheum. 2009. Gelfand JM. et al, Arch Dermatol. 2005 Acknowledgements This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared