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Clinical practice guidelines are designed to ensure that patients are treated according to best evidence, with the goal of optimizing clinical outcomes and reducing unwarranted variation in care. They compile, rate and translate the data available into recommendations that form the basis of evidence-based practice for most clinicians. Despite their importance, the evidence base informing different guidelines varies in quality. A recent study of American College of Rheumatology (ACR) Practice Guidelines demonstrated only 17 of 35 class I (strong benefit to harm ratio) recommendations were supported by level A evidence (high quality randomized controlled trails or meta-analyses)1. To review the evidence supporting the British Society for Rheumatology (BSR) guidelines. Thirteen sets of guidelines that were available on the BSR website as of October 16th 2019 were reviewed (https://www.rheumatology.org.uk/practice-quality/guidelines). A range of methodologies (including Grading of Recommendations Assessment, Development and Evaluation (GRADE), Scottish Intercollegiate Guidelines Network (SIGN), EULAR and Royal College of Physicians (RCP) recommendations) were used to assess the quality of evidence and strength of recommendation. For comparability between guidelines the level of evidence was converted to a score between I (highest quality) and IV (lowest quality) and the strength of recommendation was converted to a rating between A and D. The polymyalgia rheumatica guideline was not assessed due to unclear methodology and lack of level of evidence for all recommendations. Of the 12 BSR guidelines assessed, there were 554 recommendations in total. The number of recommendations per guideline ranged between 13 and 80. Across all assessed guidelines, 94 recommendations (17.0%) were classified as level I, 161 (29.1%) as level 2 and 299 (54.0%) as level 3 or 4. These figures are similar to those reported in the ACR guidelines (23%, 19% and 58% respectively)1. The proportion of level I evidence varied from 46.2% (Axial Spondyloarthropathy guideline) to 0% (Hot Swollen Joint guideline). Over half of all BSR guideline recommendations have level of supporting evidence of III/IV. A wide range of methodologies are used to generate BSR guidelines (GRADE, SIGN, RCP / EULAR). This makes it challenging for readers unfamiliar with these approaches to interpret evidence and hinders comparisons between guidelines. A standardized methodology for future guideline development would overcome these barriers. [1]Duarte-Garcia A, Zamore R & Wong JB. The Evidence Basis for the American College of Rheumatology Practice Guidelines. JAMA Intern Med, 2018 Jan 1;178(1):146-148. None declared

Background: The most effective treatment approach for sacroiliac joint (SIJ) pain in spondyloarthropathy (SpA) patients remains unclear. This systematic review and meta-analysis aimed to assess the safety and effectiveness of different injective therapies for SIJ pain in SpA patients. Methods: A comprehensive literature search was conducted up to January 2024. The inclusion criteria encompassed studies in English, including comparative and non-comparative studies, and case series. A meta-analysis was performed on the available data. The “Checklist for Measuring Quality” by Downs and Black was used to evaluate the quality of included papers. Results: A total of 17 studies involving 494 patients were included: 12 prospective case series, 1 retrospective comparative study, 2 prospective comparative studies, and 2 randomized controlled trials. Steroid injections were analyzed in 15 studies, etanercept in 1, and infliximab in 1. A meta-analysis of 375 patients receiving steroid injections showed a significant reduction in visual analog scale (VAS) scores from 8.2 pre-treatment to 3.2 (p < 0.001) at short-term follow-up, with stability at mid-term follow-up (VAS 3.3, p < 0.001) and worsening at the last follow-up (VAS 5.1, p < 0.001). The failure rate was 13% (p = 0.019), and one study reported a 12.5% complication rate. Biologic therapies showed no complications or failures, with improvements in both VAS and BASDAI scores. Conclusions: Intra-articular steroid injections are effective and safe for SIJ pain in SpA patients, although their efficacy diminishes over time, and not all patients respond to treatment. Biologic therapies have shown promising results, but further research is needed to confirm their long-term efficacy.

Background:limited chest expansion is a main feature of radiographic axial SpA.Objectives:We aimed to perform a dynamic evaluation of chest movement by ultrasound and to correlate our findings with other disease parameters.Methods:thirty one patients and eleven controls were involved in this cross-sectional study. Intercostal distance has been measured in the left mid-clavicular (MCL), mid-axillary (MAL), and paraspinal (PSL) lines during maximal inspiration and expiration in the fourth intercostal space. The mean differences and percent changes were compared between controls and patients with correlation of the measurements to disease activity and functional indices.Results:the mean age of patients was 34.5, SD±3.53 and 68.7% were females. There was a statistically significant mean difference between patients and controls in all the three lines of measurements; MCL (0.65 SD= ±0.212 Vs 8.5 SD ±2.82, with p = 0.003 and median % change=45.5), MAL (1.2 SD±0.424 Vs 5.3 SD ± 0.283, p = 0.001 and median % change=30.6), and PSL (2.35 SD ± 1.62 Vs 4 SD±0, p= 0.003 and median % change=30.5). Mean differences of MCL and MAL were found correlating with patients age (r=0.61, p=0.04), disease duration (r=0.68, p=0.02), BASMI (r=0.72, p=0.001), and BASFI (r=0.62, p=0.03).Conclusion:ultrasonographic intercostal distance is an easy to measure dynamic indicator on limited chest mobility in patients with radiographic axial SpA. More large scale studies are needed to support our findings and to define cutoff values for the proposed measurements.REFERENCES:NIL.Figure 1.Acknowledgements:NIL.Disclosure of Interests:None declared.

Purpose Destructive spondyloarthropathy (DSA) is a serious complication of long-term haemodialysis; it commonly occurs in the cervical spine and has been investigated in cervical lesions. Although DSA of the lumbar spine has been reported, only few studies have investigated this, and the characteristics of patients with lumbar DSA are unclear. The present study aimed to elucidate the prevalence of DSA and its clinical characteristics in patients with DSA in the lumbar spine using computed tomography (CT) images of the patients who underwent lumbar spine surgery. Methods Consecutive patients undergoing haemodialysis who underwent lumbar spine surgery ( n  = 67) were assessed. DSA was diagnosed using CT images, and the patients were divided into non-DSA and DSA groups. The differences in the clinical characteristics of the patients in the two groups were analysed. Results The prevalence of patients diagnosed with DSA was 31.3%. The mean intra- and inter-observer kappa values of DSA classification using CT images were 0.68 and 0.53, respectively. Although there were no significant differences in the age, sex, body mass index, reason for lumbar surgery, disease causing haemodialysis, age at the start of haemodialysis, or duration of haemodialysis between the non-DSA and DSA groups, the duration of haemodialysis tended to be longer in the DSA group. Conclusion Among patients on haemodialysis who underwent lumbar spine surgery, the prevalence of patients with DSA was 31.3%. Classification of DSA using CT showed moderate-to-substantial agreement. Patients with DSA tended to have a longer haemodialysis duration.

Aim Diagnostic imaging is an integral part of identifying spondyloarthropathies (SpA), yet the interpretation of these images can be challenging. This review evaluated the use of deep learning models to enhance the diagnostic accuracy of SpA imaging. Methods Following PRISMA guidelines, we systematically searched major databases up to February 2024, focusing on studies that applied deep learning to SpA imaging. Performance metrics, model types, and diagnostic tasks were extracted and analyzed. Study quality was assessed using QUADAS-2. Results We analyzed 21 studies employing deep learning in SpA imaging diagnosis across MRI, CT, and X-ray modalities. These models, particularly advanced CNNs and U-Nets, demonstrated high accuracy in diagnosing SpA, differentiating arthritis forms, and assessing disease progression. Performance metrics frequently surpassed traditional methods, with some models achieving AUCs up to 0.98 and matching expert radiologist performance. Conclusion This systematic review underscores the effectiveness of deep learning in SpA imaging diagnostics across MRI, CT, and X-ray modalities. The studies reviewed demonstrated high diagnostic accuracy. However, the presence of small sample sizes in some studies highlights the need for more extensive datasets and further prospective and external validation to enhance the generalizability of these AI models. Key Points Question How can deep learning models improve diagnostic accuracy in imaging for spondyloarthropathies (SpA), addressing challenges in early detection and differentiation from other forms of arthritis? Findings Deep learning models, especially CNNs and U-Nets, showed high accuracy in SpA imaging across MRI, CT, and X-ray, often matching or surpassing expert radiologists. Clinical relevance Deep learning models can enhance diagnostic precision in SpA imaging, potentially reducing diagnostic delays and improving treatment decisions, but further validation on larger datasets is required for clinical integration.

Autoimmunity is intrinsically driven by memory T and B cell clones inappropriately targeted at self-antigens. Selective depletion or suppression of self-reactive T cells remains a holy grail of autoimmune therapy, but disease-associated T cell receptors (TCRs) and cognate antigenic epitopes remained elusive. A TRBV9-containing CD8 + TCR motif was recently associated with the pathogenesis of ankylosing spondylitis, psoriatic arthritis and acute anterior uveitis, and cognate HLA-B*27-presented epitopes were identified. Following successful testing in nonhuman primate models, here we report human TRBV9 + T cell elimination in ankylosing spondylitis. The patient achieved remission within 3 months and ceased anti-TNF therapy after 5 years of continuous use. Complete remission has now persisted for 4 years, with three doses of anti-TRBV9 administered per year. We also observed a profound improvement in spinal mobility metrics and the Bath Ankylosing Spondylitis Metrology Index (BASMI). This represents a possibly curative therapy of an autoimmune disease via selective depletion of a TRBV-defined group of T cells. The anti-TRBV9 therapy could potentially be applicable to other HLA-B*27-associated spondyloarthropathies. Such targeted elimination of the underlying cause of the disease without systemic immunosuppression could offer a new generation of safe and efficient therapies for autoimmunity. Targeted depletion of TRBV9 + T cells induces remission in a single patient with ankylosing spondylitis, with significant improvements in functional and mobility metrics.

We sought to evaluate the association between obesity and response to anti-tumor necrosis factor-α (TNF) agents, through a systematic review and meta-analysis. Through a systematic search through January 24, 2017, we identified randomized controlled trials (RCTs) or observational studies in adults with select immune-mediated inflammatory diseases-inflammatory bowel diseases (IBD), rheumatoid arthritis (RA), spondyloarthropathies (SpA), psoriasis and psoriatic arthritis (PsA)-treated with anti-TNF agents, and reporting outcomes, stratified by body mass index (BMI) categories or weight. Primary outcome was failure to achieve clinical remission or response or treatment modification. We performed random effects meta-analysis and estimated odds ratios (OR) and 95% confidence interval (CI). Based on 54 cohorts including 19,372 patients (23% obese), patients with obesity had 60% higher odds of failing therapy (OR,1.60; 95% CI,1.39-1.83;I2 = 71%). Dose-response relationship was observed (obese vs. normal BMI: OR,1.87 [1.39-2.52]; overweight vs. normal BMI: OR,1.38 [1.11-1.74],p = 0.11); a 1kg/m2 increase in BMI was associated with 6.5% higher odds of failure (OR,1.065 [1.043-1.087]). These effects were observed across patients with rheumatic diseases, but not observed in patients with IBD. Effect was consistent based on dosing regimen/route, study design, exposure definition, and outcome measures. Less than 10% eligible RCTs reported outcomes stratified by BMI. Obesity is an under-reported predictor of inferior response to anti-TNF agents in patients with select immune-mediated inflammatory diseases. A thorough evaluation of obesity as an effect modifier in clinical trials is warranted, and intentional weight loss may serve as adjunctive treatment in patients with obesity failing anti-TNF therapy.

Evaluation of disease activity and functional impairment in Axial spondyloarthritis (AxSpA) are important in therapeutic plan. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS) and The Bath Ankylosing Spondylitis Functional Index (BASFI) scores are based largely on subjective measures, which liable to change depending on patient's expression, culture, and awareness. Assessment of reliability of BASFAI, BASDAI, ASDAS-ESR, and ASDAS-CRP as a total score and individual questions in patients with AxSpA. This cross-sectional study was conducted on 103 patients with AxSpA according to the ASAS classification criteria for AxSpA. Each patient completed BASFAI, BASDAI, ASDAS-ESR, and ASDAS-CRP during their routine visit for follow up with one rheumatologist. Then the same patients completed the three questionnaires again in the same day or on the second day with another rheumatologist. Internal consistency and reliability of ASDAS-ESR, ASDAS-CRP, BASDAI, and BASFAI scores was good (ICC was 0.841, 0.820, 0.767, and 0.852 respectively). Reliability of BASFAI score was better than that of ASDAS-ESR, ASDAS-CRP, BASDAI scores, and that of ASDAS-ESR, ASDAS-CRP was better than reliability of BASDAI score. Some questions of ASDAS, BASDAI, and BASFAI scores are more reliable than others, this depends on the question. The answers of the questions that assess sensation of pain, are liable to change. While the answers of other questions that assess stiffness or assess its duration are less liable to change. Questions that assess certain daily activity are more reliable than that assess the ability to do more than one activity. NIL. NIL. None Declared. Table 1Interclass Correlation Coefficient of BASFAI in AxSpA patients reported by observer 1 and observer 2VariablesCronbach's AlphaICCCI1) Putting on your socks or tights without help or aids (e.g sock aid) (F1).0.9310.8710.815-0.9112) Bending from the waist to pick up a pen from the floor without aid (F2).0.9030.8230.749-0.8773) Reaching up to a high shelf without help or aids (e.g helping hand) (F3).0.8370.7190.612-0.8014) Getting up from an armless chair without your hands or any other help (F4).0.7510.6010.462-0.7115) Getting up off the floor without help from lying on your back(F5).0.7790.6380.508-0.7406)Standing unsupported for 10 minutes without discomfort (F6).0.7070.5470.396-0.6697) Climbing 12-15steps without using a handrail or walking aid (F7).0.8630.7600.664-0.8318) Looking over your shoulder without turning your body (F8).0.8870.7980.715-0.8589)Doing physically demanding activities (e.g physiotherapy exercises, gardening or sports) (F9).0.8170.6900.573-0.77910) Doing a full day's activities whether it be at home or at work (F10).0.7480.5980.458-0.709Total BASFAI Score0.9200.8520.789-0.898ICC (.21 to.4) was indicative of fair agreement, ICC (.41 to.6) was indicative of moderate agreement, ICC (.61 to.8) was indicative of substantial agreement, ICC (.81 to.99) was indicative of almost perfect agreement, and ICC (1) was indicative of perfect agreement.

Patients with inflammatory rheumatic and musculoskeletal diseases (iRMDs) such as rheumatoid arthritis, connective tissue diseases, vasculitides and spondyloarthropathies are at a higher risk of osteoporosis and fractures than are individuals without iRMDs. Research and management recommendations for osteoporosis in iRMDs often focus on glucocorticoids as the most relevant risk factor, but they largely ignore disease-related and general risk factors. However, the aetiopathogenesis of osteoporosis in iRMDs has many facets, including the negative effects on bone health of local and systemic inflammation owing to disease activity, other iRMD-specific risk factors such as disability or malnutrition (for example, malabsorption in systemic sclerosis), and general risk factors such as older age and hormonal loss resulting from menopause. Moreover, factors that can reduce fracture risk, such as physical activity, healthy nutrition, vitamin D supplementation and adequate treatment of inflammation, are variably present in patients with iRMDs. Evidence relating to general and iRMD-specific protective and risk factors for osteoporosis indicate that the established and very often used term ‘glucocorticoid-induced osteoporosis’ oversimplifies the complex inter-relationships encountered in patients with iRMDs. Osteoporosis in these patients should instead be described as ‘multifactorial’. Consequently, a multimodal approach to the management of osteoporosis is required. This approach should include optimal control of disease activity, minimization of glucocorticoids, anti-osteoporotic drug treatment, advice on physical activity and nutrition, and prevention of falls, as well as the management of other risk and protective factors, thereby improving the bone health of these patients.In this Review, the authors argue that the risk of osteoporosis in patients with inflammatory rheumatic and musculoskeletal diseases (iRMDs) is multifactorial, with contributions from iRMD-specific factors, comorbidities, general risk factors and the effects of iRMD therapies such as glucocorticoids.