Objective.To identify empirical evidence of diagnostic delay in spondyloarthritis (SpA), determine whether sex-related differences persist, and conduct an analysis from that perspective of the possible causes, including the influence of quality research, in this group of inflammatory rheumatic diseases.Methods.A systematic review was done of delay in diagnosis of SpA in MEDLINE and EMBASE and other sources. Study quality was determined in line with the Strengthening The Reporting of OBservational studies in Epidemiology (STROBE) statement. A metaanalysis of 13 papers reporting sex-disaggregated data was performed to evaluate sex-related differences in diagnostic delay. The global effect of diagnostic delay by sex was calculated using means difference (D) through a fixed effects model.Results.The review included 23,883 patients (32.3% women) from 42 papers. No significant differences between the sexes were detected for symptoms at disease onset or during evolution. However, the mean for delay in diagnosis of SpA showed sex-related differences, being 8.8 years (7.4–10.1) for women and 6.5 (5.6–7.4) for men (p = 0.01). Only 40% of papers had high quality. A metaanalysis included 12,073 participants (31.2% women). The mean global effect was D = 0.6 years (0.31–0.89), indicating that men were diagnosed 0.6 year (7 months) before women.Conclusion.Delay in diagnosis of SpA persists, and is longer in women than in men. There are no significant sex-related differences in symptoms that could explain sex-related differences in diagnostic delay. Methodological and possible publication bias could result in sex-biased medical practice.

Background Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.

BackgroundDiagnostic delay is well-known in spondyloarthritis and studies have demonstrated a longer deferral in women. The aim of this study was to explore whether diagnostic delay of spondyloarthritis depends on clinical manifestations expressed by patients according to sex or whether it is related to a doctor’s misdiagnosis bias.MethodsA cross-sectional study of 96 men and 54 women with spondyloarthritis was performed at Alicante University General Hospital in Spain using a semistructured interview and clinical records. Comparative sex analysis were done via Student’s T and Mann-Whitney U tests for parametric and nonparametric continuous variables, chi-square and Fisher’s exact tests for unpaired categorical variables, and McNemar’s test for paired ones.FindingsThe median diagnostic delay in women 7.5 (11.5) years is higher than men 4 (11) years, with a difference close to statistical significance (p = 0.053). A total of 30.2% of men received a first correct diagnosis of spondyloarthritis versus 11.1% of women (p = 0.016), indicating that men have higher probability of not having a misdiagnosis of spondyloarthritis (odds ratio = 3.5; 1.3–9). Eleven different health services referred male patients to the rheumatology clinic but only six in the case of female. No sex differences were detected in patients’ manifestations of back pain at onset. However, medical records registered differences (women 44.4%, men 82.1%; p < 0.001). There were differences between patients (women 57.7%, men 35.2%; p = 0.008) and medical records in peripheral signs/symptoms at onset (women 55.6%, men 17.9%; p < 0.001).ConclusionThe few differences of self-reported manifestations between both sexes with spondyloarthritis as compared with their clinical records (more axial pain in men and more peripheral pain in women) suggests that the professionals’ annotations reflect what they expect according to Literature, which could explain the higher misdiagnosis and diagnostic delay in women with spondyloarthritis.

Our study highlights the vital complexity in which patients with SpA are immersed, especially for women in a country where a mix of new and traditional gender roles coexist. Awareness of its existence is crucial when professionals strive to provide healthcare focused on their well-being in addition to medical therapy.

Objective To determine whether the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) exhibited differences between women and men. Methods We systematically searched MEDLINE, Embase, Web of Science and other sources in English or Spanish from 01 January 1995 to 31 July 2020, to assess the differences according to sex in BASDAI and ASDAS. We performed a comparative analysis by sex using t-student test and mean difference by sex meta-analyses for BASDAI and ASDAS, using a random-effects model via the inverse-variance method. Results Forty-one studies included BASDAI (6,785 women/12,929 men) and 16 of them included ASDAS (2,046 women/4,403 men). Disease activity detected through BASDAI was significantly higher in women than in men (mean: 4.9 vs. 4.2, p=0.02), whereas ASDAS did not detect differences between sexes (mean: 2.8 women vs. 2.8 men). In the meta-analyses, BASDAI detected significant differences between women and men [mean difference= 0.55 (95% confidence intervals (95%CI): 0.46, 0.65), p<0.00001], but ASDAS did not identify significant mean difference between sexes [0.04 (95%CI: -0.05, 0.12), p=0.38]. Conclusion The two most widely used indexes of disease activity in spondyloarthritis discriminate differently according to sex by their different evaluation of peripheral disease. Their different components and weights influence BASDAI and ASDAS values. BASDAI may be influenced by fatigue, but in predominantly peripheral manifestations like enthesitis, ASDAS may not be sensitive enough to detect activity. This may represent a gender bias unfavourable to women, because peripheral spondyloarthritis is more common in women than in men.

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BackgroundAnkylosing spondylitis (AS) has been considered to be more prevalent in men compared to women. Besides, the clinical presentation in women is thought to be milder and more peripheral than in men. Some studies have suggested a higher burden of disease in women1,2 but others not confirm these differences3,4.ObjectivesTo evaluate possible gender differences in men and women with AS seen in routine care at two academic rheumatology centers of the USA and Spain.MethodsSixty one men and 30 women with AS in Spain and 61 men and 31 women in the USA completed a Multidimensional Health Assessment Questionnaire (MDHAQ). The MDHAQ includes (0–10 scores) for physical function, pain, patient global estimate (PATGL), compiled into a 0–30 RAPID3, and fatigue scores. Furthermore, demographic data, biological (anti-TNFα) and DMARD therapies, were obtained from the medical records. A comparative analysis of men and women was performed by Mann-Whitney U tests for non-parametric quantitative data (median/interquartile range), and Chi square tests for qualitative data (frequencies/percentajes).ResultsWe have not detected significant differences in men and women for function, pain, PATGL, or fatigue although a trend towards higher RAPID3 values was seen in females in both sites (Table). Anti-TNFα medications were prescribed more often in men than in women (81.2% vs 65.6%, in all patients p=0.02), statistically significant in Spain (82% vs 60%, p=0.02), and numerically higher in the USA (80.3% vs 71%, p=0.31). DMARD medications tend to be more prescribed in women than men in all patients (17.2% vs 23%, p=0.35) although no statistically significant.Table 1.Health status and treatment of patients with SpA at two academic centers (*p<0.05)USASpain Men (N=61)Women (N=31)Men (N=61)Women (N=30) Age, years41.5 (31.7–56.9)36.2 (31.7–56.8)52.0 (46.0–65.4)54.6 (43.3–61.4)Education, years16 (12–17)16 (11–18)9 (8–12)8 (8–12)White31 (51%)17 (55%)56 (92%)30 (100%)Duration disease, years12.1 (6.1–21.5)6.3 (4–16.6)22 (12.1–34.8)21.4 (12.1–30.1)HLA-B27+26 (68%)21 (88%)49 (86%)20 (69%)MDHAQ Function, (0–10)2 (0.3–4)2.3 (0.3–4)1.2 (0–2.7)0.8 (0–2.3) Pain, (0–10)4 (1–7)5 (2–7.5)3 (1.5–6)4 (1–5) PATGL, (0–10)3 (1.5–6.3)5 (2–6.5)4 (2–5.5)3.5 (1–5.5) RAPID3, (0–30)8.5 (4.2–15.3)11.8 (4–16.8)6.8 (3.5–14.2)8.1 (3.3–12.7) Fatigue, (0–10)3 (0–6.5)5 (3–8)3 (1–4.5)2.8 (1–5.5)Treatment Anti-TNFα49 (80%)22 (71%)50 (82%)18 (60%)* DMARD9 (15%)7 (23%)13 (21%)7 (23%)ConclusionsMen with SpA receive anti-TNFα more likely than women; although disease burden appears somewhat higher in women. This pattern is similar in both Spain and the USA, though statistically significant only in the Spanish population. Other parameters may be having weight in the management of SpA, such as radiographic signs versus peripheral manifestations.References van der Horst-Bruinsma IE, et al. Ann Rheum Dis 2013.Ortega Castro R, et al. Reumatol Clin 2013.Gremese E, et al. Rheumatology (Oxford) 2014.Shahlaee A, et al. Clin Rheumatol 2015. AcknowledgementsUniversity Institute for Gender S...

BackgroundThe Bath Ankylosing Spondylitis (AS) Disease Activity Index (BASDAI), an index of only patient-self-report measures, and AS Disease Activity Score (ASDAS)1, which adds patient global estimate and laboratory tests to BASDAI elements are widely used in Spondyloarthritis (SpA). Both indices are specifically designed to evaluate disease activity AS patients. Some studies have shown worse BASDAI in women, but sex-related differences by ASDAS remain unclear 2,3.ObjectivesTo analyze reports of sex-stratified disease activity measures -BASDAI and ASDAS- in patients with SpA.MethodsData sources included PubMed (1950 to December 2016), Embase, Web Of Science, and manual searches of references lists. We included observational studies and randomized trials comparing disease activity scores, specifically BASDAI and ASDAS, between men and women with SpA. Studies quality was determined in line with the STROBE statement for observational studies and CONSORT statement for RCT, considering <50% positive items as low quality. Randomized effects were performed to report the mean difference (95% confidence interval) by gender, and heterogeneity was measured via I2 statistic in order to check the results robustness.ResultsFrom 672 identified studies 18 cross-sectional studies, 3 cohort, 2 case-control studies, and 1 RTC reported sex-stratified BASDAI and ASDAS. ASDAS was evaluated in 3,758 patients (36.5% women) in 9 studies, and BASDAI included 12,329 patients (34.3% women) in 24 studies. In a metanalysis of mean difference BASDAI including 19 studies the mean difference was 0.56 (95% CI: 0.47, 0.66) and I2=43%, indicating a significantly higher disease activity in women (Figure). In a metanalysis of 7 studies ASDAS the mean difference was 0.06 (95% CI: -0.04, 0.16) and I2=41%, not showing statistically significant differences.ConclusionsWe identified relevant sex differences in disease activity according to BASDAI with higher disease activity in women, but not according to ASDAS. In SpA, women present more peripheral arthritis and higher pain, which may influence the BASDAI score, mainly based on patient-self-report measures. It is important to recognize these differences that may influence management decisions based on disease activity measures.References van der Heijde D et al. Ann Rheum Dis 2009;68:1811–18.van der Horst-Bruinsma IE et al. Ann Rheum Dis 2013;72:1221–1224.Arends S et al. heumatology 2015;54:1333–1335. AcknowledgementsFaculty of Health Sciences and University Institute for Gender Studies of the University of Alicante supported M. Blasco-Blasco.Disclosure of InterestNone declared