Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professional and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.

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Background: COVID-19 care home outbreaks represent a significant proportion of COVID-19 morbidity and mortality in the UK. National testing initially focused on symptomatic care home residents, before extending to asymptomatic cohorts. Aim: The aim was to describe the epidemiology and transmission of COVID-19 in outbreak free care homes. Methods: A two-point prevalence survey of COVID-19, in 34 Liverpool care homes, was performed in April and May 2020. Changes in prevalence were analysed. Associations between care home characteristics, reported infection, prevention and control interventions, and COVID-19 status were described and analysed. Findings: No resident developed COVID-19 symptoms during the study. There was no significant difference between: the number of care homes containing at least one test positive resident between the first (17.6%, 95% confidence interval (CI) 6.8e34.5) and second round (14.7%, 95% CI 5.0e31.1) of testing (p>0.99); and the number of residents testing positive between the first (2.1%, 95% CI 1.2e3.4) and second round (1.0%, 95% CI 0.5e2.1) of testing (P¼0.11). Care homes providing nursing care (risk ratio (RR) 7.99, 95% CI 1.1e57.3) and employing agency staff (RR 8.4, 95% CI 1.2e60.8) were more likely to contain test positive residents. Closing residents shared space was not associated with residents testing positive (RR 2.63, 95% CI 0.4e18.5). Conclusions: Asymptomatic COVID-19 care homes showed no evidence of disease transmission or development of outbreaks; suggesting that current infection prevention and control measures are effective in preventing transmission. Repeat testing at two to three weeks had limited or no public health benefits over regular daily monitoring of staff and DOI of companion article:

Background Acute otitis media (AOM) remains a common infection in children despite the introduction of pneumococcal conjugate vaccines. This study estimated AOM incidence rates (IRs) over time in children < 16 years old in Germany following PCV13 introduction. Methods AOM episodes were identified in the InGef healthcare claims database from 2014–2019 in children aged < 16 years. Each AOM episode was classified as either simple or recurrent. Recurrent AOM was defined as 3 or more episodes identified within a 6-month period; or 4 or more episodes within a 12-month period with at least one episode in the prior 6 months. AOM-related surgical procedures within 12 months and complications within 21 days of an AOM episode were also identified. Annual IRs were calculated as number of episodes/child-years (CY) at risk. 95% Confidence intervals (95%CI) were calculated using the Wilson method. The Mann–Kendall test was used to assess trends over time. Results Between 2014 and 2019, the study population comprised 916,805 children with 327,726 AOM episodes, of which 15% (49,011) of all episodes were identified as recurrent AOM and 85% (278,715) as simple AOM. There were significant declines in AOM (p = 0.003) in the study population overall and in all age groups over the study period; from 101 (95%CI 101–102)/1000 CY to 79 (95%CI 78–80)/1000 CY in the total study population, from 209 (95%CI 206–212)/1000 CY to 147 (95%CI 145–150)/1000 CY in < 2-year-olds, from 239 (95%CI 237–242) to 179 (95%CI 177–182)/1000 CY in 2–4-year-olds, and from 50 (95%CI 49–50) to 38 (95%CI 37–39)/1000 CY in 5–15-year-olds. No significant trends were identified for AOM-related surgical procedures over the study period; however, AOM-related complications overall increased (p = 0.003). Conclusion Between 2014 and 2019, AOM incidence overall declined in children aged 0–15 years in Germany. Over the study period, the incidence of complicated AOM cases increased, however the incidence of AOM-related surgical procedures remained constant. Despite the impact of PCV13, the burden associated with AOM in Germany remains substantial.

Incidence and hospital fatality rates of ACP and IPD increased with age and were highest in the high-risk group. •ACP and IPD were associated with high direct economic costs; costs highest amongst highrisk groups. •The inpatient hospital admission rates (per 1000 PY) were twice as high for IPD compared to ACP.

The use of interactive mobile and wearable technologies for understanding and managing health conditions is a growing area of interest for patients, health professionals and researchers. Self-tracking technologies such as smartphone apps and wearable devices for measuring symptoms and behaviours generate a wealth of patient-centric data with the potential to support clinical decision making. However, the utility of self-tracking technologies for providing insight into patients' conditions is impacted by poor adherence with data logging. This paper explores factors associated with adherence in smartphone-based tracking, drawing on two studies of patients living with axial spondyloarthritis (axSpA), a chronic rheumatological condition. In Study 1, 184 axSpA patients used the uMotif health tracking smartphone app for a period of up to 593 days. In Study 2, 108 axSpA patients completed a survey about their experience of using self-tracking technologies. We identify six significant correlates of self-tracking adherence, providing insight into the determinants of tracking behaviour. Specifically, our data provides evidence that adherence correlates with the age of the user, the types of tracking devices that are being used (smartphone OS and physical activity tracker), preferences for types of data to record, the timing of interactions with a self-tracking app, and the reported symptom severity of the user. We discuss how these factors may have implications for those designing, deploying or using mobile and wearable tracking technologies to support monitoring and management of chronic diseases.

Supervised physical therapy and rehabilitation are vital for effective long‐term management of axial spondyloarthritis (axSpA). However, the unprecedented year of 2020 and the COVID‐19 pandemic has prompted a drastic change in healthcare provision across all disease areas. In this review, we summarize changes that have been introduced to support rehabilitation in axSpA during the pandemic and considerations for the future of axSpA rehabilitation in the wake of COVID‐19. We have witnessed the launch of online virtual physical therapy and education, in addition to an emphasis on remote monitoring. We have been propelled into a new era of digital service provision; not only providing a temporary stop‐gap in treatment for some patients, but in future potentially allowing for a wider reach/ provision of care and resilience of vital services. Unique collaboration between patients, healthcare professionals and researchers will be key to foster relationships/ trust and facilitate wider evaluation and implementation of digital services at each stage in a patient’s journey ‐ imperative to relieve pressure from healthcare providers. Despite the potential of such digital interventions, it is important to highlight the maintained critical need for face‐to‐face services, particularly for vulnerable patients or during diagnosis or a flare of symptoms. It is also vital that we remain vigilant regarding digital exclusion, to avoid further widening of existing health inequalities. Optimisation of digital infrastructure, staff skills and digital education alongside promoting accessibility, engagement and building trust among communities will be vital as we enter this new age of blended in‐person/ digital service provision.

Physical activity (PA) is a primary non-pharmacological treatment option for those living with rheumatoid arthritis (RA) and spondyloarthritis (SpA). The aim of this systematic literature review was to summarize and present an updated synthesis of the factors associated with PA in the RA and SpA populations. A tailored search of PubMed (inc. Medline), Web of Science, Embase, APA PsycNET, and Scopus was conducted for research published between 2004 and June 2019. Methodological quality was assessed using The National Institutes of Health (NIH) Quality Assessment Tools for Observational Cohort and Cross-sectional Studies, Case–Control Studies, and Controlled Intervention Studies. Forty RA and eleven SpA articles met the inclusion criteria. Methodological quality was generally fair to good, with two RA studies rated as poor. Correlates are discussed in the sociodemographic, physical, psychological, social, and environmental categories. Environmental factors were not measured in any RA study. In individuals living with RA, consistent positive associations were found between PA and high-density lipoprotein, self-efficacy, and motivation. Consistent negative associations were found for functional disability and fatigue. In individuals with SpA, consistent positive associations were found between PA and quality of life, and consistent negative associations with functional disability. Physical and psychological factors are most consistently related with PA parameters in those living with RA and SpA. Many variables were inconsistently studied and showed indeterminant associations. Studies with prospective designs are needed to further understand the factors associated with PA in these populations, especially in those living with SpA.