Background Delay to diagnosis in axial SpA (axSpA) is longer than in many other rheumatic diseases. Prolonged delay is associate with poorer outcomes, including functional impairment and quality of life. Our aims were to describe global variation in delay to diagnosis, factors associated with delay, and delay compared with PsA. Methods We searched MEDLINE, PubMed, Embase and Web of Science using a predefined protocol. Diagnostic delay was defined as years between the age at symptom onset and at diagnosis. We pooled the mean delay using random effects inverse variance meta-analysis. We examined variations in pooled estimates using prespecified subgroup analyses and sources of heterogeneity using meta-regression. Results A total of 64 studies reported the mean diagnostic delay in axSpA patients. The pooled mean delay was 6.7 years (95% CI 6.2, 7.2) with high levels of heterogeneity. Delay to diagnosis did not improve over time when stratifying results by year of publication. Studies from high-income countries (defined by the World Bank) reported longer delays than those from middle-income countries. Factors consistently reported to be associated with longer delays were lower education levels, younger age at symptom onset and absence of extra-articular manifestations (EAMs). The pooled estimate for diagnostic delay from 8 PsA studies was significantly shorter, at 2.6 years (95% CI 1.6, 3.6). Conclusion For axSpA patients, delay to diagnosis remains unacceptably prolonged in many parts of the world. Patient factors (e.g. education) and disease presentation (onset age and EAMs) should inform campaigns to improve delay.

Microbes can be used effectively as trace evidence, at least in research settings. However, it is unknown whether skin microbiomes change prior to autopsy and, if so, whether these changes interfere with linking objects to decedents. The current study included microbiomes from 16 scenes of death in the City and County of Honolulu and tested whether objects at the scenes can be linked to individual decedents. Postmortem skin microbiomes were stable during repeated sampling up to 60 h postmortem and were similar to microbiomes of an antemortem population. Objects could be traced to decedents approximately 75% of the time, with smoking pipes and medical devices being especially accurate (100% match), house and car keys being poor (0%), and other objects like phones intermediate (~80%). These results show that microbes from objects at death scenes can be matched to individual decedents, opening up a new method of establishing associations and identifications.

Objective To describe the prevalence of extra-articular manifestations—enthesitis, dactylitis, nail disease, uveitis and IBD—in PsA, and their impact on longitudinal disease outcomes. Methods We searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies using imaging to define extra-articular manifestations (EAMs) were excluded. Where possible, we performed meta-analyses of prevalence estimates, reported as percentages (95% CI). Heterogeneity (I2 statistic) was examined according to study characteristics. Results We identified 65 studies amounting to a total of 163 299 PsA patients. Enthesitis was assessed in 29 studies with an average prevalence of 30% (95% CI: 24%, 38%). Dactylitis was reported in 35 studies with an average prevalence of 25% (95% CI: 20%, 31%). Nail disease was present in 60% (95% CI: 52%, 68%) across 26 studies, but definitions were often unclear. Uveitis (3.2%; 95% CI: 1.9%, 5.3%) and IBD (3.3%; 95% CI: 1.5%, 7.1%) were less common. Heterogeneity was high (>95%) in all meta-analyses, but could not be explained by study characteristics. No studies examined the impact of EAMs on longitudinal disease outcomes, except that dactylitis increases radiographic progression. Conclusion Enthesitis, dactylitis and nail disease are highly prevalent in PsA, but not uveitis and IBD. EAM patterns differ from axial SpA despite their shared disease mechanisms, which may help further understand differences between spondyloarthritides. More studies are needed on the impact of EAMs on disease outcomes such as response to treatment.

Background . Delay to diagnosis in axial spondyloarthritis (axSpA) is longer than many other rheumatic diseases. Prolonged delay has been shown to associate with poorer outcomes including functional impairment and quality of life. Our aims were to describe 1) global variation in delay to diagnosis, 2) factors associated with delay, and 3) differences in diagnostic delay between axSpA and psoriatic arthritis (PsA).Methods . We searched Medline, PubMed, EMBASE and Web of Science using a predefined protocol in accordance with PRISMA guidelines. Delay to diagnosis was defined as years between age at symptom onset and age at diagnosis. We pooled mean diagnostic delay using random-effects inverse variance meta-analysis. We examined variations in pooled estimates using pre-specified subgroup analyses and sources of heterogeneity using meta-regression.Results. A total of 54 studies reported mean diagnostic delay in axSpA patients. The pooled mean delay was 6.8 years (95% confidence interval 6.2 to 7.3) with high levels of heterogeneity. Delay to diagnosis did not improve over time when stratifying results by year of publication. Studies from high-income countries (defined by the World Bank) reported longer delay than those from middle-income countries. Factors consistently reported to be associated with longer delay were: lower education levels, younger age at symptom onset and absence of extra-articular manifestations. Pooled estimate for diagnostic delay from 8 PsA studies was significantly shorter, at 2.6 years (95%CI 1.6 to 3.6).Conclusion. For axSpA patients, delay to diagnosis remains unacceptably prolonged in many parts of the world, although some countries have reported remarkable improvements. Patient factors (education) and disease presentation (age at onset and extra-articular manifestations) should inform awareness campaigns to improve delay. Targets for improvement should aim to resemble delays in other spondyloarthritis patients.

Background. Delay to diagnosis in axial spondyloarthritis (axSpA) is longer than many other rheumatic diseases. Prolonged delay has been shown to associate with poorer outcomes including functional impairment and quality of life. Our aims were to describe 1) global variation in delay to diagnosis, 2) factors associated with delay, and 3) differences in diagnostic delay between axSpA and psoriatic arthritis (PsA).Methods. We searched Medline, PubMed, EMBASE and Web of Science using a predefined protocol in accordance with PRISMA guidelines. Delay to diagnosis was defined as years between age at symptom onset and age at diagnosis. We pooled mean diagnostic delay using random-effects inverse variance meta-analysis. We examined variations in pooled estimates using pre-specified subgroup analyses and sources of heterogeneity using meta-regression.Results. A total of 64 studies reported mean diagnostic delay in axSpA patients. The pooled mean delay was 6.7 years (95% confidence interval 6.2 to 7.2) with high levels of heterogeneity. Delay to diagnosis did not improve over time when stratifying results by year of publication. Studies from high-income countries (defined by the World Bank) reported longer delay than those from middle-income countries. Factors consistently reported to be associated with longer delay were: lower education levels, younger age at symptom onset and absence of extra-articular manifestations. Pooled estimate for diagnostic delay from 8 PsA studies was significantly shorter, at 2.6 years (95%CI 1.6 to 3.6). Conclusion. For axSpA patients, delay to diagnosis remains unacceptably prolonged in many parts of the world, although some countries have reported remarkable improvements. Patient factors (education) and disease presentation (age at onset and extra-articular manifestations) should inform awareness campaigns to improve delay. Targets for improvement should aim to resemble delays in other spondyloarthritis patients.