bluuebunny/crossref_metadata_2025 huggingface dataset:
Moral Sentiments in Hume and Adam Smith
Authors: Cohon Rachel
Published: April 2022

A sentimentalist theory of morality explains all moral evaluations as manifestations of certain emotions, ones that David Hume and Adam Smith, in their related but divergent accounts, call moral sentiments. The two theories have complementary successes and failures in capturing familiar features of the experience of making moral evaluations. Thinking someone courageous or dishonest need not involve having goals or feelings of desire, and Hume’s theory captures that well; but its account of how our moral evaluations are about or directed toward people or actions is deficient. Smith’s theory readily explains how moral sentiments can be about things (and which things they are about), but at the cost of construing some central moral evaluations as goal-directed desires that are simply not like that. Present-day sentimentalists also face the challenge of combining these two desiderata.
The Nature of Reasons for Action and Their Psychological Implications
Authors: Smith Michael
Published: April 2022

The chapter begins with the accounts of reasons for action given by G. E. M. Anscombe in Intention (1957) and Donald Davidson in ‘Actions, reasons, and causes’ (1963). This leads to a discussion of a number of different issues about reasons for action including: whether all actions are pursued under the guise of the good; the distinction between motivating and normative reasons; the relationship between normative reasons and good-making features; whether we should be factualists or non-factualists about evaluative judgements; and, if we should be factualists, then the kind of factualist we should be: species-relativist, disposition-relativist, constitutivist, or primitivist.
Sex by Deception
Authors: Brogaard Berit
Published: April 2022

In this chapter I will use sex by deception as a case study for highlighting some of the trickiest concepts associated with sexuality and moral psychology, including rape, consensual sex, sexual rights, sexual autonomy, sexual individuality, and disrespectful sex. I begin with a discussion of morally wrong sex as rooted in the breach of five sexual liberty rights that are derived from our fundamental human liberty rights: sexual self-possession, sexual autonomy, sexual individuality, sexual dignity, and sexual privacy. In light of this discussion, I then examine a puzzle about sex by deception—a puzzle which at first may seem to compel us to define ‘rape’ strictly in terms of ‘physical force or threat’ rather than ‘sexual autonomy’. I proceed by presenting an argument against the view that, as a rule, sex by deception undermines consent. Even when sex by deception does not compromise consent, I argue that it nonetheless is inimical to the respect we owe all persons, not because it vitiates sexual autonomy and thereby obstructs the possibility of consent, but because it fails to respect other sexual rights that we have, such as our rights to sexual dignity, individuality, or privacy.
Are Desires Interdependent?
Authors: Cushman Fiery , Paul L. A.
Published: April 2022

Some experiences transform us in profound ways. Many people, for instance, are transformed by becoming a parent. How does this occur? Is parenthood like a massive hurricane, which shapes a wide landscape directly and all at once by overwhelming force? Or could experiences like parenthood transform us the way a spark transforms the landscape—as a small force that only directly touches one dry leaf, but thereby sets off a chain reaction? We explore the possibility and implications of spark-like personal transformative experiences––those in which a relatively small, surgical adjustment of one aspect of our preferences has an extended ripple effect, rationally compelling the revision of many other aspects of our preferences––in the context of current models of the notion of ‘desire’ in the cognitive sciences, focusing especially on theories of value-guided decision-making.
Variations in Moral Concerns across Political Ideology
Authors: Graham Jesse , Yudkin Daniel A.
Published: April 2022

This chapter reviews research on variations in moral judgments and concerns across the ideological spectrum and across political groups. It pays particular attention to the pluralist model of moral foundations (moral concerns about care, fairness, loyalty, authority, purity), first reviewing how they vary along the left–right ideological spectrum. We then review research going beyond a single left–right dimension, including work on libertarians and social vs. economic ideology. We then turn to new work identifying the political ‘hidden tribes’ of US politics (Progressive Activists, Traditional Liberals, Passive Liberals, Politically Disengaged, Moderates, Traditional Conservatives, and Devoted Conservatives). The chapter closes by considering the dangers of moral convictions to civil discourse and intergroup relations.
Agency in Mental Illness and Cognitive Disability
Authors: Murphy Dominic , Washington Natalia
Published: April 2022

This chapter begins by sketching an account of morally responsible agency and the general conditions under which it may fail. We discuss how far individuals with psychiatric diagnoses may be exempt from morally responsible agency in the way that infants are, with examples drawn from a sample of diagnoses intended to make different issues salient. We further discuss a recent proposal that clinicians may hold patients responsible without blaming them for their acts. We also consider cognitively impaired subjects in the light of related issues in moral and political theory, asking whether they have been unjustly excluded from liberal conceptions of political community due to their presumed lack of agency.
Virtue
Authors: Besser Lorraine L.
Published: April 2022

What is virtue? And by what standard do we determine that something is a virtue? This chapter explores the central ways in contemporary theorists approach these questions and the limitations of their analyses. I’ll emphasize the importance of a theory of virtue’s capacity to account for both virtue’s reliable connection to action and its psychological depth in characterizing how virtue affects the ways in which a person not just acts, but thinks and responds in certain ways. I’ll argue that extant theories of virtue tend to favour one over the other; but that instrumentalist and holistic accounts of virtue are better able to appropriately accommodate both desiderata.
Railways
Authors: Gwyn David
Published: April 2022

Railways were the distinctive ‘industrial era’ transport technology but date to antiquity. They were widely adopted in the context of the English coal industry from the seventeenth century. By 1830 they had become a sophisticated mechanical technology. Key to the railway revolution of the nineteenth century was the steam locomotive engine with the capacity to haul a train carrying primary products, manufactured goods, or people at a national level. Railways had a profound effect on the economy, landscape, and society of wherever they were built, and were often consciously used to emphasize political power and colonial might. Decline in the late twentieth century has been followed by a subsequent revival. Railways take many different forms, serving industry and construction sites, military campaigns, and operating as intra-urban systems. Miniature, toy, and heritage railways reflect public interest in this technology.
Water Power
Authors: Rynne Colin
Published: April 2022

Water power was the principal source of energy for British and Irish industry for the greater part of the eighteenth and nineteenth centuries, especially in the textile industries. Even in the nineteenth century steam power in many Irish, Scottish, and Welsh industries was a supplement rather than a replacement for water-powered prime movers. In the early twenty-first century water power remains an important low-carbon power-generation option. Using British and Irish examples this chapter reviews the technological development of water power, from vertical and horizontal waterwheels, the replacement of wood with iron fabric in the transmission systems, and improvements in waterwheel design, to water turbines and the introduction of hydroelectric generation.
Commodities and Consumption
Authors: Crook Penny
Published: April 2022

This chapter reviews the importance of commodities and consumption to archaeologies of the modern industrialized world. After centuries of New World exploration saw exotic luxuries transformed into everyday commodities, the Industrial Revolution delivered a new array of domestic goods to the emerging middle classes in the Old World. The practice of household provisioning changed for good as humble town markets were dwarfed by palaces of consumption. Scholars from many fields have analyzed consumer behaviour to explore individual desire and social order, debating the significance of social, cultural, economic, and material change, past and present. Consequently, consumer theory remains diverse and ‘complex’. Archaeology offers a unique perspective and recent research in transnational archaeologies have revealed local and market-specific consumption patterns against a backdrop of global trade. Current trends suggest that future archaeologies of consumption will enable a greater pursuit of both the production and consumption of commodities.
The Linen and Wool Industries in Britain and Ireland
Authors: Rynne Colin
Published: April 2022

This chapter reviews the development of the linen and woollen industries in Britain and Ireland from the early eighteenth century to the twentieth century, the classic period of mechanization and mill building. Ulster came to dominate world linen production in the later nineteenth century, while Yorkshire was the centre of world woollen yarn and cloth production by the mid-nineteenth century. The technical development of textile machinery, and the buildings they were housed in, is reviewed along with the major stages of manufacture for each industry: preparation, spinning, weaving, and finishing. Both branches of the textile industry used similar machinery and manufacturing processes, and both adapted machinery from the mechanized cotton industry.
Mechanical Engineering and the Integrated Engineering Works
Authors: Nevell Michael
Published: April 2022

This chapter looks at the development of mechanical engineering and integrated engineering works in Britain from the eighteenth to the twentieth centuries. It focusses on the main buildings on the sites, including pattern shop, foundry and forge, fitting and machine shops, erecting shops, drawing and management buildings, and furnaces and power systems. Excavated examples at the Govan iron works, Thames iron works and shipbuilding company, and John Ashbury’s carriage and iron works in Manchester are used as case studies to illustrate the potential of below-ground archaeological material. Often these sites reveal details about manufacturing processes that have not survived in the documentary record.
OA14a Outcomes after switching from etanercept originator to its biosimilar (SB4) for the treatment of rheumatoid arthritis
Authors: Rokad Aasiyah , Kearsley-Fleet Lianne , Watson Kath , Lunt Mark ,   BSRBR-RA, Hyrich Kimme L
Published: April 2022

Background/Aims

Following the etanercept biosimilar SB4 (ETN-B) launch in the UK in 2016, nationwide guidelines encourage patients switch from the biologic originator (ETN-O) to ETN-B, known as non-medical switching (NMS). However, the long-term implications of NMS have not yet been analysed nationally among patients with rheumatoid arthritis (RA). This analysis aims to evaluate treatment outcomes and drug retention after patients with RA are switched from ETN-O to ETN-B in routine clinical practice in the UK.

Methods

The British Society for Rheumatology Biologics Register for RA (BSRBR-RA) is a prospective observational cohort study. This analysis included all patients who switched from ETN-O to ETN-B since 2016. Disease activity was assessed at the time of switch and after six months. Key outcomes included change in disease activity (DAS28), DAS28 remission and EULAR treatment response. Drug retention was analysed using Kaplan-Meier and treatment withdrawal reasons were explored for all patients who switched to ETN-B, as well as (1) patients who switched-back to ETN-O, (2) patients who changed to a non-ETN biologic, (3) patients discontinuing all biologic therapy. Multiple imputation was used to account for missing data.

Results

1160 patients with RA switched from ETN-O to ETN-B. Of the 919 (79%) with available DAS28 data, there was no change in six-month DAS28 score following switch (median: 0, IQR: -0.8, 0.7). After a median follow-up of 1.8 years (IQR: 1.0, 2.3), most patients remained on ETN-B (N = 844, 73%) with the main treatment withdrawal reason being ineffectiveness (N = 139, 44%). Among those who discontinued ETN-B, 133 (11%) patients switched-back to ETN-O and 98 (8%) patients changed to a non-ETN biologic; both primarily due to ineffectiveness (Table). Lastly, 85 (7%) patients discontinued all biologic therapy mainly due to adverse events (N = 50, 59%).

Conclusion

This analysis has demonstrated sustained effectiveness after switching from ETN-O to ETN-B using real-world nationwide data. Among the sub-cohorts of patients who discontinued ETN-B, differences were observed regarding the frequency and reasons for treatment withdrawal. These results will support UK rheumatologists and patients with treatment decisions, assist quality improvement projects to reduce drug withdrawals and refine biologic treatment delivery in the UK.

Disclosure

A. Rokad: None. L. Kearsley-Fleet: None. K. Watson: None. M. Lunt: None. K.L. Hyrich: Honoraria; Abbvie. Grants/research support; Pfizer, BMS.
OA18 The sex-specific outcomes of acute stroke in patients with comorbid Systemic Lupus Erythematosus - National Inpatient Sample Study
Authors: Jesenakova Sona , Pana Tiberiu A , Carter Ben , Mohamed Mohamed O , Mamas Mamas A , Myint Phyo K
Published: April 2022

Background/Aims

Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease with variable presentation and clinical manifestations. Previous research has established the higher risk of incident cardiovascular disease and stroke in SLE patients. However, the evidence on how stroke outcomes differ between SLE and non-SLE patient groups in contemporary practice is limited. Furthermore, given that SLE tends to affect predominantly females, with a female-to-male ratio of 9:1, the question remains if and to what extent stroke outcomes might differ between males and females with SLE. Thus, we aimed to explore sex-specific acute stroke outcomes amongst patients with comorbid SLE.

Methods

A total of 316,531 records representing 1,581,430 acute stroke hospitalisations between 2015 and 2018 from the United States National Inpatient Sample (NIS) were analysed. The primary exposure of interest was comorbid SLE. Patients were grouped according to SLE status and sex (no SLE-reference, male with SLE, female with SLE). Outcome measures of interest (in-patient mortality, length-of-stay in hospital [LoS] and routine home discharge) were examined utilising multivariable logistic regressions, adjusting for age, ethnicity, stroke type, receipt of revascularisation therapies, region, hospital status and 49 comorbidities including major cardiovascular disease.

Results

The median (interquartile range) age was 71 (60-82) years. There were 940 (0.06%) males and 6110 (0.39%) females with SLE. After adjustments, female patients with SLE had 21% increased odds of dying in hospital, adjusted odds ratios (aOR) = 1.21, 95% CI (0.92 - 1.61), whereas the risk of in-patient mortality for male patients with SLE was 24% lower compared to the reference group, aOR = 0.76 (0.32 - 1.81). However, none of the differences in the in-patient mortality were of statistical significance. Secondly, compared to patients without SLE, females with SLE had significantly longer hospitalisation, aOR=1.20 (1.06 - 1.36), while there was no significant difference for males with SLE, aOR=1.06 (0.75 - 1.49). The odds of being routinely discharged were 28% lower for females with SLE, aOR=0.72, (0.63 - 0.82), in comparison to a non-significant increase in the odds of 18% for males with SLE, aOR=1.18, (0.84 - 1.65).

Conclusion

Our results highlight the sex differences in acute stroke outcomes in patients with SLE. Due to a small sample size of males with SLE, our findings need to be cautiously interpreted. Further understanding of the influence of SLE amongst male patients with acute stroke is needed.

Disclosure

S. Jesenakova: None. T.A. Pana: None. B. Carter: None. M.O. Mohamed: None. M.A. Mamas: None. P.K. Myint: None.
OA39 Online Patient Reported Outcome Measure (PROM) engagement is dependent on demographics and locality: findings from an observational cohort
Authors: Bechman Katie , Yates Mark , Wright Hannah , Russell Mark , Nagra Deepak , Clarke Benjamin D , Ledingham Joanna , Norton Sam , Galloway James
Published: April 2022

Background/Aims

Online patient-reported outcome measures (PROMs) enable remote collection of perceptions of health status, function and wellbeing. Single-centre studies report that PROM completion is dependent on patient demographics. Here we use a large national prospective dataset to explore patterns of PROM completion.

Methods

Patients with a new diagnosis of early inflammatory arthritis (EIA) were recruited to the National Early Inflammatory Arthritis Audit (NEIAA) between May 2018 and March 2020 and followed up for one year. PROMs capturing the impact of disease using the MSK-HQ, disability using HAQ, mental health using PHQ4ADS, and work using the WPAI were requested at baseline, 3 and 12 months. Multivariable logistic regression was constructed to examine patient level associations with PROM completion. Mean PROM completion by clinical commissioning groups (CCG) were mapped across England and spatial regression models used to identify regional patterns.

Results

A total of 34,856 patients with suspected EIA were recruited to NEIAA. Of these, 11,986 were diagnosed with EIA across England, recruited from 205 CCGs. The cohort was evenly distributed across the indices of multiple deprivation (IMD) deciles. Thirteen percent were Black, Asian, or minority ethnic (BAME). At least one PROM was completed by 5,331 (44.5%) patients. Of these, 3,846 (72.1%) had completed half of all the available PROMs whilst 412 (7.7%) had completed all available PROMs. BAME participants were less likely to return a PROM in adjusted regression modelling (adj OR 0.57, 95% CI 0.48-0.66). Deprivation quintile (adj OR 0.73, 95% CI 0.64-0.83), male gender (adj OR 0.86, 95% CI 0.78-0.94), comorbidity burden (adj OR 0.95, 95% CI 0.91-0.99) and current smoker status (adj OR 0.73, 95% CI 0.64-0.82) also reduced the odds of PROM completion. The proportion with PROM completion varied across CCGs. Spatial analysis identified two autocorrelated regions in England with a hotspot of high PROM completion in the North and a cold spot in the South East.

Conclusion

This study defines key participant characteristics that influence PROM engagement in a national clinical audit and identifies a novel association between locality and PROM completion. Integral to the utility of PROMs in NEIAA is that they are representative of the population with EIA. Our results suggest there are under-represented groups with the potential to bias in favour of those likely to experience better outcome.

Disclosure

K. Bechman: None. M. Yates: None. H. Wright: None. M. Russell: None. D. Nagra: None. B.D. Clarke: None. J. Ledingham: None. S. Norton: None. J. Galloway: Consultancies; Abbvie, Sanofi, Novartis, Pfizer, UCB, Janssen. Grants/research support; Eli Lilly.
P002 Advice line ... of duty
Authors: Knight Lucy , Miller Joanna , Dahiya Sandeep
Published: April 2022

Background/Aims

Advice lines in Rheumatology services are well established and supported by NICE to provide specialist support and advice to rheumatology patients. During COVID-19 the demand on this service greatly increased due to disruption in appointments, confusion regarding national advice, concerns and fears regarding condition and medication. Although patients were encouraged to refer to national guidance, many found it difficult to interpret therefore continued to access the advice line. Our advice line service largely follows the RCN 2006 guidance regarding service provision. Despite this during COVID-19 the volume of calls increased to up to 100 calls per day during the first lockdown. Support was required to effectively manage these calls with reduced clinical staff.

Methods

A retrospective review of calls to the advice line compared to the previous year was undertaken from the call log database. A further review of the nature of calls was undertaken for April 2020 and January 2021 where the numbers of calls were at their peak. Data is recorded including time of call, nature of call, advice given and time call returned.

Results

There was a 130% increase in calls during the first lockdown. This reduced by the early 2021 lockdown to 72%. The majority of calls in April 2020 were related to shielding and risk status (53%). A further 19% of calls were related to medication, these included queries regarding homecare deliveries and delays. 6% were appointment enquiries and they were passed to the administrative team. In January 2021 the majority of calls were related to medication (30%). 19% of calls were regarding the COVID-19 vaccine. There were still 8% of calls regarding shielding. 9% of calls were related to appointments. Pressure on the nursing team was increased due to staff redeployment.

Conclusion

The analysis of calls during the COVID-19 pandemic highlighted that although there was extensive national guidance produced, many patients still required the support and guidance of their specialist teams to interpret these according to their condition. We believe there is a duty of care for the specialist teams to maintain this level of service during any future events and this should be factored into any decisions regarding redeployment of staff. Appointments and homecare delivery enquiries continued despite directions to alternate numbers, therefore impacted on workload for the clinical nursing team. In order to streamline the service we introduced ‘options’ to select: option 1 for appointments, option 2 for homecare and option 3 for advice line queries. Option 1 and 2 then directed to the relevant team. Future developments include audit to assess the impact of introducing telephone options; reviewing the funding and scope of the service, which has extended beyond medication and flare advice; and further exploration of text and email platforms.

Disclosure

L. Knight: None. J. Miller: None. S. Dahiya: None.
P006 Rituximab biosimilar switching shows non-inferior outcomes in routine clinical practice
Authors: Bilan Jimmy , Chew Xin , Perry Martin E
Published: April 2022

Background/Aims

Biosimilar biologic therapy has been widely implemented in recent years. However, little data exists outwith clinical trials to confirm patient response to therapy and any safety signal following switch from originator products or between biosimilars. This study reviewed all rheumatoid arthritis patients prescribed biosimilar rituximab in a ‘real world' clinical practice setting to a certain clinical response following switching.

Methods

Retrospective review of clinical data from medical record was undertaken across three hospital sites in the UK. Patients were identified from biologic database and infusion facility records. Basic demographics were collected. The current biosimilar brand of rituximab, previous brands including originator were also collected and previous record of biologic and steroid therapy. The DAS-28 ESR was recorded pre- and post-biosimilar switch along with any note of infusion reactions.

Results

The database screening of 925 patients on biologic therapy identified 64 patients with rheumatoid arthritis taking rituximab biosimilar therapy. 48 female and 16 male patients with mean disease duration of 7.7 years were identified. 78% of patients were seropositive and all were on 6-monthly pulse infusions of 1g rituximab, 2 weeks apart. 34 (52%) patients were also taking methotrexate, (mean dose of 15mg/wk). Nine patients (14%) were taking concurrent oral prednisolone. Mean current DAS-28 ESR was 3.23. At biosimilar initiation DAS-28 was 4.00 (19% fall, non-significant). There were 14 adverse events, of which 11 were infusion-related reactions, six of which were for truxima, the remainder were with mabthera and rixathon. No anaphylaxis was recorded, although one patient had a hypersensitivity reaction. 38 (59%) patients had rituximab as first biologic.

Conclusion

This ‘real-life’ clinical review found similar clinical efficacy of rituximab biosimilar to originator product based on the DAS-28 ESR score. There were no notable safety or infusion differences.

Disclosure

J. Bilan: None. X. Chew: None. M.E. Perry: Honoraria; Lilly, Celltrion, Gilead, Abbvie, Biogen, Jaansen.
P010 Designing a fast-track pathway for the diagnosis of giant cell arteritis in a busy Ambulatory Emergency Care Unit based on British Society of Rheumatology guidelines
Authors: Lakhani Priyanka M , Ali Sabreen , Sames Edward , Agarwal Paras , Lisk Radcliffe
Published: April 2022

Background/Aims

BSR states: “GCA is a medical emergency. Patients should be evaluated by a specialist ideally on the same working day if possible and in all cases within 3 working days.” Currently in this DGH there is no pathway for diagnosis and management of GCA. Patients are referred from their GP and A&E directly to the Ambulatory emergency care unit (AECU), but it is not guaranteed they will be seen by a specialist within 3 days. We were also receiving inappropriate referrals for possible GCA such as patients under the age of 50 or chronic headache. We have 7-day access to acute ultrasonography in this DGH. We aimed to utilise this service in our fast-track GCA pathway. Aims: 1. All patients with suspected GCA to be seen within 3 working days by specialist. 2. Reduce the number of inappropriate referrals. 3. Reduce irreversible sequelae (visual loss, scalp tissue necrosis and stroke)

Methods

We developed a fast-track pathway containing referral criteria, directions for obtaining urgent ultrasonography and management advice. This was uploaded onto the intranet and was put up as posters in the AECU (see pathway). Baseline measurement: data were collected from ambulatory care referrals over a 5-month period. 29 patients were referred as possible GCA. After introduction of the pathway, data were re-collected over a 3-month period, with nine patients referred as possible GCA.

Results

Outcomes measured:

The percentage of inappropriate referrals decreased by 16% . The percentage of patients reviewed by rheumatology within 3 days increased from 44% to 78%. The percentage of sequelae did not change. Visual loss occurred in both groups at presentation (transient in one patient).

Prior to pathway implementation, 31% of patients referred had raised CRP/ESR. ESR/CRP was not tested in 34% of referrals. Following implementation, 100% of patients had CRP and ESR tested; of these 66% had raised CRP/ESR.

Conclusion

We have shown that having a fast-track pathway in place results in higher likelihood of a specialist evaluation within 3 days, as per BSR guidelines. To improve we suggest implementation of dedicated same-day AECU appointments for Rheumatology Specialists.

Disclosure

P.M. Lakhani: None. S. Ali: None. E. Sames: None. P. Agarwal: None. R. Lisk: None.
P013 Diagnosis and Management of Giant Cell Arteritis Patients in Cardiff and Vale University Health Board (January 2017-February 2020)
Authors: Yau Jessica , Saleh Mohammed , Negi Anurag
Published: April 2022

Background/Aims

Giant cell arteritis (GCA) is a medical emergency presenting with a new-onset headache. Delay in treatment can cause permanent vision loss and other complications. It responds quickly to oral and parenteral steroids. Temporal artery biopsy (TAB) is the gold standard. However, it is not easily available in a timely manner and can produce normal results due to skip lesions and if done after starting steroids. In contrast, ultrasound (USS) is a useful non-invasive alternative. The aims of this audit were to study our current practice against the NICE guidelines/BSR pathway on GCA management, to evaluate the impact of USS on diagnosis and management of GCA and the use of tocilizumab and steroid-sparing synthetic DMARDs.

Methods

This is a retrospective, audit study on patients with a new diagnosis of suspected GCA referred to the Cardiff and Vale Health Board from January 2017 to February 2020. 105 patients who had a USS doppler test were identified, 51 were excluded due to various reasons, ultimately data on 54 patients were analysed.

Results

50 patients (93%) were >50 years old; female: male was 4:1.5. 44 (81%) were primary care referrals. 50 (93%) were seen by a rheumatologist within 48 hours. 11 had visual symptoms, all had an ophthalmology review, two had ischemic changes suggestive of GCA. Pre-USS, 21/54 (39%) were classed as likely GCA. Post-USS, 19/54 (35%) were confirmed GCA, two were refuted. Only 3/54 showed signs of GCA on USS (sensitivity: 15.79%). TAB was done in five patients (sensitivity: 20%), 1/5 showed GCA, all had negative USS. The low sensitivity of USS and TAB is likely to be due to steroid exposure, as all patients were on steroids at time of USS and three had the biopsy 2 weeks post-steroid use. 19 patients continued on steroids for GCA. At 12 months follow-up, 2/19 had discontinued steroids, only 4/17 were on prednisolone >10mg. None of the patients in our cohort required tocilizumab or other steroid-sparing agents.

Conclusion

Temporal artery USS is useful in aiding the GCA diagnosis and reduces the need for TAB, especially in patients with low clinical probability of GCA. Clinical assessment, USS and ophthalmology review together can avoid unnecessary exposure to long-term steroids. It is reassuring that the majority of patients with a low GCA probability had a normal USS. This helped in avoiding steroid use and/or to stop steroids quickly in those who had already started steroids. A local pathway for management of patients referred as suspected GCA is being established in the department. Teaching sessions for non-rheumatologists involving BSR Guidelines on GCA might help reduce unnecessary referrals and improve standard of care. We aim to study the reasons for the low utilisation of tocilizumab and other steroid-sparing agents.

Disclosure

J. Yau: None. M. Saleh: None. A. Negi: None.
P024 Real-world experience of Tocilizumab withdrawal in GCA
Authors: Khalid Salema , Davidson Brian , Hopkinson Neil , Mason Alice , Malik Mariam , Laskou Faidra , Parker Lucy
Published: April 2022

Background/Aims

Part 2 of the GIACTA trial explored the maintenance of efficacy in giant cell arteritis (GCA) patients. It showed that nearly half the patients treated with weekly tocilizumab (TCZ) maintained remission, though flares did still occur in the remaining half when TCZ was discontinued. Currently, NHS England has approved the use of TCZ in GCA for only 1 year as this duration was agreed upon by clinical experts to be sufficient to sustain remission. However, this remains a point of concern amongst clinicians as to whether data from real-life patients confirms that 1 year of TCZ can achieve sustainable remission.

Methods

Our objective is to assess the real-world experience of TCZ withdrawal in GCA patients and how different centres are trying to mitigate risk of relapse after its cessation. We are conducting a patient survey across six hospitals in Wessex, United Kingdom. Our aim is to assess the change in clinical features, acute phase reactants and the rate of sustained remission and relapse.

Results

53 patients with GCA were included in the survey. Average age of patients was 73.5 years. 36 patients had cranial GCA, five had large vessel vasculitis and no sub-type was mentioned for the 12 remaining patients. Temporal artery biopsy was the most common diagnostic tool used for 21 patients, followed by PET scan for 14 patients. Eight patients had a clinical diagnosis only, while seven were diagnosed with GCA based on findings of Anterior Ischaemic Optic Neuropathy. Only three patients had their diagnosis confirmed via ultrasound temporal arteries. Out of these 53 patients, 45 started Tocilizumab. 15 patients stopped treatment due to side effects. Of the remaining 30 patients, only 17 have completed their 1 year of TCZ so far. Two patients relapsed 6 months after stopping TCZ. One of them was on methotrexate (MTX) and low dose prednisolone, while other was on mycophenolate mofetil only. Of those who are currently stable since completing TCZ, five patients are on MTX with prednisolone, one patient on leflunomide and prednisolone, four patients on prednisolone only and three patients on MTX only. Two patients are on no treatment currently.

Conclusion

This is an ongoing study. Our figures so far show that most patients are still on treatment with steroids and MTX, either alone or in combination, after completing 1 year of TCZ. This could be due to clinicians trying to mitigate against relapse once TCZ is withdrawn. This study highlights that real-world data on relapse/remission rates following TCZ withdrawal is essential as it will help shape future GCA treatment and guidelines.

Disclosure

S. Khalid: None. B. Davidson: None. N. Hopkinson: None. A. Mason: None. M. Malik: None. F. Laskou: None. L. Parker: None.
P044 Giant cell arteritis in an immunocompromised patient with rheumatoid arthritis
Authors: Chauhan Neal , Kinder Alison
Published: April 2022

Background/Aims

Giant cell arteritis (GCA) is a common medium-large vessel vasculitis with an approximate incidence of 10 cases per 100,000 people over 50 years old. First line management of GCA is with high dose glucocorticoids followed by steroid sparing agents, namely methotrexate with tocilizumab for resistant cases. Here we describe a patient established on methotrexate for rheumatoid arthritis, receiving rituximab with intravenous methylprednisolone (IVMP) who went on to develop GCA.

Methods

A 65-year-old Caucasian female with seropositive rheumatoid arthritis (RA) established on 20mg weekly subcutaneous methotrexate and low dose 5mg prednisolone was escalated to her tenth cycle of rituximab with 100mg IVMP for an arthritic flare. The day after her second infusion, two weeks apart, the patient presented with headaches. These were severe temporal pains with scalp tenderness for the past four weeks. She denied visual changes, jaw claudication or polymyalgia rheumatica features. Examination identified bilateral thickened and tender temporal arteries. Ultrasound confirmed bilateral frontal temporal artery halo signs, with intimal thickening of 0.9mm and 0.4mm of the left and right respectively. Blood tests showed a rise in C-reactive protein to 46mg/L from 13mg/L. In view of these findings, procedural risks and recent immunosuppression biopsy was not sought. The patient was commenced on 40mg prednisolone before weaning by 5 mg 2-3 weekly. Her headache improved, without relapse and her CRP normalised within 2 weeks. Given tocilizumab had previously been ineffective in the patient’s RA management, she declined transition to this biologic and her methotrexate was increased to 25mg.

Results

Development of GCA in a patient with pre-established immunotherapy is rare. This report represents only the second case noted in the literature of the vasculitis occurring in a patient whilst on rituximab. Excluding tocilizumab (anti-IL6), a meta-analysis of other biological agents including infliximab, adalimumab, etanercept (anti-TNF) and abatacept (anti-CTLA4) have not been proven to have clinical significance over placebo in GCA. However, evidence of rituximab and its role in GCA is limited with no clinical trials. Contrary to this case of GCA, rituximab (anti-CD20) therapy has a well-recognised role in ANCA associated vasculitis and there are growing calls for trials in large vessel vasculitides. Recent case series of rituximab in Takayasu’s arteritis have presented contrasting outcomes of persistent disease activity versus clinical and laboratory remission. Robust clinical trials are therefore required to evaluate the long-term impact of rituximab on large vessel vasculitis.

Conclusion

Although rare, clinicians should be vigilant for the development of GCA despite established immunosuppression.

Disclosure

N. Chauhan: None. A. Kinder: None.
P053 Heterotopic ossification after COVID-19 infection - case report
Authors: Chang Yvonne , Stathopoulou Eleni
Published: April 2022

Background/Aims

Heterotopic ossification (HO) is the abnormal formation and deposition of mature lamellar bone within soft tissue, associated with trauma, surgery, neurologic injury and prolonged immobilisation. Several recent case reports have demonstrated this condition in COVID-19 patients requiring mechanical ventilation.

Methods

We present a case of heterotopic ossification in the shoulder after a long stay in intensive care unit (ICU) due to COVID-19 infection.

Results

A 55-year-old man with stable psoriatic arthritis on sulfasalazine was admitted to ICU for mechanical ventilation after contracting COVID-19 infection. After discharge from ICU, he began noticing increasing right shoulder pain with restricted movements of abduction, internal and external rotation. His serum alkaline phosphatase was moderately elevated. Despite physiotherapy and NSAIDs, there was slow improvement. Shoulder x-ray showed significant bony overgrowth around proximal humerus which was initially thought to be part of his psoriatic arthritis. It was confirmed at Rheumatology/Radiology MDT to be heterotopic ossification. A computed tomography of the right shoulder was requested to evaluate the extent of the condition and orthopaedic advice was sought.

Conclusion

There are many factors contributing to the development of heterotopic ossification including trauma, spinal cord injury, brain injury, hypoxia, prolonged immobilisation with limitation of joint movement and prolonged bed rest which cause alterations in calcium homeostasis, male sex and over 60 years of age.

New onset joint pain and stiffness in patients who have recovered from COVID-19 especially those who had long ICU stay should be further investigated for this condition.

Treatment includes analgesia and physiotherapy with potential surgical intervention.

Disclosure

Y. Chang: None. E. Stathopoulou: None.
P069 A phone survey on the acceptance of COVID-19 vaccination amongst adolescents in a rheumatology centre in Malaysia
Authors: Ng Chun Ruh , Ho Tze Hau
Published: April 2022

Background/Aims

According to newspaper Bernama, 6.5% of adolescents in Malaysia aged between 12 and 17 have completed their vaccination and 89.7% of the adult population have completed theirs as of 9th October 2021. The acceptance of patients with rheumatic diseases on Covid-19 vaccination are crucial in the successful long-term protection against COVID-19 infection. We conducted a phone survey to determine the acceptance of COVID-19 vaccination amongst adolescents with underlying rheumatic disease.

Methods

This was a phone survey. The electronic medical records of all rheumatology patients follow up in rheumatology clinic Hospital Sultan Ismail, Malaysia from 2019 to 2021 were reviewed and patients with the age group between 12 to 21 were identified. Demographic data, diagnosis of the disease and outcome of the survey were collected and analysed.

Results

Phone survey was done after data extracted from medical records. For those under the age of 18, guardian of the patients was interviewed. A total of 50 patients were identified. Most of the patients were female (46/50) and majority of them were Malay (33/50). This was followed by Chinese (10/50), Indian (4/50) and others (3/50). The mean age group was 18 (range from 13 to 21).

36 of them were having systemic lupus erythematosus (SLE), 5 of them were having juvenile idiopathic arthritis (JIA) ,2 of them were having psoriatic arthritis (PSA) and another 2 of them were having rheumatoid arthritis (RA), followed by RA overlapped SLE, juvenile dermatomyositis, Henoch-Schönlein purpura, SLE overlapped with JIA and mixed connective tissue disease about 1 each respectively. Majority of them patients are keen or already completed COVID-19 vaccination with the acceptance rate of as high as 92% (46/50). Only 8% of them are not keen for vaccination with the only reason of worrying the risk of myocarditis post vaccination (1 SLE patient and 1 PSA patient).

Conclusion

The overall acceptance rate of COVID-19 vaccination amongst adolescents with rheumatic diseases are very encouraging with the percentage of > 90% despite lacking knowledge about vaccination for COVID-19. This result can assist our Ministry of Health in planning for future battles to improve vaccine uptake that hopefully can lead to herd immunity against COVID-19 infection.

Disclosure

C. Ng: None. T. Ho: None.
P082 Informal opportunities for education about lifestyle factors in inflammatory arthritis
Authors: Robinson Sandra , Bourke Maurice , Scrafton Nicola , Walker David
Published: April 2022

Background/Aims

Education of patients about their disease and treatments are a central part of the Nursing and AHP roles especially in chronic diseases such as arthritis. Different patients will require different approaches; layering and repetition of information are usually necessary. Recommended advice will also change over time with increased understanding and research, requiring updates for existing patients. In this situation any contact with the Rheumatology team is an opportunity to get health messages to patients. There is increasing data confirming the effect of obesity, exercise and smoking on response to treatment and outcomes in inflammatory arthritis. We were interested to explore if these messages had been delivered to established patients by our team.

Methods

We designed a short, self-complete, questionnaire for patients asking about information they had received from the team on lifestyle advice. We included questions on drug education as a positive control as we were confident that all patients would have received education about this. 50 consecutive patients with either rheumatoid or psoriatic arthritis seen by one consultant were included.

Results

The population was of 38 RA and 12 Psoriatic arthritis. Average duration of disease was 15yrs (Range 2-60). Average BMI was 28.4 (19.7-42.8). 29% were normal, 33% overweight and 38% obese. Only 59% said that they had moderate or a lot of education about their DMARDs and 11% reported having had none. However, 83% were moderately or very confident that they had sufficient information about the drug. No one reported no confidence. The most useful sources of information included the Doctors (50%) Nurses (37%) internet (24%) and booklets (9%). There was a strong correlation between amount of education and duration of disease (p < 0.001). Responses about how much information they had received from the team about lifestyle factors are shown in the table. There was a large range for all topics.

Conclusion

It appears that patients do not always remember education about their drugs, but all have confidence that they know about the drugs. Messages about lifestyle factors are being given by the “Team”, but around 50% of patients reported receiving little or no information on each topic. A more structured approach to these opportunities for education would be appropriate.

Disclosure

S. Robinson: None. M. Bourke: None. N. Scrafton: None. D. Walker: Consultancies; Galapagos, Eli Lilly.
P088 Utilising virtual reality for remote joint injection training for the post-pandemic rheumatologist
Authors: Clarke Benjamin D , Balachandran Sathiyaa , Nagra Deepak , Russell Mark D , Bechman Katie , Adas Maryam , Hope-Smith Anthony , Yates Mark , Barrow Alastair , Smith Tom , Galloway James
Published: April 2022

Background/Aims

The impact of dealing with COVID-19 for rheumatology higher specialist trainees has been profound. Sacrifices were made to their training to support the UK's pandemic response. Virtual Reality (VR) has long been used as a solution for specific surgical skills; providing a hands-on experience to enable specific delivery of outcomes. We utilised existing technology alongside a specialist VR and haptics team to review ways at delivering a valid and reliable training tool to administer joint injections, beginning with the review of this procedure specific to the knee. We aimed to describe this process.

Methods

A qualitative study using focus groups was undertaken, one medical student, four higher specialty trainees and two consultants were convened in a focus group to review existing mannequin-based training with the purpose of identifying a skill to develop in virtual reality. A story board was developed through collaboration with a graphic designer. The scenario was imbedded into a virtual reality environment in collaboration with a virtual reality partner.

Results

The focus group identified intra-articular knee injection as the most appropriate rheumatology skill to develop. Storyboarding built a series of scenarios around clinical situations which would require injection or aspiration. Working with the engineering team we successfully mapped knee joint anatomy and rendered an authentic clinical environment for the storyboards to run inside.

Conclusion

Virtual reality training scenarios are complex to develop but have enormous potential to create immersive training and assessment experiences which are not boundaried by the challenges of social distancing and COVID-19 risks.

Disclosure

B.D. Clarke: Honoraria; Abbvie. Grants/research support; Innovate UK. S. Balachandran: None. D. Nagra: None. M.D. Russell: Honoraria; Lilly, Pfizer, Janssen, UCB, Menarini. K. Bechman: None. M. Adas: None. A. Hope-Smith: None. M. Yates: Honoraria; Abbvie, UCB. A. Barrow: Grants/research support; Innovate UK. T. Smith: Grants/research support; Innovate UK. J. Galloway: Honoraria; Abbvie, Biovitrum, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB.