bluuebunny/crossref_metadata_2025 huggingface dataset:
P115 Remote clinical management: incorporating electronic assessment of patients with rheumatic diseases into standard clinical pathways and comparison to in-person assessment
Authors: Soni Anushka , Jackman John , Manderson Sarah , Pena Larissa Saldana , Barrett Joseph , Luqmani Raashid
Published: April 2022

Background/Aims

The aim of this project was to develop generalisable digital solutions to deliver safe, efficient and effective care for patients with long-term rheumatic conditions. We have previously demonstrated that this method is feasible and acceptable to patients with RA and AxSpA. We evaluated the outcomes of remote assessment across a further range of conditions; making comparisons with corresponding in-person assessments.

Methods

We developed online questionnaires, using readily available software, to conduct remote assessments in 806 patients awaiting follow-up. Questionnaires contained: measures of disease activity; patient reported outcomes; patient preferences regarding the urgency and type of appointment required; and any other recent problems or changes in medication highlighted by the patient. The information was imported into a bespoke clinical database allowing clinicians to conduct an asynchronous assessment, integrated within electronic health records (EHR). Report letters were sent to patients and their GP. EHRs were reviewed in a subset of patients, requiring urgent in-person assessments (within 1-month) following remote assessment, to evaluate overall agreement with in-person assessment of disease activity and treatment changes. Chi-square test was used to investigate for significant differences by condition. We defined “stable” disease as patients classified as in remission or partial remission, on or off immunosuppressive therapy.

Results

Table 1 summarises all the patients assessed remotely, by condition, and subsequent follow-up requested. Agreement between remote and in-person assessment was evaluated in 56 patients (25 RA; 14 PsA; 17 AxSpA). Agreement between remote and in-person assessment was present in 21/25 (84%), 9/14 (65%) and 12/17 (71%) of patients with RA, PsA and AxSpA respectively, p = 0.35. Treatment changes were made in 21/25(84%), 9/14(65%), 11/17(65%) of patients with RA, PsA and AxSpA respectively, p = 0.26).

Conclusion

We have developed and implemented a system of remote clinical management for patients with rheumatic conditions. Following remote assessment only 284/806 (35%) required a subsequent in-person assessment and 351/806 (44%) had stable disease. Concordance with in-person assessment was highest for patients with RA, but not significantly different to outcomes for PsA and AxSpA. Further work is needed to validate this mode of assessment, including patients with vasculitis/CTD and those declared as having “stable” disease.

Disclosure

A. Soni: None. J. Jackman: None. S. Manderson: None. L. Saldana Pena: None. J. Barrett: None. R. Luqmani: None.
P117 Nailfold capillaroscopy: a survey of current UK practice and ‘next steps’ to facilitate generalised uptake
Authors: Eden Martin , Wilkinson Sarah , Murray Andrea , Bharathi Praveen Gurunath , Taylor Chris , Payne Katherine , Herrick Ariane L
Published: April 2022

Background/Aims

Nailfold capillaroscopy has a key role in the assessment of patients with Raynaud’s phenomenon (RP) providing a window of opportunity for the early diagnosis of systemic sclerosis (SSc). Anecdotal evidence indicates that this opportunity is not being fully realised across UK rheumatology centres. Reasons for apparent discrepancies in use of capillaroscopy may relate to a lack of expertise, confidence or equipment. Exploratory work has demonstrated the potential for an internet-based standardised system for clinical reporting of nailfold capillaroscopy images to mitigate current inequities in care provision. The overall aim of this study was to understand current practices in the diagnosis of SSc in UK rheumatology centres with specific reference to identifying barriers to the use of nailfold capillaroscopy. A secondary aim was to understand rheumatologists’ views on a standardised system to facilitate the timely diagnosis of SSc.

Methods

An online survey comprising closed and free-text questions was developed using expert (n = 7) opinion from clinicians, scientists and health service researchers. The survey was piloted (n = 5) and sent to UK-based rheumatologists using established electronic mailing lists between 2nd October 2020 and 8th March 2021. Respondents were asked to describe workloads and practices typically seen before the COVID-19 pandemic. Data were analysed using descriptive statistics and thematic analysis.

Results

Survey responses were received from 104 rheumatologists representing centres across the UK. Wide variation in terms of workloads and practices were described (See Table 1). Only 41% (n = 43) of respondents reported using nailfold capillaroscopy provided at their centres. Key barriers were access to equipment and a lack of expertise in terms of acquiring and analysing images. Respondents indicated that a centralised internet-based system for storing images and sharing diagnoses would provide access to expertise and the possibility of timely diagnoses.

Conclusion

Substantial variation in approaches to the diagnosis of SSc across the UK was identified. Potential benefits of a standardised system were described by respondents including the improved diagnosis and management of SSc, realising potential patient benefits and reducing current health inequalities. Survey findings provide evidence to help develop future studies to develop and evaluate the proposed new system.

Disclosure

M. Eden: None. S. Wilkinson: None. A. Murray: None. P. Gurunath Bharathi: None. C. Taylor: None. K. Payne: None. A.L. Herrick: None.
P124 Disease modifying anti-rheumatic drug (DMARD) therapy monitoring and evaluation of patient progress as part of standard clinical care in rheumatology patients
Authors: Luqmani Raashid A , Escudero Alexa , Driver Krystie , Mirza Maria , Jackman John , Manderson Sarah , Soni Anushka
Published: April 2022

Background/Aims

Review of blood results for monitoring DMARDs is performed manually in our department and subject to human error with up to 200 starters per month. In the last 6 months at least three patients have had abnormalities which were missed, highlighting a significant clinical risk. The aim of the project was to develop, test and implement an automated algorithm to detect and act on significant blood abnormalities in patients starting DMARD therapy.

Methods

We created a system to automatically analyse laboratory results supplied by our laboratory. We imported data into a specifically designed database to provide analysis based on BSR guidelines. The data is immediately ready for review by a clinician, grouped as: normal, mildly abnormal (exceeding the upper or lower limit of normal), missing (individual values not recorded), or abnormal (outside the threshold values); records with consecutive results showing a trend towards abnormality are also recorded. The clinician has the responsibility to review all records and endorse them after taking appropriate action where required.

Results

We tested the system on two cohorts of 100 and 227 sets of blood tests respectively and confirm that it is more rapid and robust than a manual process. We compared each of record with a manual evaluation of the data on a spreadsheet. We identified more abnormalities using the new system than were found on manual inspection (29% vs 10%, Chi square P < 0.001). The manual system took 3 hours to prepare the data for evaluation; the new system performed the same task in under 1 minute. Table 1 shows the summary data for 100 test records, assessed manually and then using the algorithm, followed by real data using 570 records from 160 patients initiating DMARD. Subsequent manual inspection of the test records defined as abnormal by the algorithm confirmed that the new system had correctly identified abnormalities in every case.

Conclusion

We have developed a blood monitoring system for patients initiating DMARDs, capable of processing up to 10,000 results per session. The system is practical, more efficient and more accurate than a manual process for DMARD monitoring.

Disclosure

R.A. Luqmani: None. A. Escudero: None. K. Driver: None. M. Mirza: None. J. Jackman: None. S. Manderson: None. A. Soni: None.
P127 Disrupting the cartilage mechanostat: the role of the ciliary protein IFT88 in the adolescent growth plate
Authors: Chang Emer , Coveney Clarissa , Wann Angus
Published: April 2022

Background/Aims

As long bone elongation draws to a close, the cartilaginous growth plate begins to ossify in preparation of growth plate fusion. Previous embryonic developmental in vivo work has identified the crucial Parathyroid Hormone-related Protein-Indian hedgehog (PTHrP-Ihh) feedback loop that is responsible for the proliferation of chondrocytes at the epiphysis, whilst also allowing for the hypertrophic differentiation of chondrocytes before ossification at the diaphysis. Indian hedgehog signalling relies upon the microtubule-based organelle the primary cilium, as disruption to either results in similar musculoskeletal phenotypes. Here, we asked for the first time whether juvenile and adolescent primary cilia disruption affected chondrocyte differentiation in the growth plate.

Methods

We used a chondrocyte-specific conditional knockout (AggrecanCreERT2; Ift88fl/fl, cKO) of a key primary ciliary protein (Ift88) administering tamoxifen at (4, 6, 8 weeks-of-age) to both cKO and control (Ift88fl/fl) animals, collecting two weeks later (6, 8, 10-weeks-of-age). Immunohistochemistry was performed using type X collagen (ColX), a specific marker of hypertrophic chondrocytes.

Results

Deletion of IFT88 resulted in large bi-lateral cartilaginous regions filled with disorganised ColX positive hypertrophic chondrocytes, indicating failed ossification. Our results indicate that deletion of IFT88 does not impact hypertrophic differentiation, but disrupts ossification processes downstream at the chondro-osseous junction, such as matrix remodelling and angiogenesis, necessary for growth plate closure. Interestingly, this phenotype was observed only in the bi-lateral most loaded regions of the tibia whilst the middle was unaffected.

Conclusion

This observation indicates that the primary cilium could be involved in transducing mechanically regulated biophysical and signalling cues in the adolescent growth plate.

Disclosure

E. Chang: None. C. Coveney: None. A. Wann: None.
P128 Double-blind randomized pilot study to evaluate diamagnetically enhanced transdermal ibuprofen in comparison to placebo on pain and function in individuals with knee osteoarthritis
Authors: Summers Jill , Wright Tony , Benson Heather , Moss Penny , Tsadilas George , Edwards Jeff , Will Rob
Published: April 2022

Background/Aims

Treatment of knee osteoarthritis (OA) focuses on reducing pain and improving function. Transdermal NSAID formulations have been developed as an alternative approach to reduce pain and sensitisation around the OA affected joint whilst avoiding some of the risks associated with oral NSAID administration. The aim of the study was to evaluate clinical outcomes following short-term (48 hours) administration of transdermal ibuprofen (5% w/v) from a wearable patch that incorporated a patented diamagnetic repulsion technology to enhance drug delivery, in comparison to placebo.

Methods

Double-blind, repeated measures, crossover design. Two study periods (48 hr each); diamagnetically enhanced ibuprofen or placebo, randomised. Participants: 24 (6 male: 18 female, mean age 66) people with painful knee OA. Patch applications: 6 x 4-5 hour patch applications over a 48 hour period. Active patches contained 5% ibuprofen in a gel reservoir with magnetized backing. Placebo patches had identical appearance but no ibuprofen and non-magnetized backing. Primary outcome measures: VAS for pain on movement (STS X3), WOMAC pain score, WOMAC function score.

Results:

Conclusion

The active device containing ibuprofen (5%) and magnetophoresis technology produced a significantly greater reduction in pain and improvement in function than the placebo device. This was particularly the case for movement related pain. The reduction in pain was apparent with both VAS pain ratings and WOMAC pain score. There was also a clear improvement in function based on the WOMAC function score. The number needed to treat (NNT) for a 50% reduction in movement related pain was 2.2 and for resting pain 3.4. There were no major adverse events recorded during the study.

Disclosure

J. Summers: None. T. Wright: None. H. Benson: None. P. Moss: None. G. Tsadilas: None. J. Edwards: None. R. Will: None.
P130 Pharmacist-led osteoporosis telephone service
Authors: Rusby Nathan Karl , Bridges Matthew
Published: April 2022

Background/Aims

The COVID-19 pandemic has made finding ways to consult suitable patients remotely a priority. We have introduced a telephone assessment clinic, run by our departmental pharmacist, to assess and treat patients with osteoporosis who have been referred from primary care for consideration of parenteral bone sparing therapy.

Methods

Patients with osteoporosis who have been referred from primary care were triaged electronically into a fortnightly telephone assessment clinic, according to pre-specified criteria. Prior to the appointment, information leaflets about osteoporosis, and treatments for this condition were posted to the patients. The telephone consultation was carried out and patient demographics, risk factors for fracture, bone density results, FRAX / NOGG assessment, treatment decisions, and other clinical details were recorded on a pro-forma. A satisfaction survey was sent out to each patient following consultation.

Results

Sixty patients were assessed between July 2020 and April 2021. Fifty-seven (95%) were female, and the mean age was 71 years. Following consultation, twenty-one were commenced on zoledronic acid, eighteen on denosumab, three on teriparatide and eighteen no treatments /other. Average time from referral to consultation was 1.75 months. Thirty-four patient satisfaction surveys were returned. Twenty-nine (85%) patients said they would be happy for consultations via telephone in the future, with twenty-five patients (74%) either likely or highly likely to recommend telephone consultation to family or friends. When asked to compare their experience of telephone to face-to-face consultations; twenty (58%) reported being indifferent, four (12%) said their experience was poorer or significantly poorer than face-to-face, and ten (29%) said their experience was better or significantly better. Mean saving on travel expenses was £0-£5 (41% of patients) with four patients (12%) saving £21+. Mean mileage saved was < 5 miles (33% of patients), with seven patients (21%) saving 30+ miles on travel.

Conclusion

This study reveals that patients, overall, had a positive experience with a pharmacist-led telephone consultation. Such clinics could be implemented across other areas of our rheumatology service, if clinically appropriate; reducing unnecessary patient contact, reducing consultant work load and optimally utilizing skills of the wider multi-disciplinary team. Face-to-face consultations still have an essential role where physical examination may be required, or patients have communication barriers. Our sample size was small, and data collection is on-going.

Disclosure

N. Rusby: None. M. Bridges: None.
P134 Mortality rates in individuals with a history of fracture: does sex matter? Findings from the Hertfordshire Cohort Study UK
Authors: Laskou Faidra , Westbury Leo , Patel Harnish , Cooper Cyrus , Dennison Elaine
Published: April 2022

Background/Aims

The occurrence of hip and vertebral fragility fractures has been linked to increased mortality; possible explanations including fracture complications and multi-morbidity. Given the advances in osteoporosis management in recent years, and the time since this subject was last studied, we aimed to examine associations between previous fracture and mortality, and specifically to consider whether sexual dimorphism in relationships existed, using a UK community dwelling cohort of older adults (Hertfordshire Cohort Study), linked to death registers.

Methods

2997 (1579 men and 1418 women) participants were included in the study. At baseline, participants self-reported history of fractures and a subset (n = 992) underwent hip bone mineral density (BMD) assessment. Median follow-up time for mortality was 16.2 years. Previous fracture since age 45 years (any and minor trauma) and femoral neck BMD in relation to all-cause and cause-specific mortality (cancer, cardiovascular and other) were examined separately, using sex-specific Cox proportional hazards models, with and without adjustment for age.

Results

The mean (SD) age of participants at baseline was 65.7 (2.9) years for men and 66.6 (2.7) for women. 575 (36.4%) men and 365 (25.7%) women died over the follow up study period. 230 (14.6%) men and 155 (10.9%) women died from cancer and, 169 (10.7%) men and 70 (4.9%) women from cardiovascular diseases. 174 (11.0%) men and 138 (9.7%) women died from other causes. Among men who died from other causes, the most common conditions leading to death were dementia (9.2%), bronchopneumonia (8.1%) and Parkinson’s disease (7.5%); corresponding conditions for women were Alzheimer's disease (11.6%), pneumonia (9.4%) and dementia (8.0%). In women, mortality associated with diseases other than cardiovascular disease or cancer was increased significantly in the presence of a previous fracture since the age of 45 (unadjusted hazard ratio: 1.47, 95% CI: 1.01,2.15, p = 0.04) and minor trauma fracture (1.67, 95% CI: 1.14,2.46, P = 0.01); association regarding minor trauma fracture was robust to adjustment for age (p = 0.04). In men, a history of fracture since the age of 45 was associated with increased cancer-related mortality with and without adjustment for age (1.42, 95% CI: 1.01, 1.99, P = 0.04 without age-adjustment). Baseline BMD was not associated with increased mortality from any cause in either sex.

Conclusion

Our study has highlighted different associations between fracture and mortality in men and women, possibly suggesting different pathogenesis of fracture in the two sexes. Work in other large cohorts with linked mortality data might seek to replicate and further explore these associations.

Disclosure

F. Laskou: None. L. Westbury: None. H. Patel: None. C. Cooper: None. E. Dennison: None.
P144 Phalangeal microgeodic syndrome: is this very rare condition becoming more common?
Authors: Parker Lucy , Ahmad Moneeb , Mukherjee Sandeep , McAlinden Paula
Published: April 2022

Background/Aims

Phalangeal microgeodic syndrome (PMS) is a rare condition with only a handful of published case reports. Most of these cases are recognised in childhood, typically in Japan. It presents with pain and dusky discolouration in the digits, distinct from Raynaud’s phenomenon in that the colour change is fixed and pain constant. Symptom onset is related to cold exposure with first presentation usually occurring in winter. Features on magnetic resonance imaging (MRI) are striking and characteristic, with a distinct pattern of bone marrow oedema.

Methods

We report five cases of MRI-proven PMS all identified in the last 12 months, with symptom onset during the winter. The patients were all female, aged between 25 and 79. One patient was already under the care of rheumatology with an established diagnosis of systemic lupus erythematosus (SLE), but the remainder were de novo referrals presenting specifically with pain and discolouration of the digits. One patient developed symptoms 2 days after receiving the first dose of Pfizer/Biontech RNA vaccine against COVID-19. One patient had to self-isolate following a COVID-19 contact and developed symptoms shortly thereafter, although there was no proven infection in the affected individual.

Results

Four out of five cases were managed conservatively, with advice on maintaining core and peripheral temperature and skin integrity. Without any specific therapy, these four cases improved spontaneously to coincide with increasing seasonal temperatures. The fifth case with existing SLE was treated with intravenous pamidronate and subsequently with a calcium channel blocker, with some improvement in symptoms.

Conclusion

In these authors’ experience, it would seem PMS is increasing in incidence. It is unclear if this relates to wider availability and image quality of MRI, clinician bias due to personal experience of more cases or a genuine increase. The winter 2020/21 was particularly cold with sub-zero conditions lasting well into May, which may have impacted on this flurry of new cases. We have identified one prior case report which describes PMS in a patient with existing connective tissue disease. Our patient with SLE appeared to have a more severe clinical presentation requiring additional medical therapy to control the symptoms compared with the four cases where PMS was a stand-alone condition. Dermatological manifestations of acute COVID-19 infection are well documented in children and include chilblain-like lesions and acrocyanosis. Any association between COVID-19 and PMS is purely hypothetical and would require more study to identify any true relationship.

Disclosure

L. Parker: None. M. Ahmad: None. S. Mukherjee: None. P. McAlinden: None.
P145 Safety of colchicine or NSAID prophylaxis when initiating allopurinol for gout: propensity score-matched cohort studies
Authors: Roddy Edward , Bajpai Ram , Forrester Harry , Partington Richard , Mallen Christian D , Clarson Lorna , Padmanabhan Nishita , Whittle Rebecca , Muller Sara
Published: April 2022

Background/Aims

Initiating urate-lowering therapy for gout commonly triggers a gout flare and hence co-prescription of colchicine or non-steroidal anti-inflammatory drug (NSAID) prophylaxis is recommended. However, little is known about the incidence of adverse events associated with prophylaxis. We aimed to determine the risk of adverse events severe enough to warrant seeking healthcare associated with colchicine or NSAID prophylaxis when initiating allopurinol for gout.

Methods

We conducted two matched retrospective cohort studies, using linked data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) datasets. Adults aged ≥18 years with a Read code for gout and a new allopurinol prescription between 1997 and 2016 were identified. We compared those prescribed (1) colchicine or (2) NSAID prophylaxis with those prescribed no prophylaxis, individually matched by age, sex and propensity to receive prophylaxis, to reduce the impact of confounding by indication. Adverse events were identified in CPRD and HES using Read and ICD10 codes respectively. Associations between colchicine or NSAID prophylaxis and the first occurrence of each outcome were investigated using weighted Cox proportional hazards models. CPRD Gold and Aurum datasets were analysed separately and then combined using 2-stage individual patient data meta-analysis.

Results

13,945 individuals who initiated allopurinol with colchicine prophylaxis were matched to 13,945 who initiated without prophylaxis (mean age 63.62 years [95%CI 63.54, 63.70]; 78% male). Diarrhoea was the most common adverse event in the colchicine group, followed by nausea/vomiting, myocardial infarction (MI), neuropathy, myalgia, and bone marrow suppression (Table). Diarrhoea, MI, neuropathy, myalgia, and bone marrow suppression were significantly more common with colchicine prophylaxis compared with no prophylaxis. 22,880 individuals who initiated allopurinol with NSAID prophylaxis were matched to 22,880 who initiated without prophylaxis (mean age 63.34 years [95%CI 63.26, 63.42]; 78% male). Angina, acute kidney injury, MI, and peptic ulcer disease were significantly more common with NSAID prophylaxis than without (Table).

Conclusion

Gastrointestinal, cardiorenal, myoneuropathic, and haematological adverse events were associated with prophylaxis, although absolute event rates were low. This information can inform treatment decisions and choice of colchicine or NSAID for prophylaxis when initiating allopurinol.

Disclosure

E. Roddy: None. R. Bajpai: None. H. Forrester: None. R. Partington: None. C.D. Mallen: Grants/research support; Keele University School Of Medicine has received funding from BMS to support a non-pharmacological atrial fibrillation screening study. L. Clarson: None. N. Padmanabhan: None. R. Whittle: None. S. Muller: None.
P153 A patient-led survey into the benefits and limitations of telemedicine appointments for assessing children and young people with rheumatic conditions in Canada
Authors: Wilson Jennifer , Costello Wendy , Angevare Saskya , Beesley Richard P
Published: April 2022

Background/Aims

During the COVID-19 (coronavirus) pandemic, some healthcare provision shifted to remote, technology-assisted appointments (telemedicine). This study sought the views of parents/carers about telemedicine, identifying the benefits and limitations, to assist in improvement to future service provision.

Methods

An online survey was developed and shared via social media and direct contacts, targeted at parents of children with rheumatic and autoinflammatory conditions in Canada. Fieldwork took place during May 2021. Consent was provided during enrolment.

Results

A total of 157 responses were received (78% female, median age 12). The primary diagnosis for the majority was juvenile idiopathic arthritis (JIA; 39% polyarticular, 15% oligoarticular, 8% enthesitis-related JIA, 6% psoriatic, and 9% systemic). Respondents reported in-person appointments represent a considerable time burden (87% travel more than an hour to attend; 40% take a full day [or more] out of school to attend; 38% of parents take a full day off work). During the pandemic, the proportion having a telemedicine appointment increased from 5% to 82%. Table 1 shows the scores (1 worst, 5 best) given by parents about their telemedicine experience. Overall, most aspects scored positively (p<.05). However, parents felt telemedicine was not as good as in-person appointments (mean 2.66, 95% CI 2.42-2.90).

The majority of respondents reported telemedicine appointments had saved them time (68%), and many said it enabled them to have an appointment (63%) and made the appointment safer (59%), and many said it saved money (44%). However, 78% felt that their consultant could not properly assess their child, 22% were concerned that the doctor could not identify changes in their child’s condition, 14% said it was hard to explain their child’s condition, and 18% of parents and 22% of CYP disliked telemedicine. Overall, 61% said they would prefer the next appointment to be in-person, while 31% were amenable to some combination of in-person and virtual care.

Conclusion

There are advantages to telemedicine, notably saving time and making appointments accessible, and overall parents reported satisfaction with remote appointments. However, parents continue to report the value of in-person appointments.

Disclosure

J. Wilson: None. W. Costello: None. S. Angevare: None. R.P. Beesley: None.
P169 The impact of online art therapy groups for paediatric rheumatology patients
Authors: Keane Megan H
Published: April 2022

Background/Aims

In January 2020 art therapy was offered to rheumatology patients at the Great North Children’s Hospital supported by the Teapot Trust, as open groups and 1:1 ward-based interventions. However, this service was suspended due to Covid 19 restrictions. In response to these restrictions and to the needs of the patients we offered weekly online art therapy groups.

Methods

The rheumatology team referred patients directly to the art therapist and groups were allocated. The aim was to provide a safe space for the exploration of difficult thoughts and feelings and to give opportunities for peer support and interaction. Group members defined their own goals, including: ‘to feel less worried about medical procedures’ or ‘to feel less lonely’. Parents also identified goals, including: ‘to provide something different for their child to associate with rheumatology treatment.’ Themes brought to sessions included medical anxiety, isolation, coping with loss, feeling different, resilience, control, independence and identity. Progress in therapy was measured using Goal Based Outcomes and online surveys, allowing children to report on their own progress.

Results

After six sessions all group participants reported progress towards meeting their individual goals. Clinical staff shared: “the last 18 months has been challenging for our patients and the need for additional therapy cannot be underestimated”, “we have had to adapt to provide art therapy and the ease of referral has made my job easier”, “our patients have valued and enjoyed their sessions, they can connect with each other so don’t feel so isolated with their diagnosis or treatment.” Parent feedback included: my daughter “was not in a very good place, she was very down and also grieving, these sessions have been invaluable to her, she has gained a lot of confidence in talking about her feelings and expressing them through art has been a great help.” My child “has been able to speak to other children like herself. To make friends and to open up a bit more.” “I have been surprised by how much of what they put down on paper was about the hospital. These are things that they don’t talk about and it has been an eye opener for me.” Patient's feedback included: it was important “to discuss my feelings in a safe environment without anyone thinking they were silly”, “Thank you for helping me express my feelings and have confidence to speak out”.

Conclusion

Offering art therapy online creates a forum for sharing experiences and developing a community. It has shown a positive impact on the wellbeing of the patients and their carers. In response to the positive feedback, the service will continue on a rolling basis.

Disclosure

M.H. Keane: None.
P194 Flares of rheumatoid arthritis following coronavirus vaccination
Authors: Hayward Rhys J , Farah Ziad
Published: April 2022

Background/Aims

With the emergence of the coronavirus vaccine and the clear and important role it provides in maintaining the health of individuals and the population, it is important that our patients receive or are recommended the vaccine. We here document a case series of patients who have long-term quiescent rheumatoid arthritis who then experienced a flare of disease activity after receiving a vaccine. This information is important to understand as it allows informed discussions regarding the side effect profile of the vaccine and also the influence this may have on the patient’s disease control and future management options.

Methods

Patients were reviewed in clinic as part of standard care. Individuals with rheumatoid arthritis who had experienced a flare defined as a self-reported disease activity score of > 5.1 in otherwise stable disease were noted and their response to treatment reviewed. This was a review of usual clinical practice and did not alter the treatment undertaken or monitoring of the patent. Information obtained was through the consultation with a rheumatologist and the data was collected retrospectively through review of clinical notes and clinic letters.

Results

Table 1 outlines the patient details and treatment responses.

All flares occurred within two weeks of receiving the vaccine. Of the patients who flared, two required short-term steroid treatment; three an increase in the usual medications and one who had been in disease remission to re-start previous therapy. More patients in the Pfizer vaccine group required an escalation of usual care compared to the AstraZeneca vaccine group.

Conclusion

We report six cases of rheumatoid arthritis flare soon after receipt of the coronavirus vaccine. In all, disease control was returned with minimal changes to treatment, 33% of those requiring either no treatment or an intramuscular steroid injection alone. Therefore, we recommend that clinicians should counsel patients of this potential effect, but continue to advocate the vaccine, as the risk of complications to their underlying arthritis is very low and seemingly easily treatable.

Disclosure

R.J. Hayward: None. Z. Farah: None.
P195 Defining the relationship between pain intensity and disease activity in patients with rheumatoid arthritis: a secondary analysis of six studies
Authors: Ibrahim Fowzia , Ma Margaret , Scott David L , Scott Ian
Published: April 2022

Background/Aims

Pain is the main concern of patients with rheumatoid arthritis (RA). Whilst rheumatologists often focus on reducing disease activity to improve pain the relationship between disease activity and pain in RA is incompletely characterised. Our aim was to better understand this, by defining the associations, discordance, and temporal relationships between pain intensity and disease activity in RA.

Methods

We undertook a secondary analysis of 1,132 patients with RA followed-up over 12 months in five trials and one observational study. Pain intensity was measured using a 100mm visual analogue scale (VAS), and disease activity using the DAS28-ESR. Relationships between 12-month pain VAS and DAS28-ESR (overall score and its components) were evaluated using Spearman correlations, linear regression models, Bland-Altman plots, and Kappa statistics. Temporal relationships were evaluated by describing mean pain intensity scores in patients over time stratified by disease activity status.

Results: Associations: Linear regression models showed significant associations between pain intensity VAS and DAS28-ESR (Table). Patient global assessment (PtGA) scores explained 79.3% of the variance in pain VAS, and ESR only 19.7%. Correlations between pain intensity VAS and DAS28-ESR components were highest with PtGA (R = 0.88) and least with ESR (R = 0.10).

Discordance: “fair” agreement was seen between categories of pain intensity scores (categorised as low=VAS ≤34, moderate=VAS 35-74, high=VAS >74 based on previous studies) and DAS28-ESR categories (Kappa statistic 0.287). 14% of patients in remission/low disease activity (LDA) had moderate/high pain scores; 18% of patients in high disease activity (HDA) had low pain scores. Bland-Altman plots showed many patients scored pain VAS and PtGA similarly.

Temporal relationships: changes in disease activity and pain intensity scores over time mirrored each other. When patients with baseline active RA achieved 12-month remission/LDA mean pain VAS scores fell by > 60% from baseline. When patients in baseline remission/LDA had active RA at 12-months mean pain VAS scores increased by > 60% from baseline.

Conclusion

Whilst pain intensity is closely related to DAS28-ESR, discordance occurs in a substantial minority of patients. The relationship between DAS28-ESR and pain intensity VAS scores is largely attributable to its significant association and strong correlation with PtGA scores.

Disclosure

F. Ibrahim: None. M. Ma: None. D.L. Scott: None. I. Scott: None.
P200 Combining protein quantitative trait and genetic risk score analysis to identify biomarkers of treatment response to TNFi in patients with rheumatoid arthritis
Authors: Li Zhaoxun , Ling Stephanie F , Nair Nisha , Isaacs John D , Hyrich Kimme L , Morgan Ann W , Wilson Anthony G , Barton Anne , Plant Darren
Published: April 2022

Background/Aims

Rheumatoid arthritis (RA) is an inflammatory joint disease that can lead to disability if inflammation is not controlled. Biologic disease modifying anti-rheumatic drugs (bDMARDs), including tumour necrosis factor inhibitors (TNFi), are an effective line of therapy for moderate to severe RA. However, treatment response to TNFi is not universal and cannot be predicted from clinical factors. In this study, a protein quantitative trait loci (pQTL) study and genetic risk score (GRS) analysis were combined to identify protein-based biomarkers that are predictive of TNFi treatment response.

Methods

Protein expression data were generated using Sequential Window Acquisition of All Theoretical Mass Spectra (SWATH-MS) in serum samples taken from 80 RA patients about to commence therapy with etanercept. Protein expression was log2 transformed and the k-nearest neighbour model was used to impute missing values. A pQTL study was performed in patients with available imputed genome-wide genetic variation data to detect cis-acting genetic markers (p < 1E-05). GRS for pQTLs were subsequently tested in 1,430 RA patients with available genome-wide genetic and TNFi treatment response data (improvement in DAS28 between pre-treatment and 3/6 months on drug). The GRS analysis was adjusted for baseline disease activity, sex, conventional synthetic DMARD co-therapy and the first 10 principal components, calculated from the genetic datasets.

Results

Following imputation, expression levels for 271 proteins were analysed in 69 RA patients with available genotype data. 514 cis-pQTLs were found for 16 proteins. GRS for the proteins Apolipoprotein(a) (UniProt ID P08519, p = 0.017) and Carboxypeptidase N subunit 2 (P22792, p = 0.027) were found to be modestly associated with treatment response; however, scores for both proteins explained less than 1% of the variance in DAS28 difference between time-points.

Conclusion

This study identified two protein-based genetic biomarkers of treatment response to TNFi. However, genetic scores based on these proteins are unlikely to be useful predictors, explaining little variance in on-treatment disease activity.

Disclosure

Z. Li: None. S.F. Ling: None. N. Nair: None. J.D. Isaacs: None. K.L. Hyrich: Honoraria; Abbvie. A.W. Morgan: None. A.G. Wilson: None. A. Barton: None. D. Plant: None.
P211 Comparing standing and stepping activity in people with rheumatoid arthritis with and without foot and ankle pain
Authors: Quinn Karen , Murphy Grainne , Larkin Louise , Leary Helen O'
Published: April 2022

Background/Aims

Foot and ankle pain is common in people with RA and is reported to influence physical activity levels. However there is limited objective data exploring differences in physical activity behaviours in RA in those with and without foot/ankle pain. This cross-sectional study aimed to examine the differences in objectively measured step count, cadence and standing time in people with RA reporting foot/ankle pain compared to those with no foot/ankle symptoms.

Methods

Adults with RA recruited from a rheumatology outpatient department wore an ActivPAL4 accelerometer over a 7-day period. A step cadence of > 100 steps per minute was estimated to correspond to moderate physical activity. Assessments of pain intensity, location of painful joints and disease activity (Clinical Disease Activity Index-CDAI) were conducted. Cadence characteristics, total step count and standing time between groups with and without foot/ankle pain were compared using independent sample t-tests.

Results

Participants (n = 72) clinical characteristics are presented in Table 1. Current foot/ankle pain was reported by 66% (n = 47). Those with foot/ankle pain had higher disease activity as measured by CDAI and higher BMI scores. Daily standing time was less in the group with foot/ankle pain with a mean (SD) of 257 (77.7) minutes compared to 300 (95.9) minutes in those without. No significant differences in daily total step count or in any cadence characteristics were identified between groups (Table 1). No difference was observed in the minutes spent in moderate physical activity- foot/ankle pain group 10.6 (15.4) minutes versus no foot/ankle pain 10.6 (15.2) minutes.

Conclusion

People with RA who report foot and ankle pain spend less time standing. Interestingly this study did not show differences in step count and cadence between those with and without foot and ankle pain. Participants included in this study had relatively well controlled disease. This study also only examined the presence or absence of foot pain and there was wide variation in pain levels and also daily step counts recorded. Further research exploring the relationship between activity behaviours and foot pain is warranted, particularly in populations with higher pain levels and more active disease.

Disclosure

K. Quinn: None. G. Murphy: None. L. Larkin: None. H. O' Leary: None.
P213 HLA-DRB1 haplotypes predict cardiovascular mortality in inflammatory arthritis
Authors: Sharma Seema D , Plant Darren , Bowes John , Macgregor Alex , Barton Anne , Viatte Sebastien
Published: April 2022

Background/Aims

Haplotypes defined by amino acids at HLA-DRB1 positions 11, 71 and 74 associated with susceptibility to rheumatoid arthritis (RA), are associated with radiological outcome, anti-TNF response and all cause-mortality. RA is associated with cardiovascular (CV) morbidity and mortality, but increased prevalence of risk factors of CV disease in RA only partially explains this association. The aim was to investigate whether haplotypes associated with RA disease susceptibility and disease severity are associated with CV mortality.

Methods

The Norfolk Arthritis register (NOAR) is a primary care-based inception cohort of patients with inflammatory polyarthritis (IP). NOAR patients with at least 2 years of follow-up and available mortality and genetic data were included. Mortality data was provided by the Office for National Statistics. Univariate Cox proportional hazard models were applied using STATA/IC 14.0. Models for CV mortality were adjusted for CV risk factors selected using stepwise regression: namely obesity, gender and hypertension. Hazard models were applied to the entire cohort of patients with inflammatory polyarthritis (IP). When calculating differences between highest and lowest risk genetic factors, bivariate analysis was used.

Results

HLA-DRB1 amino acids, haplotypes or haplotype groups associated with RA susceptibility are also associated with CV mortality as shown in the table. HLA-DRB1 polymorphisms encoding amino-acid haplotypes associated with an increased or decreased susceptibility to RA consistently show the same magnitude and direction of association for overall and CV mortality in IP. For example, the SEA-haplotype, associated with the lowest susceptibility to RA, and the best radiographic outcome, was found to be associated with decreased CV mortality (HR 0.67, 95% CI 0.47, 0.91, p = 0.023). The relative difference in CV mortality between carriers of the high susceptibility VKA haplotype and carriers of the SEA haplotype was significant (HR 1.67, 95% CI 1.13, 2.48, p = 0.01). Associations were independent of anti-CCP status.

Conclusion

HLA-DRB1 haplotypes associated with susceptibility to RA also predispose to increased risk of CV mortality in IP, independent of known CV risk factors and anti-CCP status, which suggests that, in the future, genetic factors will add to prediction of risk of cardiovascular mortality beyond serological markers.

Disclosure

S.D. Sharma: None. D. Plant: None. J. Bowes: Grants/research support; British Heart Foundation. A. Macgregor: None. A. Barton: Grants/research support; BMS. Other; Speaker Fees from Roche Chugai. S. Viatte: None.
P214 Classifiable early RA shows heterogeneous imaging features and potential means of stratification
Authors: Shukla Rudresh , Levy Roxanne , Ho Pauline , Mankia Kulveer , Wakefield Richard J , Emery Paul , Buch Maya H
Published: April 2022

Background/Aims

Synovitis and tenosynovitis (TS) are key findings seen in patients with rheumatoid arthritis (RA) on musculoskeletal ultrasound (MSUS). Both power Doppler TS (PDTS) and power Doppler synovitis (PDUS) have also been reported in preclinical-RA. We aimed to describe the prevalence of PDTS and PDUS in a treatment-naïve, new-onset RA trial cohort and their association with clinical and disease activity data.

Methods

The VEDERA (Very early Etanercept and Methotrexate versus Methotrexate with/without Delayed Etanercept in RA) trial recruited 120 treatment-naïve, new-onset RA patients fulfilling ACR-EULAR 2010 classification criteria with at least moderate DAS28-ESR to either first-line etanercept + methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT), and included clinical and dominant hand (MCP 1-5, wrist, flexor tendons 1-5 and extensor carpii ulnaris tendon) MSUS assessments. Joint Grey scale (GS), PDUS and PDTS were assessed semi-quantitatively and converted to dichotomous scale (absent = total score 0; present = total score ≥ 1). Patients were categorised in one of four groups based on presence of PDUS and/or PDTS: no PDUS or PDTS (PDUS-PDTS-), PDTS alone (PDUS-PDTS+), PDUS alone (PDUS+PDTS-) and both PDUS and PDTS (PDUS+PDTS+). Clinical and GS features are described for these groups.

Results

At time of diagnosis, 17% (20/120) were PDUS-PDTS-, 16% (19/120) PDUS-PDTS+, 15% (18/120) PDUS+PDTS- and 53% (63/120) PDUS+PDTS+. Table 1 details demographic, clinical and disease activity data.

GS was present in 60% (12/20) and 74% (14/19) of PDUS-PDTS- and PDUS-PDTS+ groups respectively, while all patients with PDUS + (PDUS+PDTS- and PDUS+PDTS+ groups) demonstrated GS (table 1). The PDUS+PDTS+ group had the shortest symptom duration. PDUS-PDTS- group had lower DAS28ESR, tender/swollen joint counts (28 joints), CRP and pain. The two groups with PDTS + (with/without PDUS) had higher visual analogue pain scores.

Conclusion

Heterogeneous imaging features of classifiable, new-onset RA likely reflect different rates of progress along the continuum and presentation, and timing in capturing PDUS and PDTS. Severe clinical and imaging features associate with more rapid presentation. A minor proportion show no clear features of PDUS or GS yet are classifiable as RA indicating other contributors to diagnosis. MSUS features may offer a means of stratifying patients and tailoring treatment approaches.

Disclosure

R. Shukla: None. R. Levy: None. P. Ho: None. K. Mankia: None. R.J. Wakefield: None. P. Emery: None. M.H. Buch: None.