bluuebunny/crossref_metadata_2025 huggingface dataset:
P73 Trends in ultrasound guided musculoskeletal injections at one tertiary care centre over 6 years
Authors: Lall Kunal , Ejindu Vivian , Kiely Patrick D. W
Published: April 2020

Background

Ultrasound (US) has brought many benefits into rheumatologic practice, delivery of targeted injections into joints, bursae and other structures. Whilst many joints may be accurately injected in clinic, guided by clinical landmarks, US permits injections into anatomically less accessible sites. We have assessed trends in the number and type of requests for US guided joint or soft tissue injections from the rheumatology department over the last 6 years, and the impact on waiting times.

Methods

Details of all requests for US guided joint or soft tissue injections were obtained from the St George’s PACS system from 1 January 2013 - 31 December 2018. Review of patient records was conducted to determine whether the referral was routine or urgent, the waiting time between referral and appointment, the joint or structure to be injected, and whether an injection into the requested site was actually performed.

Results

Table 1 shows the total number of out-patient attendances in rheumatology per year from 2013 - 2018, the number of referrals for US-guided injection, the proportion requested urgently and waiting times for routine and urgent cases. Over 6 years requests for US guided injections have risen 2.3-fold, from <1% to nearly 2% of all out-patient attendances. Of 1834 requests, no injections were given in 420 instances (23%), due to patient preference or lack of indication at time of US. In 2018 of all joint or tendon/bursa injections initiated in rheumatology, 260 (38%) were given in routine clinic time without delay, and 420 (62%) were requested by US with a delay of over 2 months.

Conclusion

Over 6 years a 33% increase in out-patient clinic workload has been accompanied by a disproportionate 2.3-fold increase in requests for US guided injections, representing >50% of injections initiated by the service. One explanation may be time pressure in clinic. This trend has not been matched by increased radiology capacity, with urgent requests now waiting >6 weeks. This has implications for quality of care, staffing and effective service delivery. The trend to fewer injections in clinic will continue if clinicians become increasingly reliant on radiology colleagues.

Disclosures

K. Lall None. V. Ejindu None. P.D.W. Kiely None.
P74 Group counselling: a holistic care model
Authors: Nadesalingam Kavitha , Short Catherine
Published: April 2020

Background

Disease modifying anti rheumatic drugs (DMARDs) play a vital role in controlling autoimmune disease. They are complex medications requiring nurse counselling to initiate. Staff vacancies and increasing referrals led to 12-week waiting times from decision to treat in our Trust. We wanted to improve the efficiency of the medication counselling process, but at the same time use it as an opportunity to educate our patients on their disease, management and self-care.

Methods

We designed and delivered a successful group clinic to improve patient experience, reduce waiting times and improve efficiency. As well as covering the necessary DMARD information, the clinic includes patient education on general, physical and mental well-being, dietary advice as well as physiotherapy and occupational therapy input. The clinic format consists of a presentation/discussion, peer support and individual consultation, providing truly holistic care.

Results

Waiting times: reduction from 84 days to 7-14 days from decision to treat for our two main DMARDS and 56 days to 14 days for our anti TNF therapies. Clinical outcome/patient safety: Earlier initiation of DMARDs has been shown to reduce morbidity. Financial: Additional £444 income per clinic (compared with previous clinic process) at a tariff of £111 per patient. Group clinics currently run weekly. Patient feedback: 50 patient feedback forms have been collected and reviewed. Of these 50 patients 97.8% of questions asked were marked as agree or strongly agree to a positive experience. Shared learning: The clinic format was presented at a regional meeting and at our Trusts Quality Improvement Day. There is interest in adopting a similar approach in other departments in the Trust and in other rheumatology departments in the region.

Conclusion

Our group consultation model provides a holistic model to care that has been very popular with our patients. We have subjectively had an increase uptake in physiotherapy services and patients seem to be persevering and tolerating their medications better. Our group consultations have been running successfully for a year, and we have expanded the sessions to cover more drugs including our anti TNF therapies. It is yet early days to comment on the long-term impact our clinic has on patients, but with our clinic providing patient education and empowering patients through self management we are hopeful that we will be improving the long-term outcome of our patients.

Disclosures

K. Nadesalingam None. C. Short None.
P84 Implementation of advanced practice rheumatology clinics
Authors: Gotting Laura M
Published: April 2020

Background

Ashford and St Peters NHS Trust implement an iMSK Service with an aim to deliver biopsychosocial assessment and care across Orthopaedics, Pain and Rheumatology settings. Our impression was the Rheumatology Service could be assisted by the implementation of Advanced Clinical Practitioners Clinics considering the benefits that had been offered to Orthopaedic and Pain Services. The Rheumatology Service had high waiting times to see a Consultant, were understaffed in relation to national recommended ratio of Consultant to catchment population and were motivated to promote a biopsychosocial approach to patient care. There were poor links between Rheumatology and the MSK Triage Service as well as the Physiotherapy Service which were recognised as areas for improvement and integration for both patient and staff. The plan was to improve the efficiency of pathway into Rheumatology, reduce unnecessary contacts for the patient and offer best practice advice at first contact. An aim to reduce non-inflammatory referrals to consultants, in turn reducing overall waiting times for inflammatory presentations.

Methods

We researched and benchmarked against existing services, learning from experiences and various models of implementation. We audited our MSK triage process, to include numbers of referrals into the Rheumatology Service. We developed an ACP Triage Criteria as a multi-disciplinary team to highlight our skillset and best fit to the service needs. We observed the existing MDT in clinic to include consultant and nurse specialists as well as undertaking injection, bloods and radiology training. We collaborated with the service managers to implement ACP clinics for the assessment of non-inflammatory presentations and widespread pain. We are collecting PREM data with the 'CARE' patient satisfaction questionnaire, as well as clinical outcome data collection to include the Widespread Pain Index, Symptom Severity Score and evaluation of patient onward referral destination and management plan.

Results

We have seen over 60 patients and continue to collate our data. Over 50% of patients have been discharged at first appointment to confidently begin a self-management approach to their care. We have referred only 2 patients onto rheumatology consultant appointments - therefore saving a minimum of 35 Consultant Hours within our service in a 3-month period. We have had 100% positive feedback for patient's who have completed satisfaction questionnaires PREM data after appointment.

Conclusion

We continue to collect and analyse our data but can already highlight a positive trend for successful implementation of ACP's into the Rheumatology Service within only a 3 month period. We feel this is a starting point for the further development of a Widespread Pain Pathway across the MSK Service to further incorporate integration of Rheumatology, Pain and Physiotherapy Services in the prevention of duplicate or unnecessary appointments and reduction in the ‘revolving door patients’ across all 3 services.

Disclosures

L.M. Gotting None.
P93 Outcomes of enhanced triage of rheumatology referrals at a single point of access
Authors: Forgie Bethan , Garrood Toby
Published: April 2020

Background

With increasing pressure on rheumatology services there is a need to identify alternative pathways for patients which are better aligned to their needs. East Surrey CCG is formed of 17 GP practices serving an adult population of 137,000. First Community Health and Care acts as a single point of referral for patients with musculoskeletal conditions. In 2018 a triage service was established, run by a GP with an extended role (GPweR), for patients referred to rheumatology. Analysis of triaged patients was undertaken to explore the feasibility of diverting a subgroup of patients with non-inflammatory conditions into community-based care.

Methods

Referrals from February 2018 to March 2019 were analysed from the point of triage to confirmation of the diagnosis in secondary care. Triage was undertaken with additional reference to the primary care record in EMIS. For each referral it was recorded whether, according to the available information, this was more likely to be an inflammatory or non-inflammatory condition and whether they could have been seen first in a community GPwER rheumatology clinic. The final diagnosis after their hospital appointment was recorded. A pilot GPweR-led community clinic was established in April 2019 to see those patients selected by the process as suitable for community-based care.

Results

407 patients were triaged. 96% were triaged to secondary care. Of these, records from the subsequent rheumatology appointment(s) were available for 312. The final diagnosis was inflammatory in 120 (38%) and non-inflammatory in 192 (62%). 152 patients (49%) were thought to have a non-inflammatory condition at triage which was confirmed in 83% of cases after a consultant appointment. 160 patients (51%) were thought likely to have an inflammatory condition which was confirmed in 59%. Positive predictive value of the triage process for non-inflammatory conditions was 83%, negative predictive value 59%, sensitivity 66%, specificity 79%. 57 patients selected from triage were seen in the pilot community clinic. Final diagnoses were: 53% fibromyalgia, 19% osteoarthritis, 12% soft tissue rheumatism, 14% gout/inflammatory arthritis. 54% of patients needed blood tests and 39% imaging. 31% required a face to face follow up appointment and 47% were referred to physiotherapy. 7% were referred on to rheumatology.

Conclusion

Referrals to secondary care rheumatology are rising and putting increasing pressure on services and referral to treatment times. There is a need to develop alternative pathways for patients with non-inflammatory conditions who could be managed in community settings. Our work shows that a majority of these can be identified at the point of triage with good specificity. We have also shown that of those seen in a pilot community clinic few needed onward referral. Our work suggests that there is a substantial opportunity to develop alternative and potentially more cost-effective community-based pathways for patients.

Disclosures

B. Forgie None. T. Garrood None.
P94 Development of a methotrexate digital media card and methotrexate website
Authors: Martin Una E. S
Published: April 2020

Background

Methotrexate (MTX) remains the standard treatment for inflammatory arthritis. For patients prescribed MTX they tell us that they find it difficult to source correct information. Patients require this at different time points in their disease and in different formats that encompass literacy and language challenges. Patients are usually given instruction about MTX at the time of their diagnosis when they are faced with absorbing a lot of information in a very short time frame, yet the majority of patients are required to take MTX for the duration of their disease.

Methods

Following on from the development of the MTX patient education guide in Ireland in 2017 we looked at developing the content into a different format. In partnership with a digital media company and the pharmaceutical industry the content was converted into a digital media card and website for use in the clinical setting. The content was designed as an additional support to patients prescribed MTX. The animation consists of both audio and images and provides the viewer with essential information and key messages required when taking MTX. The animation guides the patient through MTX, outlines how it works, how to take MTX, and highlights the important safety issues and monitoring required when taking MTX. Audio content was written by the author and designed in collaboration with a digital media company. The digital media card and website was launched nationally in September 2018 with the support of the Irish Rheumatology Nursing Forum and Arthritis Ireland. Rheumatology departments nationally were provided with copies of the digital media card and details of the website. Patients can use the digital media card and be signposted patients to www.methotrexate.ie.

Results

Since the launch of both the website and the digital media card there has been 1.5 K sessions, and 1.4K users on the website. The website has been accessed globally with over 781 users from Ireland, 220 from the United States and 144 from the United Kingdom. The website is accessed predominately by mobile device followed by tablet device.

Conclusion

To date the website continues to be accessed by patients and we have received very positive feedback. The digital media card has been adopted nationally and has become incorporated as part of the education of patients about MTX. Both the website and the digital media card are designed to support and enhance the education about MTX and not replace the formal education that nurses give to patients about MTX. The next step is to survey both the patients and healthcare professionals using the tools and identify what additions may enhance these tools. For further information go to www.methotrexate.ie to access the website and view the animation.

Disclosures

U.E.S. Martin Honoraria; U.M has received honoraria from Novartis, Abbvie Ireland. Grants/research support; U.M has received educational grants from Novartis, Janssen, Abbvie, Pfizer.
P97 Implementation of a regional trainee-led leadership and management programme for rheumatology trainees
Authors: Benson Rosalind , Sharp Charlotte , Macphie Elizabeth
Published: April 2020

Background

We identified a lack of formal learning opportunities provided by Health Education England North West (HEE (NW)) to achieve the many leadership and management requirements stipulated by the Joint Royal College of Physicians’ Training Board Speciality Training (ST) rheumatology curriculum. This gap was highlighted through discussion at the HEE (NW) Specialty Training Committee by trainee representatives and regional Training Programme Directors (TPD), in 2017. Furthermore, the merger of two pre-existing Deaneries (Mersey and NW) into the NW Local Education and Training Board (LETB) created a pressing need to develop a network across the region.

Methods

Two regional ST representatives engaged with trainees across the new LETB through formal surveys and informal conversations regarding training to address this. Specialty trainees (STRs) elected a bi-annual half-day session in conjunction with an existing clinical regional event, the North West Rheumatology Club (NWRC). Sessions have covered a range of topics (Table 1) and provide an opportunity for networking across the deaneries. Learning objectives are mapped against ST curriculum. HEE (NW) TPDs support the programme, facilitating study leave. Meeting costs are supported by the NWRC. Trainees shape future sessions submitting topic ideas and have autonomy over content and speakers. Formal anonymous sessional feedback uses a Likert scale evaluating whether learning objectives have been met and quality of session delivery. Now entering its third year the scheme is well-established, with succession planning in place.

Results

With feedback response rates of 85% (mean across 4 sessions), median scores are 5 (IQR 4.9-5) for meeting learning objectives and 5 (IQR 5-5) for session delivery. Free text feedback is overwhelmingly positive. Six months after sessions trainees reported ‘feeling more encouraged to raise concerns’, ‘being more proactive in whistleblowing‘, ‘having a better understanding of conflict situations’, and ‘better awareness of reasons for difference in individual behaviours’.

Conclusion

Filling unmet training needs in leadership and management through trainee-led sessions provides an excellent learning opportunity for STRs both attending and leading the events, and facilitates cross-regional collaboration. This programme demonstrates the role of stakeholders to inform programme design successfully, showing excellent long-term impact in an important and previously underserved curriculum requirement.

Disclosures

R. Benson None. C. Sharp None. E. Macphie Grants/research support; EM is the Secretary of the North West Rheumatology Club; meetings are supported by an unrestricted educational grant from UCB.
P100 Factors associated with educational needs in patients with inflammatory arthritis
Authors: Johnston Alice R , Ndosi Mwidimi
Published: April 2020

Background

With an overarching aim to inform person-centred patient-education, this study had two objectives: (i) to identify factors that may be associated with educational needs in patients with inflammatory arthritis (IA) (ii) to assess whether educational needs and priorities differ between subtypes of inflammatory arthritis i.e. rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS).

Methods

Secondary analysis of cross-sectional survey data originally used to validate the Educational Needs Assessment Tool (ENAT) was conducted. The outcome variable was educational needs, summarised as ENAT domain scores. The explanatory variables were: Age, gender, IA subtype, school leaving age and disease duration. ENAT scores were Rasch-transformed prior to analysis. Univariable analyses were conducted to explore differences between groups and multivariable analyses (multiple regression) to determine factors associated with educational needs. All explanatory factors were entered into a preliminary multivariable model. Factors that achieved statistical significance at the 10% level were entered into the final multivariable model. Those that achieved a statistical significance at the 5% level were associated with educational needs. To determine educational priorities, percentage contribution of each domain score to the total score was calculated and compared between factors with one-way analysis of variance.

Results

The evaluable population comprised 388 patients, 125 with RA, 133 with AS and 130 with PsA. Their mean (SD) age was 48 (13.95) years and male/female ratio 177/210. Those with early arthritis (disease duration <2 years) were 36 (9.2%), RA = 15, AS = 3 and PsA=18, and 116 (29.7%) left school before the age of 16. Table 1 presents the final multi-variable models. The proportion of variance explained by the model varied across ENAT domains, the highest being movement (25%). Female gender was found to be an independent predictor of educational needs across all ENAT domains. Significant differences in educational priorities were observed between disease groups in all domains except disease process and support.

Conclusion

Female gender is independently associated with educational needs across all three sub-types of IA. Results of this secondary analysis are inconclusive due to limitations in the available data. Further research should include factors such as disease severity, treatments, disability and self-efficacy.

Disclosures

A.R. Johnston Other; Work conducted as part of Nurse and Allied Health Professional Internship Programme funded by versus Arthritis (Grant number 20867). M. Ndosi None.
P127 Factors associated with self-reported fatigue in hip and/or knee osteoarthritis: a systematic review
Authors: Fawole Henrietta O , Idowu Opeyemi A , Abaraogu Ukachukwu O , Riskowski Jody L , Dell'Isola Andrea , Steultjens Martijn P , Chastin Sebastien F. M
Published: April 2020

Background

Fatigue is an important, under-researched and poorly understood symptom among hip and/or knee osteoarthritis (OA) populations. To devise the best fatigue management strategy in these populations, it is necessary to evaluate the evidence on risk factors for fatigue. This study aimed to give an overview and evaluate the evidence on the factors associated with fatigue in hip and/or knee OA populations.

Methods

We conducted a systematic review using MEDLINE, AMED, CINAHL, ProQuest, and Web of Science Core Collections databases from inception to June 2019. Inclusion criteria comprised cross-sectional and longitudinal studies on patients with a diagnosis of hip and/or knee OA, included a measure of self-reported fatigue and studies that performed a subgroup analysis of hip/knee OA from other included populations. Two reviewers simultaneously screened articles for eligibility and extracted the following data: study design, fatigue outcome tool, follow-up time and association between factors and fatigue. The methodological quality of the included studies was assessed using the National Heart, Lung and Blood Institute quality appraisal tool. Study quality and study designs were combined to determine the level of evidence using best-evidence synthesis, which comprised six levels of evidence (Table 1).

Results

Eighteen studies (10 cross-sectional designs, 8 longitudinal designs) were included. A majority of the studies included were of good quality, whilst two had fair quality and one poor quality. Lower physical function, more pain, higher depressive symptoms, lower physical activity, older age, increased anxiety, greater pain catastrophizing, worse radiographic evidence, higher body mass index, greater comorbidity/illness burden, lower six minutes walk and increased joint stiffness were included in the best evidence synthesis. From the best evidence grading, most of these factors had limited or conflicting evidence on its association with fatigue within the hip/knee OA populations. However, lower physical function and higher depressive symptoms were graded as having strong evidence on their associations with fatigue while higher pain levels had moderate evidence.

Conclusion

Lower physical function levels, higher depressive symptoms and higher pain are related to fatigue in the hip/knee OA population. More longitudinal studies are warranted to investigate the potential association of other identified factors and fatigue.

Disclosures

H.O. Fawole None. O.A. Idowu None. U.O. Abaraogu None. J.L. Riskowski None. A. Dell'Isola None. M.P. Steultjens None. S.F.M. Chastin None.
P133 Chronic recurrent multifocal osteomyelitis (CRMO) associated with polymyositis and polyarthritis in a boy
Authors: Pandya Devang B
Published: April 2020

Background

CRMO is an autoinflammatory bone disease mainly affecting the paediatric age group. It may have overlapping features with other rheumatological diseases. I report a case of a 7-year-old boy who presented with fever, persistent limp and pain at multiple sites involving the extremities.

Methods

His complaint started with pain in the gluteal region with an accompanying limp. Two months later, he started having fever, pain and localised swelling around multiple sites - right knee, right ankle and left wrist associated with intermittent night pain and morning stiffness. MSK examination revealed localised peri-articular swelling and restriction of movements involving bilateral knees, ankles, hips and wrists. Lab reports showed low hemoglobin, neutrophilic leucocytosis, elevated platelets, CRP and ESR. Muscle enzymes (CPK, SGPT, SGOT, LDH), bone profile, ferritin, RF, ASO titer, ANA and ANA profile were normal. Whole body MRI (WBM) revealed multifocal bone marrow edema predominantly in metaphyseal regions involving multiple bones. Polymyositis and mild effusions were noted in bilateral hips and knees. He was put on oral naproxen, prednisolone, methotrexate and pamindronate infusion for two days. He responded dramatically and continues to remain well at two weeks' follow up.

Results

CRMO is mainly associated with severe acne, palmoplantar pustulosis, generalised pustular psoriasis, pyoderma gangrenosum, ankylosing spondylitis and inflammatory bowel disease. There are only 2-3 reported cases of CRMO associated myositis in adolescents to the best of my knowledge. This child will be the youngest diagnosed CRMO with polymyositis.

Conclusion

When any child presents with fever, recurrent or chronic night pain and/or swelling at multiple sites with moderate elevation of inflammatory markers, we should suspect CRMO and our first choice of investigation should be whole body MRI to reveal associated extra-osseous lesions.

Disclosures

D.B. Pandya None.
P138 Are adolescents prepared for transition? A survey of practice in Northern Ireland
Authors: Masih Claire , McKenna Dearbhla , McHenry Michelle , Rooney Madeline
Published: April 2020

Background

In Northern Ireland we have a single paediatric rheumatology service in which patients often stay until the end of education, before transferring to adult care. We lack a formal transition clinic or uniform process for transition. We wished to investigate whether adolescents transitioning to adult rheumatology care are sufficiently prepared for the process.

Methods

We surveyed the charts of patients within the paediatric rheumatology service aged over 16 years. Excluding patients who had were not under active follow up and those who had completed transition we studied 86 patients in a retrospective chart review. We studied the seven areas of readiness for transfer as recommended in the 'Ready Steady Go' programme.

Results

We had a population eligible for transition of 57 female and 29 male patients between the ages of 16 and 26. Around fifty percent had JIA, most commonly oligoarticular and polyarticular with other diagnoses including Raynauds, JIO, mechanical and pain conditions. Fifteen of these had been referred to the appropriate geographical area for transfer to adult service and 71 were yet to be referred. Readiness for transfer was poorly documented. Lifestyle issues (diet, exercise) and vocational (school, hobbies) were the best addressed with 41 and 56 patients respectively having at least one discussion on these aspects. Knowledge, self advocacy, ADLs, psychosocial and transition aspects were poorly documented.

Conclusion

We acknowledged that time pressures may have restricted what was recorded following appointments with focus on clinical information. However, we are aware of the lack of a formal transition programme within Northern Ireland and we feel this may contribute to patients spending a relatively prolonged time within the paediatric service. We have implemented quality improvement by using the 'Ready Steady Go' questionnaires within the paediatric service to improve preparedness for adult transfer and are reviewing our service of paediatric transfer. Introduction of the ‘Hello to adult services’ questionnaire by adult rheumatologists may help to achieve a more successful transition process by highlighting areas in which the young person may benefit from extra care by their adult team.

Disclosures

C. Masih None. D. McKenna None. M. McHenry None. M. Rooney None.
P139 What impact does JIA have on health-related quality of life over time and by gender?
Authors: Smith Andrew , Saqib Bishma , Lee Rebecca , Thomson Wendy , Cordingley Lis
Published: April 2020

Background

Juvenile idiopathic arthritis (JIA) is a heterogeneous group of arthritic conditions presenting in children and young people, in which physical limitations and associated complications can have detrimental effects on physical and psychosocial wellbeing. This study aims to investigate the impact of living with JIA on different aspects of health-related quality of life (HRQoL) and to explore how this changes over time, using data from the Childhood Arthritis Prospective Study (CAPS).

Methods

Longitudinal data collected as part of CAPS were analysed. HRQoL was assessed at baseline, 1 year and 3 years’ post-diagnosis using the Child Health Questionnaire (CHQ), a parent-completed form for children from 5 years of age. The CHQ measures physical, emotional and social components of child health status. Raw domain scores were transformed via algorithm into values ranging from 0-100, with higher scores indicating better health status. Mean (standard deviation) and median (interquartile range) for each domain were determined, both for the full cohort and by gender. Differences between median scores at baseline and 3 years were assessed using the Wilcoxon signed-rank test. Mean scores of each domain were visually compared with a reference population sample of healthy children from the United States.

Results

184 participants completed the questionnaire at all 3 time points. At baseline, compared to the reference population, children with JIA scored lower in every domain although scores were closer between the 2 groups at 3 years. Median scores improved over time, the exception being the general health perceptions domain which decreased after baseline. Domains with the greatest improvement were physical functioning,“bodily pain and social-physical. The largest changes occurred from baseline to 1 year. Statistically significant differences between baseline and 3-year scores were found for all domains. Domain scores for male and female participants were very similar at baseline, though scores for male participants indicated slightly better health at 1 and 3 years for both physical and psychosocial domains.

Conclusion

JIA has significant impact on HRQoL, which improves within 3 years of diagnosis with the greatest improvement occurring within the first year. Physical health domains show greater improvement over time than psychosocial domains, although psychosocial scores were generally higher throughout the study. Male participants tend to score slightly higher than female participants in both physical and psychosocial domains after baseline. Further research should explore measurable patient, age or disease-related drivers of HRQoL.

Disclosures

A. Smith None. B. Saqib None. R. Lee None. W. Thomson None. L. Cordingley None.
P140 Validation of EULAR/ACR 2019 classification criteria for SLE in a south Indian juvenile SLE cohort
Authors: Nair Harikrishnan Bhaskaran , Balan Suma
Published: April 2020

Background

To date there is no specific classification criteria for juvenile systemic lupus erythematosus (jSLE). Our aim is to compare the real world performance of EULAR/ACR 2019 criteria when applied to a known cohort of jSLE cases in Kerala, India.

Methods

We retrospectively reviewed the electronic medical record of all patients (n = 735), admitted under the Pediatric Rheumatology Department, Amrita Institute of Medical Sciences, Kochi, a tertiary care center in Kerala, India, during the period January 2012 to June 2019. 107 patients were diagnosed with jSLE by a qualified experienced pediatric rheumatologist and were independently assessed by an adult rheumatologist. Every sixth patient of the remaining 628 patients were selected as the control (n = 105). Patients were excluded if the diagnosis was uncertain or, if there was an overlap with jSLE. Each patient was evaluated to see if he or she satisfied the ACR-1997, SLICC-2012, or EULAR/ACR- 2019 criteria.

Results

Female: male ratio in cases and controls was 4.1:1 and 2.4 :1 respectively. Mean age for cases and controls was 12.6 +/-2.9 and 11.8 +/-3.5 respectively. The comparison of performance of each criterion is shown in table 1. Table 1: Validation of the EULAR/ACR 2019 SLE classification criteria using clinically diagnosed 107 jSLE cases.

ACR- American College of Rheumatology; EULAR- European League Against Rheumatism; SLICC-Systemic Lupus International Collaborating Clinics; PPV- positive predictive value; NPV- negative predictive value

Conclusion

The new EULAR/ACR 2019 criteria achieved sensitivity, specificity, PPV, NPV and accuracy greater than SLICC 2012 criteria. It also achieved sensitivity, NPV and accuracy greater than 1997 ACR criteria.

Disclosures

H. Bhaskaran Nair None. S. Balan None.
P149 Haematopoietic stem cell transplantation in systemic sclerosis: Sheffield Teaching Hospitals’ experience
Authors: Smith Ruth , Snowden John , Akil Mohammed
Published: April 2020

Background

Haematopoietic stem cell transplantation (HSCT) was first used as a treatment for systemic sclerosis (SSc) in the 1990s. By April 2018 the European Society for Blood and Bone Marrow Transplantation had 533 cases on its registry. Sheffield is the main UK centre for HSCT for SSc with 6 people having undergone the procedure since 2007. HSCT works by rebooting the immune system. Autoreactive T cells are suppressed by proliferation of regulatory T cells and improvement in T cell receptor diversity. Autologous HSCT has been shown to be an effective treatment for SSc, and has been compared to monthly pulsed intravenous cyclophosphamide in the ASSIST, ASTIS and SCOT trials. HSCT showed greater improvement in respiratory and cutaneous disease (ASSIST) and produced a superior global rank composite score based on a hierarchy of disease features (SCOT) compared with cyclophosphamide. However, although there was longer term survival benefit compared with cyclophosphamide, treatment related mortality (TRM) was high at 10% (ASTIS). TRM was attributed to SSc-related cardio-pulmonary dysfunction, and therefore patient selection for HSCT is important and all must undergo a thorough cardio-pulmonary evaluation to mitigate risk.

Methods

We performed a retrospective review of the characteristics and outcomes of patients who have undergone HSCT for SSc in Sheffield.

Results

Legend Symptom

s

R Raynaud’s; DU digital ulcers; dSSc diffuse systemic sclerosis; ILD interstitial lung disease; P pericarditis; M myositis; GAVE gastric antral vascular ectasia; SRC scleroderma renal crisis. Previous treatments: MTX methotrexate; MMF mycophenolate; CYA cyclosporine; CYCLO cyclophosphamide; AZA azathioprine; HCQ hydroxychloroquine mRSS modified Rodnan skin score

Conclusion

Patient numbers are small and follow-up is limited to 12 years, but the procedure has been well tolerated and improved patients’ skin score, with the exception of patient 6. His pre-procedure screening tests showed no evidence of interstitial lung disease, pulmonary artery hypertension or left ventricular dysfunction. The cause of his acute deterioration is unclear but acute campylobacter myocarditis or cyclophosphamide cardiac toxicity have been postulated. Sheffield’s experience has shown HSCT to be an effective treatment for SSc, but one that is not without risk.

Disclosures

R. Smith None. J. Snowden Other; Speaker fees at educational events supported by Janssen, Jazz, Mallinckrodt & Gilead. Member of a trial IDMC for Kiadis Pharma. Chairs NHS England Clinical Reference Group for Blood & Marrow Transplan. M. Akil Honoraria; AbbVie, Actelion, Celgene, Astra Zenica, Lilly and UCB.
P156 Understanding the associations and impact of severe gastrointestinal involvement in systemic sclerosis: a structured approach
Authors: Ahmed Fiza , Nihtyanova Svetlana I , Chatzinikolaou Stamatia , Ong Voon H , Murray Charles D , Denton Christopher P
Published: April 2020

Background

Gastrointestinal (GI) involvement in systemic sclerosis (SSc) has a profound negative impact on patients’ quality of life. However, due to the diversity in manifestations of SSc-associated GI disease, this impact has proven difficult to quantify and to associate with other clinical and demographic features, to identify those most at risk of severe disease.

Methods

Between September and December 2018, consecutive SSc patients attending a specialist scleroderma clinic completed the UCLA Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 (UCLA SCTC GIT 2.0) questionnaire. Total score and separate domain scores (reflux, distention/bloating, diarrhoea, soilage, constipation, social functioning and emotional wellbeing) were calculated. Domain scores range between 0 and 3, with higher scores indicating greater severity. Associations between mean scores and demographic or clinical characteristics were analysed using Wilcoxon rank-sum test.

Results

In total, 224 SSc patients fully completed the UCLA SCTC GIT 2.0. Eighty-three percent were female, mean age was 58.2 years and mean disease duration was 14.3 years. Diffuse cutaneous systemic sclerosis (dcSSc) was present in 37.1%, and 22.3% had an overlap syndrome. The most common autoantibodies were anti-centromere (ACA) in 38.0%, anti-topoisomerase I (ATA) in 20.1%, anti-RNA polymerase in 11.2% and anti-U3RNP in 4.5% of patients. For the cohort, the total GIT score was 0.62±0.57 (mean±SD), correlating strongly with visual analogue scale self-reported impact of GI disease (Pearson’s r = 0.72, p < 0.001). Distribution of total and domain scores is summarised in Table 1. We found no association between demographic or clinical characteristics and total GIT score, reflux, distention/bloating, diarrhoea and social functioning. Constipation was most common among ATA + (score 0.69, p = 0.080 v ATA-) and least common among ARA+ subjects (score 0.25, p = 0.014 v ARA-). Soilage was more common in limited cutaneous SSc (score 0.56 v 0.29 in dcSSc, p = 0.048) and ACA+ subjects (score 0.67 v 0.33 in ACA-, p = 0.008). ACA+ patients also had worse emotional wellbeing (score 0.70 v 0.52 in ACA-, p = 0.014). Emotional wellbeing was more severely affected in females (score 0.62 v 0.43 in males, p = 0.078).

Conclusion

We found that moderate to severe GI disease affects nearly half of all subjects with SSc, which significantly contributes to disease-related morbidity.

Disclosures

F. Ahmed None. S.I. Nihtyanova None. S. Chatzinikolaou None. V.H. Ong None. C.D. Murray None. C.P. Denton None.
P170 Predictors of renal survival in a cohort of patients with lupus nephritis with more than 30 years of follow-up
Authors: Farinha Filipa , Pepper Ruth J , Oliveira Daniel G , McDonnell Thomas , Isenberg David A , Rahman Anisur
Published: April 2020

Background

Despite the improvement in survival of patients with lupus nephritis (LN) over the last decades, LN is associated with progression to end-stage renal disease (ESRD) in a significant proportion of patients. We aimed to investigate the factors influencing renal survival in patients with LN.

Methods

Single-centre retrospective observational study. Patients with biopsy-proven proliferative, membranous or mixed LN were included. Individual clinical files were reviewed to obtain demographic, clinical, laboratory and pathological data. Cox regression analysis was performed to investigate predictors of progression to ESRD and Kaplan-Meier curves were obtained.

Results

We studied 187 LN patients (135 proliferative, 38 membranous and 14 mixed LN), followed for up to 42 years (mean 13±9 years). Cumulative renal survival rates at 5, 10, 15 and 20 years were 93%, 85%, 78% and 70%, respectively. In univariable analysis, urinary protein/creatinine ratio (uPCR) above 42 mg/mmol or estimated glomerular filtration rate (eGFR) below 76 mL/min/1.73m2, one year after the diagnosis of LN, were the strongest predictors of progression to ESRD, with hazard ratios (HR) of 8.081 [95%CI:1.856-35.179] and 4.985 [95%CI:1.964-12.651], respectively. HR for uPCR and eGFR at the time of diagnosis were considerably smaller (2.508 [95%CI:1.062-5.922] and 2.833 [95%CI:1.156-6.945] respectively). Other factors associated with increased risk of ESRD were Afro-Caribbean ethnicity (HR = 3.861 [95%CI:1.817-8.206]), proliferative LN (HR = 3.423 [95%CI:1.049-11.173]), not having taken antimalarials (HR = 2.180 [95%CI:1.089-4.363]) and poorly controlled diastolic blood pressure (HR = 1.016 [95%CI:1.001-1.030]). The effect of uPCR and eGFR at one year remained significant after adjusting for ethnicity, histological class, uPCR and eGFR at the time of diagnosis, use of antimalarials and diastolic blood pressure (Table 1).

Conclusion

uPCR above 42 mg/mmol and eGFR below 76 mL/min/1.73m2, one year after the diagnosis of LN, were the strongest predictors of progression to ESRD.

Disclosures

F. Farinha None. R.J. Pepper None. D.G. Oliveira None. T. McDonnell None. D.A. Isenberg None. A. Rahman None.
P175 MASTERPLANS: prediction of response to rituximab in SLE using a validated two-score system for interferon
Authors: Alase Ade , Wigston Zoe , Burska Agata , Yusof Yuzaiful Md , Reynolds John , Consortium The MASTERPLANS , Wittmann Miriam , Bruce Ian , Vital Edward M
Published: April 2020

Background

Rituximab is used for resistant SLE, but clinical response varies. We previously validated two interferon-stimulated-gene expression scores (IFN-Score-A and IFN-Score-B) that improved prediction of clinical outcomes in SLE. IFN-Score-A included most reported ISGs and predicted flares and glucocorticoid requirements. IFN-Score-B included ISGs that respond to multiple IFN subtypes and predicted development of SLE in At-Risk individuals. Diagnosis of SLE was associated with both scores, while only IFN-Score-B was elevated in RA. The British Society for Rheumatology Biologics Registry (BILAG-BR) collects samples for RTX-treated patients in the UK. MASTERPLANS ISA consortium to identify predictors of drug response.

Methods

Patients were recruited if they were starting a first cycle of RTX for active SLE (BILAG A or 2xBILAG B) despite previous cyclophosphamide or mycophenolate mofetil. Disease activity was measured using BILAG-2004. Clinical response was defined as improvement by > =1 grade in active BILAG-2004 systems with no worsening in other systems. Whole blood was collected into TEMPUS tubes and RNA extracted. IFN-Scores were measured using a custom Taqman array as previously described [El Sherbiny et al., 2018]. Multivariate logistic regression was used to test IFN-Scores and baseline clinical covariates as predictors of BILAG response at 6 months.

Results

Samples were available from 147 patients, of whom 84 had complete baseline and 6-month clinical data available and were included in this analysis. 40/84 (47.6%) patients had BILAG response at 6 months. In univariate and multivariate analysis, high IFN-Score-B expression was significantly associated with clinical response (see Table 1).

Conclusion

This preliminary analysis suggests that assessment of IFN activity has a role in predicting response to RTX. A novel IFN score (Score B) was more predictive than classic ISGs (Score A). These results add to a body of work showing that IFN-Score-B predicts clinically significant outcomes independently of overall IFN activity. Future work will analyse this biomarker in a larger cohort of patients and integrate with other putative clinical and biological predictors of response.

Disclosures

A. Alase None. Z. Wigston None. A. Burska None. M. Md Yusof None. J. Reynolds None. M. Wittmann None. I. Bruce None. E.M. Vital None.
P179 Glucocorticoid exposure and link to serious adverse events in patients with ANCA-associated vasculitis
Authors: Spearpoint Philip , Sammon Cormac , de Antonio Ramirez , Serna Arellano , Rutherford Peter
Published: April 2020

Background

Remission induction in ANCA-associated vasculitis (AAV) is with high dose glucocorticoids (GC) and immunosuppressants. Patients are exposed to high GC dose and/or prolonged low dose. EULAR/EDTA guidelines target 7.5-10mg at 3 months but acknowledge this is often achieved later. This study used UK real world practice data to examine the scale of GC exposure and associated clinical risks in AAV.

Methods

The study utilised the Clinical Practice Research Datalink (CPRD) - Hospital Episode Statistics (HES) linked database. AAV patients were identified using specific READ and ICD codes and followed between 01/01/1997 and 01/01/2018. GP prescriptions were used to describe periods of continuous GC use, stop and restart and when high dose (> 30mg/day) and low dose (<30mg/day) was prescribed. Diagnostic codes indicative of infections and adverse events linked to GCs were used to estimate rates in the AAV population using a generalized linear model with a Poisson distribution.

Results

450 AAV patients with at least one GC prescription were analysed. The median dose decreased to 9.3 mg (IQR 5.0 - 17.0) at 6 months and 5.1 mg (0.00 - 10.0) at 12 months,50% patients were taking > 10mg at 5 months and 25% were still > 10mg at 12 months. However, within 6 months of achieving 10mg/day, 50% relapse to needing dose >10mg, 75% within 2 years and 90% within 6 years. In adjusted Poisson model (age, gender, year of diagnosis before/after 2013) the rate of infection in AAV patients taking high dose was 2.59 times (CI95 1.95, 3.45) that of those on low dose and lower in those not taking GCs (IRR 0.27 (0.22-0.34)). Increased risk of new onset cardiovascular disease (IRR 2.55 (0.92, 7.04)) and new onset renal disease (IRR 3.4 (1.29-8.96)) were higher in patients receiving high dose.

Conclusion

AAV patients have significant exposure to high dose GCs and in real world practice, GC dose remains higher than recommended in current clinical guidelines. High dose GCs are associated with high risk of infection and new cardiovascular disease and renal disease. This creates a significant patient burden and has implications for healthcare resource use.

Disclosures

P. Spearpoint: Corporate appointments; Employee of Vifor Pharma. C. Sammon: Corporate appointments; Employee of PHMR. A. Ramirez de Arellano Serna: Corporate appointments; Employee of Vifor Pharma. P. Rutherford: Corporate appointments; Employee of Vifor Pharma. Shareholder/stock ownership; Vifor Pharma.
P189 Diabetes may confer protection from giant cell arteritis: results from a large inception cohort
Authors: Spray Luke , Reynolds Gary , Heaney Jonathon , Houghton Karolyn , Hargreaves Ben , Thompson Ben , Lorenzi Alice
Published: April 2020

Background

Giant cell arteritis (GCA) is the commonest large-vessel vasculitis. Until recently high dose corticosteroids had been the mainstay of treatment. Significant concern about steroid related co-morbidities have driven interest in developing new treatment strategies, and the potential to reduce costs associated with managing these complications was pivotal in securing funding for tocilizumab. Despite this little is known about the at-risk population, comprising both those diagnosed with GCA and those suspected of GCA, as both groups undergo the same steroid exposure. We therefore sought to determine if patients referred to our GCA fast track pathway (GCA-FTP) were more or less at risk than the general age matched population of developing corticosteroid related side effects.

Methods

Data from 356 consecutively referred patients to our GCA-FTP between January 1st 2017 and December 31st 2018 were reviewed. Co-morbidity data is routinely collected as part of our GCA-FTP rolling audit. We determined the frequency of pre-existing co-morbidities most often associated with steroid related side effects and compared these with published background prevalence estimates for a similar age group in the UK.

Results

In general rates of co-morbidities were lower than published estimates in over-70s, as we did not actively pursue their identification beyond what was readily available at referral (Table 1). Interestingly, however, whilst the prevalence of diabetes mellitus in our cohort (n = 356) was comparable to that in the general population (23.6%), it was significantly lower in those diagnosed with GCA (n = 83) at 11% (p = 0.0017). Despite this difference, background rates of cardiovascular and peripheral vascular disease were similar in each group.

Conclusion

In our cohort, diabetes mellitus seems to be a protective factor against the development of GCA. Similar results were reported in 2015 from a meta-analysis of inception cohorts involving 903 patients with GCA and 1064 controls. The interaction between diabetes and the onset of GCA merits further investigation.

Disclosures

L. Spray None. G. Reynolds None. J. Heaney None. K. Houghton None. B. Hargreaves None. B. Thompson None. A. Lorenzi None.