bluuebunny/crossref_metadata_2025 huggingface dataset:
P003 Quality improvement project on rituximab use in rheumatoid arthritis - how do we improve quality and cost effectiveness?
Authors: Ahmad Nadia , McNally Jeremy
Published: April 2022

Background/Aims

Rituximab (RTX) is a chimeric monoclonal antibody against CD20, a transmembrane protein on B lymphocyte surfaces. It is now established as an effective treatment for rheumatoid arthritis (RA). The timing of re-treatment is not well defined and varies widely in clinical practice. Our aim was to assess departmental practice on retreatment doses and frequency of RTX in RA patients. We proposed retreatment with reduced dose (1gm) as compared to the standard dose (1gm x 2, 2 weeks apart). We envisage this would maintain efficacy and lead to significant cost saving for the CCG and Rheumatology department.

Methods

Data were collected retrospectively over 3 years (2017- 2020) on patients who had received at least one re-treatment RTX dose no less than 24 weeks after first course of standard regime. Information was obtained on patient demographics, serology, disease activity scores, previous treatment, concurrent therapy including steroids, frequency and dosing of RTX.

Results

50 patients were included with an average age 66 years (range 32- 85), 58% were females, 83% were seropositive and 59% had established erosive disease. Most patients had received prior therapy of non-biologic and biologic DMARDs, methotrexate and anti-TNF being the most used agents in 70% and 52%, respectively. 40% were biologic DMARD naïve mostly due to anti-TNF contraindication. 78% patients were receiving concomitant non-biologic DMARDs, methotrexate being the commonest in 50% patients. 16% were on steroids with dose ≤ to 5mg in 87% of patients. 43% of patients received RTX 6 monthly, 33% 6- 9 monthly and 24% > 9 months. 96% of the patients received 1gm infusion x2, 2 weeks apart.

Conclusion

Our data showed most patients were receiving standard retreatment regime (1gm x2 fortnightly) at 6 monthly intervals. Previous studies including SMART (Study of Re-treatment With MabThera), SERENE, IMAGE and MIRROR trials suggested reduced dose of RTX had similar clinical efficacy to the standard dose. We optimised retreatment schedule of RTX from 2g to 1g, thereby reducing infection risk, especially in view of the COVID-19 pandemic and achieving significant cost savings. The cost savings over 3-year cycle of treatment for a DGH is of the order of £236,927.

Disclosure

N. Ahmad: None. J. McNally: None.
P022 Audit of vitamin D and calcium level monitoring in sarcoidosis patients taking calcium and/or vitamin D supplements
Authors: Gunawardana Shannon , Nagra Deepak , Bechman Katie , Birring Surinder , Galloway James , Patel Amit
Published: April 2022

Background/Aims

Sarcoidosis is a chronic inflammatory disorder, for which steroids are a common treatment. A side effect of long-term steroid therapy is an increased risk of osteoporosis, and calcium and/or vitamin D supplementation may be indicated. In sarcoidosis patients, increased expression of 1α-hydroxylase triggers the conversion of 25(OH)D3 to 1,25(OH)2D3 (calcitriol). Therefore, monitoring of calcium and vitamin D levels are recommended for patients taking supplementation, as they are at increased risk of hypercalcemia.

Methods

We conducted a retrospective analysis on community measurements of serum calcium and vitamin D levels, in sarcoidosis patients, who were prescribed calcium and/or vitamin D supplementation. Patients with biopsy confirmed sarcoidosis were identified using the King’s College Hospital sarcoidosis database and electronic primary care records were reviewed for each patient.

Results

The database identified 431 patients with biopsy confirmed sarcoidosis, of whom 102 patients (24%) had been prescribed calcium and/or vitamin D supplementation and were further evaluated. Of these 102 patients, 63 (62%) were taking calcium and vitamin D supplementation simultaneously; and 39 (38%) were taking vitamin D supplementation alone. In the last 12 months, 46 patients (45%) had measurements of serum calcium and vitamin D levels taken in the community. One patient taking vitamin D supplementation was identified as having hypercalcemia.

Conclusion

This audit has found infrequent monitoring of serum calcium and vitamin D levels over the last 12 months, in sarcoidosis patients, who were prescribed calcium and/or vitamin D supplementation. A Clinical Commissioning Group wide prescribing alert has been implemented to alert primary care physicians to the importance of monitoring these levels, to reduce the risk of hypercalcemia.

Disclosure

S. Gunawardana: None. D. Nagra: None. K. Bechman: None. S. Birring: None. J. Galloway: None. A. Patel: None.
P040 A Tale of Three Rashes
Authors: Lee Martin A
Published: April 2022

Background/Aims

Skin rashes are commonly an external marker of internal disease and are often useful in the diagnosis of a variety of systemic diseases managed by rheumatologists. I present a case of a lady who developed three discrete episodes of different skin rashes over the course of two months that represented three different underlying pathologies but were nevertheless intrinsically linked.

Methods

In September 2019, a 42-year-old lady returned from holiday in Thailand with mosquito bites on her arms and legs. She presented to another hospital with fevers, myalgias and severe arthralgias. Her CRP was raised at 128mg/l and she was given intravenous cefuroxime for 3 days followed by oral co-amoxiclav for presumed infected mosquito bites. Shortly after starting the intravenous cefuroxime, she developed a second rash on her torso, arms and legs. She was seen a week after discharge from hospital with ongoing severe arthralgias although her CRP had settled and was prescribed celecoxib 200mg twice daily. In October 2019, she developed pedal oedema and a non-blanching, purpuric rash across her shins bilaterally and presented to out-patient clinic.

Results

In clinic, she complained of widespread large and small joint polyarthralgias but there was no synovitis on examination. An anti-streptolysin O titer (ASOT) was negative but IgM and IgG antibodies to Chikungunya were positive. Her CRP was raised at 22 mg/l and a urinalysis was negative for blood and protein. A diagnosis of Chikungunya fever transmitted by mosquito bites was made followed by a maculopapular drug eruption secondary to cefuroxime and subsequent Henoch Schonlein Purpura (HSP) secondary to recent infection. Her symptoms were treated with a reducing course of prednisolone 40mg once a day and her rashes and arthralgias settled over the course of 2 months. Her urinalysis remained negative for blood and protein throughout.

Conclusion

Chikungunya virus is an arthropod-borne virus that is transmitted by mosquito bites. It can cause fevers, severe polyarthralgias (70-100% of cases) and polyarthritis (44-63% of cases). Chronic arthritis has been reported in 25% to 75% of cases. Chikungunya fever is endemic in parts of Western Africa but is also common in many regions of Asia. Maculopapular drug eruptions are the most common type of drug hypersensitivity reaction and are characterized by a generalised eruption of erythematous macules and/or papules after initiating drug therapy. Maculopapular drug eruptions are common side effects of cephalosporins. HSP is a small vessel leucocytoclastic vasculitis characterized by palpable purpura. The purpuric rash is typically symmetrical and located primarily in pressure dependent areas such as the lower extremities. Many cases of HSP are preceded by an upper respiratory tract infection such as Streptococcus but many other infectious agents have been implicated as possible triggers.

Disclosure

M.A. Lee: None.
P056 Rheumatology haematology interface: an unusual case of aortitis
Authors: Raghuvanshi Subhra , Tarar Bilal , Shaaban Asma
Published: April 2022

Background/Aims

In rheumatological practice it in not unusual to see patients with haematological involvement. We would like to present a very rare diagnosis of Erdheim-Chester disease presenting as retroperitoneal fibrosis and large vessel vasculitis who failed to respond to conventional treatments with steroids and methotrexate.

Methods

A 71-year-old man presented to haematology with retroperitoneal mass. This was investigated with CT thorax, abdomen and pelvis and a biopsy was performed which was negative for haematological malignancies. However, CT scan picked up thickening of aorta and a PET scan was performed subsequently confirming widespread aortitis and peri-renal mass thought to be consistent with retroperitoneal fibrosis. The patient was started on reducing course of oral steroids with a working diagnosis of retroperitoneal fibrosis with large vessel vasculitis.

Results

Subsequent staining for IGG-4 was negative and biopsy was not typical with IgG4 cells. The patient was started on high doses of oral steroids by haematologist with Methotrexate started subsequently by rheumatologist due to persistent changes on PET scan, high inflammatory markers and worsening of patient with generalised malaise, weight loss and fatigue. The patient failed to respond to uptitrated doses of methotrexate and was discussed with a specialist unit for consideration of anti-IL6 tocilizumab to control his large vessel vasculitis. On discussion of imaging in MDT, unusual appearance with sparing of ureters, splaying of peri-nephric fat, lack of IgG4 cells pointed towards an alternative diagnosis.

Conclusion

The patient was subsequently discussed in the national adult histiocytosis meeting with national and international haematologists. The clinical presentation, radiological appearance was thought to be classic of Erdheim-Chester disease, a rare form of adult onset histiocytosis. After further discussions with specialist centre the patient has been commenced on trametinib, a MEK inhibitor treatment (cell tissue negative for BRAF mutation). The patient has recently developed heart failure and has undergone right heart catheter which has found extremely rare pulmonary artery vasculitis too.

Disclosure

S. Raghuvanshi: None. B. Tarar: None. A. Shaaban: None.
P068 Monitoring of methotrexate blood toxicity during the COVID-19 pandemic for patients with rheumatoid arthritis: data from the Greater Manchester Care Record
Authors: Costello Ruth E , Williams Richard , Bruce Ian N , Hyrich Kimme , Dixon William G , Humphreys Jenny H
Published: April 2022

Background/Aims

Current British Society for Rheumatology guidance suggests 3-monthly blood monitoring for patients prescribed methotrexate whose disease, drug dosage and blood results are stable, although evidence for this recommendation is limited. Anecdotal reports suggest monitoring may have reduced during the pandemic. The study aims were, in patients with rheumatoid arthritis (RA) prescribed methotrexate, to determine: 1) interval length between blood tests during the pandemic, and 2) whether prolonged intervals were associated with abnormal blood test results.

Methods

Data came from the Greater Manchester Care Record, a database containing electronic health records from both primary and secondary care for people across Greater Manchester. Inclusion criteria were: a diagnosis of RA; regular blood monitoring ( < =91 days between blood tests) and regular methotrexate prescriptions in the year prior to the pandemic (01/03/2019-01/03/2020). Blood test intervals during the pandemic were determined, a prolonged interval was defined as > 91 days. Cytopenia and transaminitis events were identified between March-December 2020 and March-December 2019 (as a comparator). Proportions of events are presented for each time-period and stratified by whether the interval was prolonged.

Results

1011 patients met the inclusion criteria, with a median of 5 blood tests (interquartile range (IQR): 3-7) during the pandemic and a median interval of 57 days (IQR: 34-84). 612 (61%) patients had at least one prolonged interval, with 241 (23.8%) having multiple. Prolonged intervals had a median length of 112 days (IQR: 99-135). 115 (11.4%) people had a prolonged interval but no subsequent blood test before the study end date (median 120 days [IQR: 104-150]). The proportion of cytopenia and transaminitis events was low and similar across time-periods and when stratified by interval length (Table 1).

Conclusion

Nearly two-thirds of patients on stable methotrexate had at least one prolonged interval and 1 in 10 had a prolonged interval with no subsequent blood test. Initial analyses of test results do not indicate increased occurrence of methotrexate blood toxicity in those with prolonged blood test intervals during the pandemic. Further work is required to determine whether those with prolonged intervals represent a group at lower risk where less frequent blood tests would be appropriate.

Disclosure

R.E. Costello: None. R. Williams: None. I.N. Bruce: None. K. Hyrich: None. W.G. Dixon: Consultancies; Consultancy fees from Abbvie and Google unrelated to this work. J.H. Humphreys: None.
P070 Patients with idiopathic inflammatory myopathies suffer from poor self-reported PROMIS physical function after COVID-19 infection: an interview-based study from the MyoCite cohort
Authors: Kharbanda Rajat , Ganatra Keya , Agarwal Vikas , Gupta Latika
Published: April 2022

Background/Aims

Patients with rheumatic diseases are known to exhibit worse outcomes with COVID-19. However, the effect on individual diseases such as idiopathic inflammatory myopathies (IIM) remain unexplored.

Methods

A self-report e-survey with 36 questions was pilot tested and validated to cover demographics, history of COVID-19 contact, course and severity of COVID-19 infection, influence of COVID-19 infection on physical state one-month after the infection and vaccination status. Baseline characteristics were retrieved from the MyoCite registry and biobank archive. PROMIS-10a, a validated self-report tool was used to quantify physical function. Age and gender similar healthy controls (HC) were included for comparison.

Results

10 patients of IIM were compared with 40 controls. Fever was the most common symptom reported by both the groups however, fatigue, chest pain, and breathlessness were experienced more by patients of IIM compared to HC. However, severity of COVID-19 infection as substantiated by pneumonia, hospitalization, and oxygen requirement was comparable in IIM and HC, possibly due to small numbers PROMIS physical function was comparable before COVID-19 in both groups, and in HC physical function remained the same a month before and after COVID-19. On the other hand, the physical function deteriorated at 30-days after COVID-19 in the IIM group as compared with their baseline function as well as HC. Specific tasks were more challenging for IIM, including climbing stairs, bending or kneeling and shampooing hair, although the limitation was mild (Table 1). IIM patients were also less likely to be vaccinated, suggesting prevalent hesitancy in this group (50% vs 90%, p: 0.007) (Table 1).

Conclusion

Patients with IIM exhibit increase in fatigue, and dyspnoea during COVID-19 although there is no increase in hospitalisation and had similar disease severity compared to HC. Short term physical function is impacted at 30-days post COVID-19, suggesting the need for closer long-term follow-up. Vaccine hesitancy is prevalent and merits addressing in patients with IIM.

Disclosure

R. Kharbanda: None. K. Ganatra: None. V. Agarwal: None. L. Gupta: None.
P111 Patient-related factors influencing remote consultations in rheumatology - lessons from a COVID-19 initiative
Authors: Hannides Michael , Wig Surabhi , Vasireddy Sreekanth
Published: April 2022

Background/Aims

The COVID19 pandemic significantly altered healthcare provision. Our department switched immediately to remote consultations without suspending service, including telephone and video consultations. In this analysis we aimed to explore the role of patient-related factors in influencing the process and outcome of remote consultations with a view to improving the quality of service provision.

Methods

A data collection form was developed and offered to all clinicians to complete after each remote consultation. Information on age, gender, new or follow up status and interpreter use were collected. Clinicians were asked to rate the effectiveness of specific components of the consultation process (time adequate, relevant history, physical examination, management plan and communication quality) as compared to the usual face to face appointments on Numerical Rating Scales (NRS, 0–0). Data were collated in a Microsoft Access database. Statistical analysis was performed using SPSS version 25.

Results

In total, 285 valid forms were evaluated. 193 (67.7%) were women. Patients registered for new appointments (n = 51, 18%) were significantly younger (mean±SD 52.9 ± 19.7 vs 60.6 ± 17.2 years, P = 0.012). There were no significant correlations with age or any significant differences with gender in mean scores of NRS. New patients scored lower on NRS for relevant history (8.0 ± 1.1 vs 8.9 ± 1.2, P<0.001), management plan (4.8 ± 2.5 vs 7.8 ± 2.0, P<0.001) and communication quality (6.6 ± 2.0 vs 8.4 ± 1.6, P<0.001). Interpreter usage (n = 9, 3.4%) had lower scores for relevant history (7.1 ± 2.4 vs 8.8 ± 1.1, P = 0.012) and communication quality (5.4 ± 2.6 vs 8.1 ± 1.8, P = 0.002). There was no significant association of age or gender with subsequent follow up appointment requested as face-to-face or remote. New patients were significantly more likely than follow-up patients to be offered a face-to-face follow up appointment (univariate regression, odds ratio (OR) 5.49, 95% CI 2.7-11.1, P < 0.001). However, once adjusted for management plan in multivariate regression, new patients were no longer significantly associated with subsequent follow up face-to-face appointment (adjusted OR 1.19, 0.48-2.92, P = 0.71).

Conclusion

Our study is one of the first in the UK to explore patient-specific factors influencing remote consultations in rheumatology. In our cohort, patient age or gender was not a limiting factor in utilising remote consultation. New consultations and interpreter use pose challenges for remote consultations, and further studies are needed to address these to see if any measures such as appropriate selection at triaging new appointments may be possible, to improve outcomes.

Disclosure

M. Hannides: None. S. Wig: None. S. Vasireddy: None.
P123 Switching to biosimilars: what do patients think?
Authors: Coady David , Parkin Lindsay , Fairle Louise , Smith Andy
Published: April 2022

Background/Aims

Newer ‘biosmilars’ come with a potential cost saving to the NHS. Switching of generic medicines has been studied (1) but not in the context of biologic drugs. We are interested in patients’ views on switching to biosimilars. Will they have concerns and what can we do as Professionals to support them?

Methods

A sample of 20 patients previously switched to a biosimilar were invited to a semi-structured face to face or telephone interview, lasting approximately 45mins. Interviews were recorded, anonymized and transcribed. Thematic analysis was undertaken by the research team using grounded theory (2).

Results

15 interviews took place until ‘saturation’. Themes to emerge included: Trust: several patients mentioned ‘trusting’ someone they had an established relationship with, such as their consultant or specialist nurse. This would influence their decision to switch. Cost for NHS: awareness of costs to the NHS was discussed with a realisation that these are expensive drugs and there is a wider ‘altruistic’ need to switch to cheaper drugs when asked. But not all patients were happy. One patient felt ‘pushed’ into switching ‘Cross, you know I have worked, my husband has worked, we’ve paid out National Insurances all out lives ⋯⋯ I was being pushed towards this cheaper version ⋯’ Quality of delivery device: many comments were made on the quality of the delivery devices. ‘It’s just a bit more flimsy⋯’. Pre Switch training: some patients felt ‘information’ overload. Others did not read any extra information given. Others felt there was not enough support for the new device or training to use it. Preconceptions: several patients had preconceptions, that switching may create issues and described pre-switch anxiety: ‘I was quite nervous about changing from one to another because I’d been perfectly fine with the one I was on ⋯⋯’

Conclusion

Patients fell into two groups: 1) no particular anxiety about switching and 2) those with pre-switch anxiety. Pre switch anxiety seemed to be driven by prior experiences (reactions or ineffectiveness of prior medications). As the number of biosimilars increase it is likely that patients may be asked to switch multiple times. Confidence in the product and clinical support appear key to successful switching. We suggest a need for further research into this issue and intend to use the above themes in developing a questionnaire for wider sampling.

Disclosure

D. Coady: Grants/research support; Biogen grant, N/A. L. Parkin: None. L. Fairle: None. A. Smith: None.
P129 Quantification of longitudinal joint and cartilaginous changes within ankles with haemophilia joint degeneration using MRI imaging
Authors: Schaper Madeleine , Sharrock Megan , Wilkins Richard A , Redmond Anthony C
Published: April 2022

Background/Aims

Haemophilia is an X-linked recessive genetic disorder characterised by episodes of spontaneous and traumatic intra-articular bleeding. 90% of bleeds are of musculoskeletal origin, with the ankle being most affected joint. Recurrent bleeding results in haemosiderin accumulation, linked to progressive, end-stage ankle haemarthropathy in adolescent and adult patients. Magnetic Resonance Imaging (MRI) is gold-standard for the evaluation of early soft tissue and cartilage changes in ankles with haemarthropathy. This study utilised MRI sequences to quantify longitudinal changes within the ankle joint, via changes in cartilage thickness (CT), subchondral thickness (ST) and joint space width (JS) over time.

Methods

Clinical T1 Sagittal MRI scans of HJD ankles were selected (N = 5). Each patient had a minimum of two MRI scans available, at least one year apart, to allow for comparison of longitudinal changes. All images were identity coded but fully anonymised. The earliest available and most recent MRI scan were measured in three slices (medial, lateral and middle slice) and at different points along the joint space (anterior, middle and posterior). Measurements taken were cartilage thickness on the talar dome (CT) and the distance between the subchondral bone of the tibial plafond and talar dome (ST). The joint space width (JS) was then determined by subtracting CT from ST.

Results

Chondral thickness measurements showed most reduction, particularly at the antero-lateral aspect (-0.4mm) compared to the antero-medial and middle sections, with -0.24mm and -0.34mm (Table 1). ST and JS reduction was predominantly seen in the anterior joint, with most reduction in antero-lateral joint (-1.13mm). The posterior joint showed minimal reduction in the postero-medial and middle sections, with the posterior-lateral joint space width increasing (0.2mm). Subchondral thickness and joint space measurements were variable and did not demonstrate linear change over time.

Conclusion

A systematic longitudinal decrease in cartilage thickness was seen in the antero-lateral and antero-medial aspect of the ankle joint. The antero-lateral aspect of the ankle showed the greatest reduction in joint space and cartilage thickness. This suggests that this area of the joint is likely to provide the best early indications of haemarthropathy when using MRI as a diagnostic tool.

Disclosure

M. Schaper: None. M. Sharrock: None. R.A. Wilkins: None. A.C. Redmond: None.
P136 Methotrexate osteopathy - clinical and radiological characteristics in a case series of twenty-one patients
Authors: Merriman Andrew T , Foley Jon , Golla Janardhana , McRorie Euan , Hauser Barbara
Published: April 2022

Background/Aims

Methotrexate osteopathy was originally described in the 1980s as a combination of bone pain, osteoporosis and insufficiency fractures in paediatric patients receiving high-dose methotrexate for leukaemia. Since then, cases of insufficiency fractures in patients on long-term, low-dose methotrexate for rheumatic disease have been sporadically reported as methotrexate osteopathy. This case series aims to characterise the clinical and radiological features of this poorly defined condition.

Methods

Patients were identified by searching the MRI reports of rheumatology patients in NHS Lothian for the term ‘insufficiency fracture’ and asking consultant rheumatologists to submit cases where methotrexate osteopathy was suspected. Patient demographics, clinical and radiological features were analysed.

Results

We identified 21 patients with insufficiency fractures taking long-term methotrexate. The mean age at presentation with methotrexate osteopathy was 66.9± 9.5 years. 20 of the patients (95%) were women. 18 of the patients (86%) had rheumatoid arthritis. The average BMI of the cohort was 25.7± 5.4. The average duration of methotrexate use was 7.5± 4.5 years. The most common sites of fracture were the calcaneus (12 patients, 57%) and the metaphysis of the distal tibia (13 patients, 62%). Other frequent fracture sites included the proximal tibia, talus, and distal femur. 13 of the patients (62%) had more than one fracture and 12 (57%) had bilateral fractures. 12 of the patients (57%) required an MRI to identify the fracture and there was an average delay of 4.8± 4.0 months between the initial presenting symptoms and imaging confirming a fracture. Osteoporosis was found in 12 of the 15 patients (80%) who had a DEXA scan, with an average T-score of -2.23± 1.14 for the spine and -2.64± 0.78 for the femoral neck. 14 of the 21 (66.6%) patients received antiresorptive osteoporosis treatment. Only 2 of the patients (9.5%) were on long-term steroids at the time of diagnosis.

Conclusion

Methotrexate osteopathy should be suspected in patients on long-term methotrexate with unexplained pain in the lower limbs. There are often multiple, bilateral fractures which most commonly affect the distal tibia and calcaneus. Fractures may not be visible on X-ray, and pain from the fractures may mimic synovitis, causing a delay in diagnosis. A high index of suspicion and detailed imaging with MRI is often required to identify insufficiency fractures associated with methotrexate osteopathy. If the condition is suspected, a detailed fracture risk assessment should be organised, and the cessation of methotrexate considered.

Disclosure

A.T. Merriman: None. J. Foley: None. J. Golla: None. E. McRorie: None. B. Hauser: None.
P170 I think the mental aspect is just awful: experiences of young men living with inflammatory arthritis
Authors: McNeil-Walsh Ruben J , Flurey Caroline A , Cramp Fiona , Robson Jo , Eccleston Christopher , Galdas Paul M , Cushnie Lewis
Published: April 2022

Background/Aims

Health-related quality of life (HRQoL) is consistently reported to be reduced in people with inflammatory arthritis (IA), but little is known about the specific experiences of young men living with these conditions. This study seeks to address this knowledge gap and identify key aspects of the patient perspective.

Methods

Online semi-structured interviews with male IA patients age 16-30. Participants were recruited via online platforms and participating NHS Trusts. Data were analysed using reflective thematic analysis.

Results

17 male patients (RA, JIA, PsA, AS); mean age 23 years (SD: 3.87); disease duration 7 years (SD 6.41); medication (100% on DMARDs/ biologic). Five themes are proposed: “it had a massive mental impact on me”: Psychosocial burden. Participants explicitly described the burden of IA on mental health and wellbeing (“From the diagnosis afterwards is when my mental health was really impacted”). Participants highlighted difficulties in discussing these challenges with healthcare professionals, despite a desire to do so. “I’m still quite candid about who I disclose it to”: Selective disclosure. Participants reported using caution in discussing their condition, which may be a protective mechanism for young men giving them a sense of control (“I think just as a bit of a control thing [...] I didn't want people to know everything”).“I view my arthritis as emasculating”: Disrupted and disruptive masculinity. For some, IA interfered with how they wanted to be as a man (“That kind of sums it up, just not being able to fulfil that role of sort of being the man”). Societal expectations seemed to shape their view on how they as young men should manage (“I think you're expected to manage your own feelings and your own everything and go through it [⋯] like, just man up and take it”). “You have to keep going, you have to keep the ball rolling”: Remarkable resilience. Participants expressed resilience in response to setbacks and ongoing challenges. (“I can't just sit back and cry, I need to get on with it and move on”). “It is a roller coaster, you know, you're okay one minute then you're not”: Sense of uncertainty. Participants explained IA brought uncertainty and instability into their lives, adding a layer of difficulty to planning next steps as a young adult (“It makes planning very difficult. I feel like I'm always waiting for something to happen”).

Conclusion

IA can influence young men’s sense of self and may interfere with their ability to navigate emerging adulthood. Some young men report IA having considerable impact on their mental health and wellbeing. Next steps will explore clinician’s perspectives on caring for this patient group to help understand how young men might be better supported

Disclosure

R.J. McNeil-Walsh: None. C.A. Flurey: None. F. Cramp: None. J. Robson: None. C. Eccleston: None. P.M. Galdas: None. L. Cushnie: None.
P202 Impact of ‘moderate' active RA on patient lives
Authors: Jacklin Clare , Nikiphorou Elena , Kiely Patrick , Jacklin Hannah , Bosworth Ailsa
Published: April 2022

Background/Aims

The objective of this survey was to highlight the everyday impact of living with active Rheumatoid Arthritis for people not meeting the eligibility criteria (pre-July 2021), to be treated with advanced therapies.

Methods

NRAS wanted to reach people living with RA for more than 2 years but not being treated with any advanced therapies with a national survey to gauge if they had active disease that was not well controlled and the impact of that active disease on their lives. The survey was designed to capture demographics, current treatment, frequency of RA flares, impact of disease (utilising the validated tool of RAID) as well as work status and restrictions on lifestyle. The national online survey was distributed via all NRAS social media platforms as well as email.

Results

612 responses from across the UK with a mean age of 59 years were gathered. 88% were female and 37.7% had a disease duration of 2-5 years with a further 27.9% with disease duration of 5-10 years. 90% declared having RA flare in the previous 12 months with 23% reporting having had six or more flares within the year. A total RAID score was calculated for 611 respondents. A RAID patient acceptable state was recorded in only 12.4%. 74.3% scored sleep problems and 72% fatigue in the high range. Working hours alteration was reported by 70% of respondent. The RAID scores were significantly predictive of number of flares.

Conclusion

Patients not currently treated with biologics/biosimilars or targeted synthetic DMARDs experience profound difficulties affecting their health, emotional state, work and families. NRAS advocate that patient reported measures be used to facilitate holistic care, addressing inflammation and other consequences of RA on everyday life. Since this piece of work was carried out the threshold for accessing some advanced therapies has been lowered by NICE meaning that in England and Wales many of these people will now have access to being treated on an advanced therapy however there still exists issues in Scotland and Northern Ireland in being able to offer such treatments to those with RA disease activity score of less than 5.1 as well as cost barriers.

Disclosure

C. Jacklin: None. E. Nikiphorou: None. P. Kiely: None. H. Jacklin: None. A. Bosworth: None.
P215 In a treatment-naïve, early rheumatoid arthritis cohort, baseline ultrasound power Doppler synovitis and tenosynovitis are highly associated with remission when treated with first line etanercept + methotrexate (MTX) but not MTX alone
Authors: Shukla Rudresh , Hum Ryan , Ho Pauline , Wakefield Richard J , Emery Paul , Buch Maya H
Published: April 2022

Background/Aims

Clinical remission is the treatment target in rheumatoid arthritis (RA). In a treatment-naïve, early RA trial (VEDERA: ‘Very early Etanercept and Methotrexate versus Methotrexate with/without Delayed Etanercept in RA’), we previously reported the presence of ultrasound power Doppler synovitis (PDUS) at diagnosis that improved in the majority with treatment. For this study, we aimed to investigate specifically for an association of baseline PDUS and PD tenosynovitis (PDTS) with subsequent clinical remission (DAS28ESR ≤ 2.6) in VEDERA, also comparing the two treatment groups.

Methods

The ‘VEDERA’ trial randomised 120 treatment-naïve, new-onset RA patients to either first-line etanercept+methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT) regime with escalation to ETN+MTX if not in DAS28ESR remission at week 24. Clinically symptomatic and dominant hand (MCP 1-5, wrist, flexor tendons 1-5 and extensor carpii ulnaris tendon) ultrasound assessments were completed at baseline, weeks 12, 24 and 48. PDUS and PDTS were assessed semi-quantitatively and converted to dichotomous (absent = total score 0, present = total score ≥ 1) for this logistic regression analysis.

Results

At baseline, 68% (81/120) demonstrated PDUS and 68% also demonstrated PDTS overall. In the MTX-TT group, 63% (38/60) had PDUS and 62% (37/60) had PDTS at baseline. In ETN+MTX group, 72% (43/60) had PDUS and 75% (45/60) had PDTS at baseline. As per randomised trial, there were no differences in baseline demographics, DAS28ESR and HAQ between the groups.

Overall, baseline PDUS was associated with week 24 remission and baseline PDTS was associated with week 24 and 48 remission (table 1).

Baseline PDUS was particularly associated with week 24 remission in the ETN+MTX group, with a high OR (95% CI) of 6.83(1.2 - 38.91) compared to the MTX-TT group [1.75(0.5 - 6.14)]. Baseline PDTS was also associated with a high OR for week 48 remission in the ETN+MTX group (OR [95% CI] 9.13[1.77 - 47.02]) in contrast to an absence of association in the MTX-TT group.

Conclusion

Baseline PDUS and PDTS are associated with remission in early RA patients treated with TNF-inhibitor treatment. These measures may be useful to stratify patients early for TNF bDMARD to attain the target of clinical remission in RA.

Disclosure

R. Shukla: None. R. Hum: Other; R.H holds an Academic Clinical Fellowship funded by the National Institute for Health Research (NIHR) through the Integrated Academic Training (IAT) Programme. P. Ho: None. R.J. Wakefield: None. P. Emery: None. M.H. Buch: None.
P259 Survey of diagnostic delay in axial spondyloarthritis across two NHS rheumatology services
Authors: Pandhal Jasmin K , Gregory William J , Tahir Hasan , Bamford Sian
Published: April 2022

Background/Aims

Diagnostic delay is an ongoing challenge in axial spondyloarthritis (axSpA), with a recent, comprehensive literature review suggesting an 8.7-year delay between symptom onset and formal diagnosis in the UK. The aim of this study was to ascertain the axSpA delay in diagnosis and explore contributing factors locally within two major NHS trusts.

Methods

A 13-question survey was created to identify the delay in diagnosis and contributing factors across two urban NHS axSpA services, from onset of symptoms to diagnosis and commencement of treatment. Participants were recruited from clinic visits.

Results

A cohort of 88 patients with a diagnosis of axSpA who attended the axSpA service at either Royal Free NHS Foundation Trust or Salford Royal NHS Foundation Trust responded between August and September 2021. See Table 1 for survey results. The average time from onset of symptoms to diagnosis was similar across centres despite the differences in demographics. Across the two sites, prior to diagnosis 89% of patients saw a general practitioner (GP), of which 68% of patients saw a GP one to five times, 16% five to ten times and 13.25% more than ten times. Many patients also saw other healthcare professionals (HCPs) (see Table 1) aside from the GP and rheumatologist prior to diagnosis. 31.9% saw one other HPC, 20.7% two other HPCs, 12.4% three, 2.4% four and 1.19% five other HCPs prior to diagnosis. 87.5% of patients received adequate axSpA education at diagnosis and 76.5% of patients were aware of who to contact in the event of a flare.

Conclusion

These data highlighted that the mean time to diagnosis for both trusts was less than six years, somewhat lower than the 8.7 years national UK average. However, despite being specialist centres, we are a long way away from the NASS gold standard of 1 year time to diagnosis. Contributors to this include lack of awareness about axSpA, its recognition and appropriate onwards referral. There is a need for concerted ways of working, development of patient pathways, and education to reduce this delay and allow the ambitious NASS gold standard of 1 year time to diagnosis to be achieved.

Disclosure

J.K. Pandhal: None. W.J. Gregory: Honoraria; W.G. has received speaker, conference registration and advisory board fees from Abbvie, Pfizer Novartis and UCB. H. Tahir: None. S. Bamford: None.
P267 Engaging with electronic PROMs in axial spondyloarthropathy
Authors: Fish Sarah J , Brazendale Jane , Greenall Carol , MacPhie Elizabeth
Published: April 2022

Background/Aims

Patient reported outcome measures (PROMs) engage and empower patients and are a powerful tool in helping clinicians understand the impact healthcare interventions make to a person’s quality of life. Where PROMs are embedded in clinical practice, trends can be recognised and used in shared decision-making conversations. In August 2020, the British Society for Rheumatology launched its ePROMs platform and recruitment of our axial spondyloarthritis (axSpA) patients to the platform commenced. One year on we were keen to explore patient engagement and determine if patients felt that ePROMs had enhanced their consultation and care.

Methods

The ePROMs platform was discussed with each patient attending the physiotherapy-led axSpA clinic. 222 of 321 axSpA patients consented to register on ePROMs and were sent an immediate BASDAI to complete followed by quarterly BASDAIs. In September 2021, an ePROMs survey was created on SurveyMonkey® and emailed to all axSpA patients registered on the ePROMs platform. The survey gathered: age, employment status, disease duration, clinical pathway, previous use of apps to record BASDAI, ePROM utilisation to record BASDAI, response times to BASDAI completion requests, time taken to complete BASDAI electronically, preference for ePROMs or paper PROMs, experience of clinician discussing ePROM data in consultation, perspective on ePROMs and the perceived influence on consultation and care.

Results

The response rate was 32.4% (n = 72), with 69.4% (n = 50) of respondents having completed a BASDAI ePROM. The below table displays the ePROM questionnaire results. There was a representative distribution of respondents across all age groups, disease duration and treatment options; 88% of patients reported that the BASDAI took less than 5 minutes to complete. Of the patients who had an appointment post-ePROM completion, 91% felt that the health professional discussed their scores, with over one third reporting appointment enhancement and improved care.

Conclusion

The results demonstrate that a good proportion of our axSpA patients have engaged with the ePROMs platform and are completing their BASDAI prior to their appointment. When a BASDAI is completed prior to the clinic appointment, time in clinic can be better utilised to enhance patient discussion, supporting a shared decision-making approach.

Disclosure

S.J. Fish: None. J. Brazendale: None. C. Greenall: None. E. MacPhie: Other; EM is the North West Rheumatology Club secretary and meetings have been sponsored by MSD, UCB, Abbvie and Lilly.
P279 Prevalance of frailty in patients with ankylosing spondylitis: a cross-sectional study
Authors: Öztürk Özgül , Feyzioğu Özlem
Published: April 2022

Background/Aims

Frailty is characterised by increased fatigue and vulnerability, which leads to adverse health outcomes. Although common in older adults, recent studies have reported the increased prevalence of frailty in various rheumatological diseases regardless of age. However, there are very few studies of the prevalence of frailty in people with ankylosing spondylitis (AS). Thus, this study aims to address this gap in the literature by investigating frailty prevalence in a group of AS patients and assessing the disease-specific outcome measures.

Methods

50 AS patients aged between 40 and 65 were included in this monocentric cross-sectional study. The study protocol was approved by the university ethics committee and all participants provided written informed consent. Patients were grouped as pre-frail, frail and robust according to the Kihon Checklist; <4 was accepted as robust, ≥4 pre-frail, and 8≥frail. Grip strength, walking speed, pain during activity and rest were determined. Nutritional status, disease activity, functional level and quality of life were assessed using the Mini Nutritional Assessment (MNA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) respectively. One-way ANOVA was conducted to compare the patients in groups with post-hoc comparisons.

Results

26% of patients were robust, 32% were pre-frail and 42% were frail. Compared to robust individuals, the pre-frail and frail individuals had significantly higher BASFI, BASDAI, ASQoL scores and a higher level of pain severity during rest. Pain during activity and walking speed were not significant between frail and pre-frail individuals.

Conclusion

Our preliminary findings indicate that frailty or pre-frailty is common in working-age AS patients. Being frail resulted in higher disease activity and pain severity, and especially worse self-reported outcome measure scores. Since frailty is a reversible condition, identifying the pre-frailty and frailty status of AS patients may help to prevent further decline in functional level and to design appropriate treatment interventions.

Disclosure

Ö. Öztürk: None. Ö. Feyzioğu: None.
P304 Performance of the Southend GCA Probability Score on the NHS Lanarkshire fast track pathway
Authors: Melville Andrew R , Donaldson Karen , Ciechomska Anna
Published: April 2022

Background/Aims

Fast track GCA pathways (GCA FTP) with use of confirmatory ultrasound are growing in popularity, but the burden of referrals can overwhelm services and represents a barrier to timely assessment. The Southend GCA Probability Score (GCAPS) has shown promise in determining pre-test probability and may have a role in triage, but there is limited data supporting its use in external cohorts. We evaluated the performance of GCAPS in patients assessed on the NHS Lanarkshire GCA FTP.

Methods

Consecutive patients assessed on the GCA FTP between November 2018 and August 2021 were included. All underwent GCAPS assessment as part of routine care. GCAPS risk groups were defined as follows: low risk ≤8, medium risk 9-12, high risk ≥13. GCA diagnoses were supported by USS +/- TAB and confirmed at 6 months. Overall performance of GCAPS in distinguishing GCA / non-GCA final diagnoses was assessed by ROC analysis. Test characteristics for different GCAPS binary cut-offs were also determined.

Results

176 patients were included in total; mean age 69.0 years (SD 9.8), 63.6% female, median GCAPS 10 (IQR 8, 14). 54 patients were diagnosed with GCA, including 0/57 low risk patients, 3/60 medium risk patients (5.0%), and 51/59 high risk patients (86.4%). ROC analysis for total GCAPS in distinguishing GCA/non-GCA gave an AUC of 0.973 (95% CI 0.951 - 0.999). A GCAPS cut-off of ≥ 13 had the highest accuracy for GCA diagnosis (93.8%), with 94.4% sensitivity and 93.4% specificity. A GCAPS cut-off of ≥ 10 captured all cases of GCA (100.0% sensitivity), with 64.8% specificity.

Conclusion

Performance of GCAPS as a risk stratification tool in our cohort was excellent. GCAPS may have additional roles in screening FTP referrals and guiding empirical glucocorticoid therapy. No patients with GCAPS <10 had GCA; this is consistent with previously published data and suggests specialist review and/or USS may not be required in this group. By contrast, most patients with GCAPS ≥13 had GCA, and this group is most likely to benefit from empirical glucocorticoid treatment while awaiting confirmation. Patients with GCAPS between these values should undergo prompt assessment to minimise the risk of missed diagnoses, or overtreatment.

Disclosure

A.R. Melville: Other; Dr Melville is a Medical Research Council and GlaxoSmithKline Experimental Medicine Initiative to Explore New Therapies clinical training fellow, with project funding outside the submitted work. K. Donaldson: Other; Speaker fees from Menarini Pharma UK. A. Ciechomska: Other; Speaker, travel and registration fee sponsorship from Novartis, Abbvie, Chugai Pharma, Colgene, Roche and Lilly.
Cortical and Subcortical Structural Morphometric Profiles in Individuals with Nonaffective and Affective Early Illness Psychosis
Authors: Hua Jessica P Y , Mathalon Daniel H
Published: April 2022

Research has found strong evidence for common and distinct morphometric brain abnormality profiles in nonaffective psychosis (NAff-P) and affective psychosis (Aff-P). Due to chronicity and prolonged medication exposure confounds, it is crucial to examine structural morphometry early in the course of psychosis. Using Human Connectome Project-Early Psychosis data, multivariate profile analyses were implemented to examine regional profiles for cortical thickness, cortical surface area, subcortical volume, and ventricular volume in healthy control (HC; n = 56), early illness NAff-P (n = 83), and Aff-P (n = 30) groups after accounting for normal aging. Associations with symptom severity, functioning, and cognition were also examined. Group regional profiles were significantly nonparallel and differed in level for cortical thickness (P < .001), with NAff-P having widespread cortical thinning relative to HC and Aff-P and some regions showing greater deficits than others. Significant nonparallelism of group regional profiles was also evident for cortical surface area (P < .006), with Aff-P and N-Aff-P differing from HC and from each other (P < .001). For subcortical volume, there was significant profile nonparallelism with NAff-P having an enlarged left pallidum and smaller accumbens and hippocampus (P < .028), and Aff-P having a smaller accumbens and amygdala (P < .006), relative to HC. NAff-P also had larger basal ganglia compared to Aff-P. Furthermore, NAff-P had enlarged ventricles (P < .055) compared to HC and Aff-P. Additionally, greater ventricular volume was associated with increased manic symptoms in NAff-P and Aff-P. Overall, this study found common and distinct regional morphometric profile abnormalities in early illness NAff-P and Aff-P, providing evidence for both shared and disease-specific pathophysiological processes.