bluuebunny/crossref_metadata_2025 huggingface dataset:
O32 Digital artery volume index (DAVIX©) predicts the onset of future digital ulcers in patients with SSc
Authors: Gjeloshi Klodian , Danzo Fiammetta , Lettieri Giovanni , Abignano Giuseppina , Hinton Mark , Dean Anne-Maree , Cuomo Giovanna , Kubassova Olga , del Galdo Francesco
Published: April 2020

Background

Digital Ulcer Disease is a main vascular manifestation of Systemic Sclerosis (SSc) caused by progressive narrowing of digital arteries with consequent tissue ischemia. Time of flight angiography (TOF) is an MRI technique based on flow-related enhancement of spins entering into an imaging slice. It can visualise flow within vessels, without the need to administer contrast. Here we measured Digital Artery Volume index (DAVIX ©) as an MRI TOF quantitative score of digital arteries flow and determined its value in predicting the onset of digital ulcers (DUs) in patients with SSc.

Methods

We studied 91 consecutive patients, 63 of which fulfilled the 2013 ACR/EULAR classification criteria for SSc and 28 had a score <9. The data collected included: clinical examination, pulmonary function tests (PFTs), echocardiography, nailfold capillaroscopy. DAVIX of the dominant hand was calculated as % mean of the 4 fingers, employing MeVisLab software. The distribution was analysed with D’Agostino-Pearson normality test. Correlation with clinical parameters was performed using Spearman’s or Pearson test, as appropriate (Prism 7).

Results

78/91 patients were females and median disease duration was 4 years (IQR 1.91-9). Complete historical and prospective follow-up data were available for 68 patients. At baseline 7 patients had DUs (5 with a positive history for DUs). 12 patients developed DUs within 12 months, 3 of them had DUs at baseline. 38 patients did not have either previous or current DUs, neither did they develop new DUs within 12 months. The median of DAVIX in this population was 0.65 (IQR 0.46-0.82). DAVIX of patients with current DUs was 3-fold lower than DAVIX of patients without DUs (0.18 vs 0.63 p = 0.0093). Further, DAVIX of patients with positive history of DUs was 50% lower than in patient with a negative history (median 0.34 vs 0.64, p = 0.0052). In patients without current DUs who developed new DUs within 12 months of follow-up the DAVIX was 3-fold lower than in patients who didn’t develop (0.21 vs 0.65, p = 0.0156). Most importantly in patients with no current DUs a DAVIX <0.47 gave a 35% risk of developing DUs ( vs 15% overall risk).

Conclusion

Outcome measures of vascular involvement in SSc are scanty. We demonstrated that DAVIX© is a promising and feasible surrogate outcome measure of neointima proliferation in SSc. Furthermore, the predictive value of DAVIX for the future onset of DUs could be employed as a useful stratification tool in Clinical trials.

Disclosures

K. Gjeloshi None. F. Danzo None. G. Lettieri None. G. Abignano None. M. Hinton None. A. Dean None. G. Cuomo None. O. Kubassova None. F. del Galdo None.
O33 Earlier cancer diagnosis after myositis onset is associated with improved long term survival: results from UK, French and Czech cohorts
Authors: Oldroyd Alexander , New Paul , Lamb Janine , Ollier William , Cooper Robert , Mariampillai Kuberaka , Benveniste Olivier , Vencovský Jiří , Mann Heřman , Chinoy Hector
Published: April 2020

Background

The idiopathic inflammatory myopathies (IIMs) are associated with cancer. Cancer screening is advocated in new IIM cases; however no study has investigated if this confers improved long-term survival. This study aimed to investigate if a shorter time between IIM onset and cancer diagnosis is associated with improved survival.

Methods

Verified adult-onset IIM (dermatomyositis, polymyositis, anti-synthetase syndrome) cases, according to the International Myositis Classification Criteria, were recruited from three separate UK (UKMYONET), France and Czech-based cohort studies. Only cases with cancer diagnosis following IIM onset were included in analysis. The time between IIM onset and cancer diagnosis was calculated for each case. The relationship between survival at the end of follow up and time between IIM onset and cancer diagnosis was quantified via calculation of hazard ratios using a Cox-proportional hazard model, adjusted for age and gender.

Results

A total of 193 (66% female) IIM cases with a total of 1,395 person-years follow up were included in the analysis (Table 1). Data of 120 UK, 45 Czech and 28 French participants were analysed. Breast was the most common site of cancer (16%), followed by lung (9%) and bowel (6%). Forty six (24%) deaths occurred within the follow up period. The IIM onset to cancer diagnosis time was shorter for those that survived at the end of follow up, compared to those that died: 4.6 years (IQR 1.2, 10.7), vs 5.8 years (IQR 1.6, 13.8), respectively. Cox-proportional hazard modelling, indicated that a longer time between IIM onset and cancer diagnosis was significantly associated with death (HR 1.06 [95% CI 1.02, 1.10]). This significant relationship was only demonstrated in the female cohort when analysed separately: female HR 1.06 (95% CI 1.01, 1.10), male HR 1.08 (95% CI 0.98, 1.18).

Conclusion

Using data from three international cohorts, this study has, for the first time, identified that earlier cancer diagnosis after IIM onset is associated with improved long term survival. This finding was observed in the female cohort only. This study therefore indicate that cancer screening in newly diagnosed IIM cases without a preceding cancer history should be carried out, especially in female cases.

Disclosures

A. Oldroyd None. P. New None. J. Lamb None. W. Ollier None. R. Cooper None. K. Mariampillai None. O. Benveniste None. J. Vencovský None. H. Mann None. H. Chinoy None.
O36 Validation of methods to enable national registration for rare autoimmune rheumatic diseases
Authors: Pearce Fiona A , Rutter Megan , Griffiths Bridget , Mukhtyar Chetan , Al-Jayoussi Reem , Watts Richard A , Aston Jeanette , Bythell Mary , Stevens Sarah , Lanyon Peter C
Published: April 2020

Background

The National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) records those people with congenital anomalies and rare diseases across the whole of England. The NCARDRS Rare Rheumatology Project is establishing methodologies to identify and register people with rare rheumatic diseases. Hospital Episode Statistics (HES), comprising data from all admitted-patient NHS care in England, provides a promising source for case ascertainment. We aimed to confirm the reliability of diagnostic ICD codes for rare autoimmune rheumatic diseases within HES.

Methods

We used NCARDRS’ legal permissions (CAG 10-02(d)/2015) to extract cases who had at least one inpatient or daycase admission recorded in HES during 2003 to 2017 with a primary or additional diagnostic code for Kawasaki disease, Takayasu’s arteritis, Adult-onset Still’s disease, Relapsing polychondritis, Polyarteritis nodosa, Granulomatosis with polyangiitis (GPA), Microscopic polyangiitis (MPA) or Eosinophilic granulomatosis with polyangiitis (EGPA). Using Data Sharing Agreements between NCARDRS and NHS Trusts, we reviewed medical records for all cases admitted to one NHS Trust to confirm diagnoses. For ANCA-associated vasculitis (AAV), up to 20 randomly selected cases admitted to 5 Trusts with a diagnostic code of GPA, MPA and EGPA were reviewed.

Results

Table 1 shows the positive predictive value (PPV) of each diagnosis at one Trust: Kawasaki disease 100%, Takayasu’s arteritis 91.7%, Adult-onset Still’s disease 42.8%, Relapsing polychondritis 40.0%, and Polyarteritis nodosa 5.0%. For AAV, which had a PPV at the index Trust of 92.0%, the PPV across the 5 Trusts varied from 92.9% to 74.0%. Combining all 5 Trusts PPV for AAV was 85.9%. It was higher in MPA (PPV=98.4%) than in GPA (PPV=83.3%) and EGPA (PPV=77.4).

Conclusion

This is the first study to validate the coding of rare rheumatic disease diagnoses within HES data. Our results highlight heterogeneity in coding accuracy both between conditions and between NHS Trusts. Further work is needed to develop and validate algorithms for conditions where HES coding alone has poor positive predictive value, and test sensitivity. National rare disease registration will enable robust, cost-effective and reproducible population-based epidemiology of rare rheumatic diseases across England which is needed to inform service provision and aid development of new treatments.

Disclosures

F.A. Pearce None. M. Rutter None. B. Griffiths None. C. Mukhtyar None. R. Al-Jayoussi None. R.A. Watts None. J. Aston None. M. Bythell None. S. Stevens None. P.C. Lanyon None.
O39 VTE risk in the general population: applying context to the impact of JAK inhibition
Authors: Baroncini Serena , Yates Mark , Bechman Katie , Patel Sanjeev , Rutherford Andrew , Kleymann Alexander , Galloway James
Published: April 2020

Background

Trial data indicate an increased risk of VTE with JAK inhibition. The EMA and FDA have given regulatory advice for their use as a result. To understand the context of any association, we need to understand VTE risk in the background population. Our objective was to describe the changing epidemiology of VTE risk including a breakdown of DVT and PE in the general population in England, over a 20-year period.

Methods

We utilised hospital episodes statistics data to study all patients presenting for hospital care in England between 1 January 1998 and 31 December 2017. We identified VTE events using ICD10 codes I26.0, I26.9, I80.1, I80.2 and I80.3. To estimate annualised event rates, we used the number of finished consultant episodes for admitted care where the primary diagnosis was VTE for the numerator; the denominator was the whole population estimate, from the office for National Statistics, for the relevant year for England. Rates were calculated per 100,000 population, and the Cochrane Armitage test was used to evaluate statistical significance of trends over time. Linear regression allowed modelling of estimates over time, with model assumptions tested using residual versus fitted plots. To explore non-linearity, we used a cubic spline model.

Results

The average VTE rate across the 20 years was 127/100,000. VTE rates have increased over time, climbing from 108/100,000 in 1998, to 151/100,000 in 2017. The relative frequency of DVTs and PEs has changed over this time: in 1998 DVT was more frequent than PE (rates 68/100,000 and 40/100,000 respectively). By 2018 this ratio had reversed (DVT 52/100,000: PE 98/100,000). This change was statistically significant (p < 0.0001). DVT rates declined in a linear manner over time. PE rates increased with a non-linear pattern, with a sharp rise apparent between 2008 and 2010.

Conclusion

The inversion in the frequency of DVTs and PEs is consistent with previous findings using European data. One possible explanation is changing diagnostics (CTPA replacing V/Q), capturing previously subclinical PE events. Limitations include our ecologic design as well as lack of linkage to mortality records. The presumed VTE risk associated with JAK inhibition is small. It is plausible that future shifts in population wide patterns of VTE could obscure or amplify any effect attributable to JAK inhibitors. As longer-term observational data become available, it is crucial they are interpreted in the context of background population trends.

Disclosures

S. Baroncini: None. M. Yates: None. K. Bechman: None. S. Patel: None. A. Rutherford: None. A. Kleymann: None. J. Galloway: None.
P02 Osteoporosis management when denosumab therapy ends: an audit of current practice
Authors: Zhang Jean , Clynes Michael A , Cooper Cyrus , Dennison Elaine M
Published: April 2020

Background

In recent years denosumab therapy has been widely used in the treatment of osteoporosis. However, since its first introduction to clinical practice, evidence has demonstrated discontinuation leads to rebound bone loss and risk of vertebral fracture. In view of this, guidance has been updated recommending transition to an alternative osteoporosis therapy. Given that osteoporosis management is largely managed in primary care, we performed this audit to investigate whether this educational message was being effectively relayed to primary care clinicians.

Methods

In this study, we closed the audit loop of a previous study of the first 50 patients commenced on denosumab at University Hospital Southampton in 2013; we explored the percentage of patients remaining on denosumab 6 years later, using the hospital electronic system, which is linked to the general practice electronic system, to confirm prescriptions for osteoporosis therapy. In cases where it was unclear, letters were written, or telephone calls were made to general practices for clarification. Continuation of denosumab or use of an alternative agent was then recorded.

Results

Nineteen (38%) patients had died since the initial audit, reflecting the use of the agent in later life post hip fracture. Of 15 patients no longer on denosumab, 9 (60%) were found not to be on alternative bone protection without other information recorded, 1 (7%) had denosumab suspended by the GP (with the presumption it may be restarted at a later date), 1 (7%) had denosumab suspended due to recurrent cellulitis with the view to reassess in a year and 3 (20%) were on alternative therapy. One patient was recorded as being on a ‘drug holiday’. Of 16 patients remaining on denosumab, 13 (81%) had pre-injection calcium level checks, and 12 (75%) had a recorded pre-injection renal function check.

Conclusion

These data reflect inappropriate widespread discontinuation of denosumab without follow-on with an alternative osteoporosis therapy, suggesting that targeted education of primary care physicians is necessary. A high proportion of patients on denosumab are having the relevant blood tests in primary care as per clinical guidelines.

Disclosures

J. Zhang None. M.A. Clynes None. C. Cooper None. E.M. Dennison None.
P09 Audit of anti-nuclear antibody testing in East Kent and the British Society for Rheumatology Choosing Wisely recommendations
Authors: Rasool Sheraz , Beharry Karen , Afifi Amr , Shahzad Faisal , mahadi riham , Lord denise De
Published: April 2020

Background

The British Society for Rheumatology has recently issued Choosing Wisely guidance on ANA testing, to avoid unnecessary testing and inappropriate use of resources. Currently there are no local guidelines on ANA testing. The aim of this audit was to use the BSR guidance as best practice to assess current local testing and then develop guidelines. The standards assessed were as follows: testing ANA should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.

Methods

Retrospective data collection of ANA requests at East Kent Hospitals University & Foundation Trust was extracted from the pathology IT system (Apex) from January to March 2019. The clinical indications entered for electronic requesting were recorded. All ANA requests were recorded as ‘appropriate’, ‘inappropriate’ or having ‘insufficient documentation’. A request was considered appropriate if it documented one of the following indications/suspected diagnoses: inflammatory arthritis, connective tissue features - Raynaud’s, vasculitis/photosensitive rash, scleroderma, clinical myositis, autoimmune haemolytic anaemias, cytopenia, Suspected autoimmune liver disease, pleurisy, pulmonary fibrosis, pericarditis, serositis, autoimmune renal disease, autoimmune neurologic disease, BILAG registered patients, patients on/requiring biologics. All other requests which did not meet these standards were considered inappropriate.

Results

There were 1,517 requests made in 3 months; 180 requests (11.86%) were positive and 1,337 (88.14%) were negative. 61% of ANA requests were from outpatients, 25% were inpatient requests and 14% were requests from GPs. Outpatients requests: neurology, rheumatology, gastroenterology, respiratory and renal medicine (in order of frequency). Only 17% of requests met the set standards; 41% were inappropriate requests and 42% were requests with insufficient details.

Conclusion

ANA testing is relatively expensive compared to other routine screening tests. The assay is time consuming and labour-intensive, and due to the volume of requests made, 2 batches are tested daily in East Kent. With only 17% of the 1,517 tests meeting the standards, this suggests the majority were inappropriately requested. There were >15,000 requests from East Kent and nearby trusts from April 2018 to December 2018. At £2.50 per test, adhering to guidelines could save potentially £12,000 per year. Local guidelines have now been devised based on the Choosing Wisely standards, indications & suspected diagnoses documented. ANA testing will be re-audited in 6 months.

Disclosures

S. Rasool None. K. Beharry None. A. Afifi None. F. Shahzad None. R. mahadi None. D. De Lord None.
P35 Vasculitis by any other name would present just the same
Authors: Rasul Sajida , Dockery Morven , Tattersall Rachel , Hawley Dan , Maltby Sarah , McMahon Anne-Marie
Published: April 2020

Background

Vasculitis can present in many ways and large vessel vascultis is reported rarely to co-present with inflammatory bowel disease. We would like to present two adolescent patients who presented in very similar ways via the gastroenterology team with a seemingly clear diagnosis of inflammatory bowel disease but who were found to have large vessel vasculitis later in their disease journey. The presentation is to raise awareness of this rare co-presentation and to discuss treatment challenges in particular those apparent in adolescent patients crossing the transition bridge.

Methods

Patient A is a 17 year old boy who has had a long and rocky road to control of his inflammatory bowel disease which presented when he was 2 years old. Histologically it fitted a Crohn’s classification. His journey included moderate response to oral steroids and little to no response to a range of DMARDs, biologics (including infliximab and adalimumab which both had secondary failure) and elemental nutrition, over a period of 12 years. Vedolizumab was introduced this year with almost immediate improvement of gut symptoms, but with ongoing raised inflammatory markers (CRP 79, ESR 86). Incidental investigations of neck pain following the start of vedolizumab revealed significant abnormality in the external carotids, with 70% stenosis. MR angiography confirmed a typical pattern of stenotic large vessel vasculitis. The second patient, B is also 17 and was diagnosed with histological ulcerative colitis aged 14. He has an older brother with IBD but has recently been found to have small bowel disease and is likely therefore to have Crohn’s disease. He is on infliximab 10mg/kg 4 weekly but presented with a 3-month history of high inflammatory markers, malaise towards the end of the 4 week infliximab cycle and drenching night sweats. CT Chest confirmed vasculitis in the thoracic aorta, subclavians and carotids. On PET CT there is mural thickening and no stenosis.

Results

Patient A presented in paediatric care and B in adult care but because of the seamless rheumatology service and combined MDT with gastroenterology both patients’ care has been widely discussed amongst relevant adult and paediatric teams.

Conclusion

Large vessel vasculitis might be driving the inflammatory bowel disease in both patients as such the life threatening element of the disease ought to be managed immediately, while ensuring safe transition to between paediatric and adult care.

Disclosures

S. Rasul None. M. Dockery None. R. Tattersall None. D. Hawley None. S. Maltby None. A. McMahon None.
P50 Gossypiboma causing SLE and dermatomyositis overlap
Authors: Borukhson Liubov , Wing Charlotte , Stratton Richard J
Published: April 2020

Background

Gossypiboma is a term referring to tumours arising from a retained, non-absorbable cotton matrix left behind during surgery. Serious implications for patients include infections, migration of the retained particles into a systemic circulation, local obstructions, as well as autoimmune reactions. To our knowledge, we describe the first case of SLE-dermatomyositis overlap associated with the gossypiboma.

Methods

A 44 year old lady, who is originally from Poland, presented with a few months history of oral ulcers, photosensitive rash over her chest and neck, myalgia, heliotrope rash and subcutaneous calcified nodules. Her ANA screen was positive 1:100 homogenous pattern, ENA, DsDNA negative, normal complements, CK up to 1636 u/L, nailfold capillaries demonstrated dilated capillaries and capillary dropouts. She was initially managed by a hydroxychloroquine and methotrexate combination for a presumed lupus and dermatomyositis overlap, followed by rituximab for recurrent lupus flare ups. The left knee MRI revealed a well-defined lesion medial to the tibia measuring 4.5 x 2.8 x 2.2 cm. It was heterogenous and contained calcium depositions. The initial diagnosis was in favour of peripheral nerve sheath tumour (schwannoma). However, surgical resection and histological analysis revealed foreign body sponge like material consistent with a retained surgical sponge. On revisiting the past medical history, the patient recalled some form of an operation on her left knee, evidenced by a small scar over posterior aspect of the knee, around twenty-five years ago. A subsequent operation was undertaken to remove the gossypiboma. After this, the patient’s symptoms had gradually improved and ANA screen came back as negative, and she was able to cease steroid therapy.

Results

Immune type of reactions secondary to adjuvants (silicone, pristane, aluminium, vaccines, etc) have been described by Israeli immunologist Shoenfeld and named ASIA syndrome (Autoimmune Syndrome Induced by Adjuvants) in 2011. He described late-onset (sometimes after many years) systemic symptoms associated with the immune reaction following silicone breast implantation. As per his theory, adjuvants influence both adaptive and innate arm of the immune system via different mechanisms, especially in genetically predisposed individuals. The great variety of manifestations have been described, among which Sjögren’s and lupus-like syndromes. We believe that our patient developed autoimmune disease secondary to constant antigenic stimulation caused by a retained cotton wool in the knee. The fact that the symptoms have improved after the removal of the foreign body combined with the negative ANA test is the evidence of the above-mentioned causality.

Conclusion

In summary, we believe that the presence of the foreign body in our patient’s knee has propagated the foreign body reactions and lead to an autoimmune disease.

Disclosures

L. Borukhson None. C. Wing None. R.J. Stratton None.
P53 Gastric antral vascular ectasia in Sjögren's syndrome?
Authors: Tan Yvonne , Gough Andrew
Published: April 2020

Background

Gastric antral vascular ectasia (GAVE) is a rare, but severe cause of non-variceal upper gastrointestinal bleeding (UGIB). It commonly manifests as iron deficiency bleeding and associated with liver cirrhosis, chronic renal failure and connective tissue diseases. Many therapeutic options have been proposed, but the first line of treatment for GAVE remains as endoscopic Argon plasma coagulation (APC). At present, there are no clear satisfactory results to opt for medical therapy as an alternative to invasive approach. We present a case of primary Sjögren's syndrome who has developed GAVE and successfully treated with medical therapy.

Methods

A 68 years old lady was initially referred to Rheumatology with new symptoms of Raynaud’s, affecting her hands and toes. She had dry eyes and mouth, which were managed conservatively. There was no skin change or gastrointestinal symptoms. She had strongly positive ANA with negative ENA and low levels of IgG and IgM. Nifedipine was initiated to control her Raynaud’s symptoms and the diagnosis of Sjogren’s syndrome was made. Eight months following the initial diagnosis, she was found to have iron deficiency anaemia. There was no change in her symptoms or dietary intake. CT colonography revealed no colonic abnormality. Gastroscopy revealed gastric antral vascular ectasia (GAVE) and the patient was treated with endoscopic argon plasma coagulation (APC). This patient underwent second APC after three months as her haemoglobin dropped despite regular iron supplements. We had made a decision to start pulsed cyclophosphamide and methylprednisolone infusion to control her disease activity. Her haemoglobin remained stable for seven months following the last infusion. She then underwent her third APC and another pulsed cyclophosphamide infusion was resumed. Nine months since her last infusion, her haemoglobin dropped once again, and she underwent another APC. In view of her good response to cyclophosphamide infusion, this lady was started on mycophenolate as maintenance. Since the introduction of mycophenolate, we were pleased that this lady’s haemoglobin had normalised, and the iron supplement was no longer required.

Results

The association of GAVE with Sjögren's syndrome is not commonly known. There were two other case reports of patients with primary Sjögren's syndrome and developed a mild form of GAVE. As patients with GAVE in the absence of cirrhosis are more at risk of active upper gastrointestinal bleeding, they require more frequent endoscopic treatments following initial diagnosis. APC is an effective treatment; however, it is uncomfortable for these patients to experience repeatedly.

Conclusion

This case has shown the importance of recognition the possible association of primary Sjögren's and GAVE syndrome as a cause of iron deficiency anaemia. The successful medical therapy of GAVE provides a safe alternative for endoscopic APC, however, more evidences are required to prove the significant of the outcome.

Disclosures

Y. Tan None. A. Gough None.
P55 Carcinoid syndrome on etanercept and subsequent treatment with secukinumab in a patient with psoriatic arthritis
Authors: Sheikh Ali S. F , Srivastva Sagar G , Wood Fiona
Published: April 2020

Background

Psoriatic arthritis requires early recognition and treatment for prevention of disease progression. Conventional disease modifying drugs are first-line agents followed by biologic DMARDs for patients with active disease. TNF-alpha blockers are first line biologic agents in the UK. Th17 inhibitors are used since the elucidation of Th17 pathway. Safety and efficacy profiles of biologic agents inhibiting the Th17 pathway, including secukinumab (IL-17A) and ustekinumab (IL-12/23p40) have been studied.

Methods

We report a case of carcinoid syndrome in a lady on etanercept for psoriatic arthritis, carcinoid as a potential TNF alpha side effect. We also report safety of Th17 (secukinumab) inhibitors in the patient to date (>1 year).

Results

A female with a history of acne rosacea, was diagnosed with psoriatic arthritis in 2000 age 32. Initial sulphasalazine failed, then received methotrexate until 2011, when her arthritis flared. She was commenced on etanercept which proved effective. After 4 years of etanercept and methotrexate, her liver profile became deranged. Investigations off treatment included ultrasound abdomen demonstrating a liver mass, which resembled focal nodular hyperplasia on magnetic resonance imaging. Further screening revealed high urinary 5HIAA (527 umol/24h) and raised chromogranin A & B levels (1574 pmol/L and 373 pmol/L respectively). She had no symptoms suggestive of carcinoid, although facial flushing could have been camouflaged by her rosacea. Octreotide scan was positive, CT enterogram showed a distal ileal neuroendocrine tumour with adjacent lymphadenopathy. She underwent right hemihepatectomy and hemicolectomy. Her liver profile deteriorated again on methotrexate, leflunomide was ineffective. In November 2017 she was started on ustekinumab, which was ineffective and was withdrawn after 8 months. There was no alteration in carcinoid blood markers and no CT changes. In July 2018, she was commenced on secukinumab, which has allowed reduction in steroids. The patient is aware of lack of safety data in her circumstances. Regular surveillance has shown no recurrence of carcinoid with serial negative 5HIAA and chromogranin levels. There are no progressive CT changes at 1 year.

Conclusion

This is a case of carcinoid tumour occurring on TNF-alpha blockers and may represent a rare complication. Screening biomarkers including 5HIAA and chromogranin levels can be useful if disease is suspected. We could not find other similar case reports to guide further management. Within time limited data available - ustekinumab had no effect on the carcinoid. Th17 inhibitors can be safe options for treating psoriatic arthritis and psoriasis with highly sustained efficacy and favourable safety profile seen in large clinical trials. In this case, after > one year of secukinumab treatment - there is no adverse effect on carcinoid syndrome.

Disclosures

A.S.F. Sheikh None. S.G. Srivastva None. F. Wood None.
P60 Daily fluctuations in fatigue severity and C-reactive protein in people with rheumatic diseases
Authors: Druce Katie L , Gibson David S , McEleney Keven , Meleck Stephanie , James Ben , Hellman Bruce , Dixon William G , Mcbeth John
Published: April 2020

Background

Fluctuations in fatigue severity are common in people with inflammatory (e.g. rheumatoid arthritis (RA)) and non-inflammatory (e.g. fibromyalgia (FM) and osteoarthritis (OA)) rheumatic diseases. We tested whether fluctuations in fatigue in RA, OA and FM were explained by fluctuations in inflammation (C-reactive protein (CRP)), pain and mood.

Methods

Participants in the GIRAF (Gaining Insight into RheumAtic Fatigue) study used a patient co-configured app to report fatigue severity, pain severity and mood on a 5-point ordinal scale (increasing scores = worse state) twice daily for 7 days. Daily CRP (mg/L) was measured via dried blood spot sampling. Fluctuations in fatigue were calculated as within-day (morning to evening variability) and between-days (morning to morning; evening to evening variability). Multi-level mixed effects ordered logistic regression models tested the relationship between fluctuations in CRP and fatigue over 7 days. The relationships between fluctuations in fatigue, pain and mood were also examined. Models were adjusted for age, sex and disease diagnosis.

Results

Thirty-eight people (RA:12, OA:13, FM:13) participated and contributed data on 190 (71% of eligible) days. Participants were mostly female (81.6%), with a median age of 56 years. There were no demographic differences between disease groups. Within-day changes in fatigue severity of ≥one point were observed on 97 (51.1%) days and between-days changes were observed on 52% of mornings (92/177 eligible periods) and 49.4% of evenings (85/172 eligible). Fluctuations in pain severity and mood of ≥one point were similarly common (data not shown). Median CRP levels were low (<5mg/L) across all diseases and did not fluctuate substantially between days (change ≥1mg/L:17.5% (33/189) of days). 8 participants (21.1%: RA:4, OA:2, FM:2) had “active inflammation” (CRP>5mg/L) on a total 22 (8.3%) days in the study (range:1-8 days). Fluctuations in CRP were not associated with fluctuations in fatigue (odds-ratio:1.01, 95%CI:0.83-1.22). Fluctuations in pain severity (6.93, 4.68-10.28) and mood (4.58, 3.26-6.45) were associated with fluctuations in fatigue (Table 1).

Conclusion

Fluctuations in fatigue severity were common in people with rheumatic diseases. Inflammation was low and did not predict fatigue variability. Optimal management should target fatigue independently of inflammatory disease management and may benefit from modification of pain and mood.

Disclosures

K.L. Druce None. D.S. Gibson None. K. McEleney None. S. Meleck None. B. James None. B. Hellman None. W.G. Dixon None. J. Mcbeth None.
P63 The association between presenting clinical features and subsequent diagnosis of giant cell arteritis
Authors: Barnett Lauren A , Helliwell Toby , Jordan Kelvin P , Prior James A
Published: April 2020

Background

The diagnosis of giant cell arteritis (GCA) remains challenging due to the varied number and type of clinical features (symptoms and comorbidities) that patients with GCA can present with. Prompt diagnosis is important, as if left undiagnosed and untreated, some patients may experience irreversible sight loss. Given the rarity of GCA and that many of the presenting clinical features may pertain to other, more prevalent illnesses in the typical age range for GCA, diagnostic delay is common. Such delay may increase the risk of GCA related complications. The aim of this study was to quantify the association between a diagnosis of GCA and the clinical features observed prior to diagnosis.

Methods

Patients with a coded record of GCA and aged 40 years or older at the time of diagnosis, were identified from the Clinical Practice Research Datalink (CPRD) between 1990 and 2017. CPRD is a large, national UK database of primary care records. Every GCA case was matched to 5 controls with no GCA diagnosis, by year of birth, gender and practice. Clinical features linked to GCA in previous research studies were identified in the patient’s primary care records at any time prior to GCA diagnosis. Conditional logistic regression was used to determine associations between clinical features and a subsequent diagnosis of GCA, adjusting for Body Mass Index, smoking status, and alcohol consumption.

Results

9,205 patients with GCA were included, the majority of which were female (70.9%). 15 clinical features were examined. For example, 53.3% of GCA cases had a recorded consultation for headache prior to diagnosis (38.4% within six months prior to diagnosis), compared to 9.9% of controls; 3.2% of cases had recorded jaw pain (0.3% within six months prior to diagnosis) compared to 0.5% of controls; 39.4% of cases had a diagnosis for hypertension prior to their diagnosis of GCA. GCA cases were more likely than controls to have recorded consultations for headache (adjusted OR 10.57; 95% CI: 9.93, 11.25), jaw pain (5.37; 4.47, 6.44) and hypertension (1.33; 1.26, 1.40). Other clinical features that were statistically significantly associated with GCA included fever, anxiety/depression, and PMR. Cancer was the only clinical feature not associated with GCA.

Conclusion

Symptoms such as headache, jaw pain and hypertension are highly prevalent in GCA, but are also common symptoms in the usual age group affected by GCA and common features of many conditions. In isolation and considering the rarity of GCA in the UK population, these symptoms may not be immediately attributed to GCA by the diagnosing GP. It is therefore necessary to conduct further research where clinical features are not treated independently, but as groups or clusters, which together may more accurately help clinicians to diagnose GCA early.

Disclosures

L.A. Barnett None. T. Helliwell None. K.P. Jordan None. J.A. Prior None.
P68 Age-related muscle strength decline in mid-late life varies in men and women and is associated with diet and physical activity: observations from the Hertfordshire Cohort Study
Authors: Zhang Jean , Laskou Faidra , Jameson Karen , Cooper Cyrus , Dennison Elaine M
Published: April 2020

Background

In the context of an aging population, age-related decline in muscle strength is well recognised, and is associated with functional limitation and increased mortality. However, scarce epidemiological data are available regarding its prevalence, or lifestyle associations at a time when intervention is still possible to retard or prevent loss. We considered these issues in the Hertfordshire Cohort Study, a cohort of late-middle aged community dwelling adults.

Methods

2,987 participants were seen in 1999-2004, 1,572 men and 1,415 women. A lifestyle questionnaire was administered that asked about social class, physical activity, diet, co-morbidities and cigarette and alcohol consumption. Grip strength was measured with a Jamar dynamometer, three times on each side with the highest value used. Age related muscle strength decline was defined, according to current convention, as a grip strength <30kg in men and <20 kg in women.

Results

The mean age of participants was 65.8 (IQR 63.5-67.8) years for men and 66.5 (IQR 64.5-68.7) years for women. Muscle strength decline was more common in women (10.3%) than men (3%); the odds ratio (OR) for age-related muscle strength decline was 3.73 (95%CI 2.66-5.23) in women relative to men (p < 0.001). Factors that appeared protective included higher physical activity scores in men (OR 0.97, 95%CI 0.96-0.99, p = 0.003) and in women (OR 0.97, 95%CI 0.96-0.98, p < 0.001) and a higher prudent diet score in women (OR: 0.74, 95%CI 0.60-0.90 p = 0.003). Muscle strength decline was strongly associated with quality of life in women (p ≤ 0.001) as assessed by SF36 and EuroQoL EQ-5D for all domains, although EuroQOL anxiety/depression and SF36 role emotional were less strongly associated (p-value=0.042, p-value=0.006, respectively). Table 1 shows self-reported impaired ability to move, self-care, perform usual activities and increased pain were associated with higher risk of age-related muscle strength decline in women.

Conclusion

Age related muscle strength decline was more common in community dwelling women than men, and diet and physical activity were predictors of such decline. Research into effective preventative interventions is now warranted.

Disclosures

J. Zhang None. F. Laskou None. K. Jameson None. C. Cooper None. E.M. Dennison None.
P69 Occupational and leisure activities as a risk factor for hip and knee revision surgery
Authors: Lasala Elena Zaballa , Harris Clare , Walker-Bone Karen
Published: April 2020

Background

Lower limb arthroplasty is a highly successful orthopaedic procedure, but the prosthesis may fail over time, necessitating revision surgery. Recognised risk factors for revision include obesity and metal on metal devices, but it is less clear whether heavy physical activity, at work or during leisure time, can impact the survival of the replaced joint. We undertook a systematic review to explore this question.

Methods

Original studies published 1985-2017 reporting risk factors for hip or knee revision arthroplasty (excluding revision for infection) in people aged over 18 years and with ≥1 year follow-up post-arthroplasty were identified from Medline, Embase, and Scopus. The search yielded 10,361 results, amongst which 12 addressed the research question.

Results

Out of the 12 studies, 9 were concerned with failure of primary hip arthroplasty and only 3 with failure of primary knee arthroplasty. We found extraordinary variation in the methods used to quantify exposure to both occupational and leisure-time physical activity. As a result, the data were poorly comparable, and some studies reported that post-operative physical exposures were beneficial for joint survival whilst others reported that they were deleterious. Many studies only assessed the relevant exposures before the operation, which may limit the relevance to post-arthroplasty physical activities. Overall, we found some (variable quality) evidence suggesting that agriculture/farming and industry/engineering/construction work and, in women, health services work may increase the risk of revision. Likewise, there was conflicting and moderate quality evidence that exposure to high-intensity leisure-time activities may increase the risk of failure.

Conclusion

As increasing numbers of arthroplasties are performed at younger ages, and people are encouraged to work to older ages, more evidence is urgently needed about returning to some types of work and any future risk of joint failure. This is particularly important for advising people doing manual and emergency services/military type work. Leisure-time physical activity is good for health and high-quality evidence is needed here to inform if specific types of sport should be avoided, particularly for knee patients.

Disclosures

E. Zaballa Lasala None. C. Harris None. K. Walker-Bone None.
P78 Introduction of video consultation into the general rheumatology clinic
Authors: Griffith Sian M , Brewer Eleanor
Published: April 2020

Background

An expansion in consultant work force and increasing demand for outpatient services has led to a shortage of clinic space to run clinics, overcrowding in waiting rooms, and lack of space in patient car parks. We therefore decided to trial a video consulting technology that is used in remote areas by NHS Scotland, in an urban rheumatology clinic.

Methods

All follow up patients due to attend a weekly rheumatology clinic were contacted by letter 2-4 weeks before their appointment, and invited to opt for video consultation. Patients were asked not to use the service if they were likely to need a physical examination or procedure such as joint injection. The participating consultant then provided her usual clinic at the usual time using a mixture of face to face and video consultations. The service was evaluated by looking at the number of patients opting for this service, age and diagnosis of participating patients, and feedback from patients and consultant.

Results

Between 1 September and I October 2019, 77 patients were invited to attend, of which 12 patients requested video consultation. 2 patients did not attend their video consultation meaning 10 patients (13%) participated in the initial pilot. The average age of participants was 53 (range 36 to 68): 6 female, 4 male. The patients had the following diagnoses: rheumatoid arthritis (5), psoriatic arthritis (3), ankylosing spondylitis (1), and fibromyalgia (1). 7 patients gave feedback (4 male: 3 female). 7/7 rated process of booking and joining video consultation good or very good, 7/7 satisfied with picture quality, 4/7 satisfied with sound quality, 7/7 able to communicate everything they wanted to the doctor during the consultation. 6/7 rated the experience as the same as a face to face consultation, 1/7 better. 7/7 happy to have further consultations using video technology. In terms of time saved travelling to outpatients less than one hour (2), 1-2 hours (4), 2-3 hours (1).The feedback from the consultant was that clinic time was saved by using video consultations, and that all patients who had selected the technology has done so appropriately.

Conclusion

Inviting all rheumatology follow-up patients to use video technology for consultation resulted in 13% fewer patients attending the outpatient clinic, reducing congestion in the patient car park and clinic waiting room. Patients opted appropriately for such consultations, as none needed to return on another occasion for further consultation. The video consultations took less time than face to face consultations, saving time in the clinic. The overall patient and doctor satisfaction with the technology was good, and patients saved significant time on travel to the clinic.

Disclosures

S.M. Griffith None. E. Brewer None.
P79 The changing face of rheumatology referrals 2011-2018
Authors: Ford Mark , Panchal Sonia , John Holly
Published: April 2020

Background

‘Getting it right first time' includes seeing the right patient, at the right time, in the right place, by the right person. This includes seeing suspected inflammatory arthritis patients within 3 weeks of referral. An understanding of the case mix of new referrals is therefore required. Such an audit would allow capacity planning for early arthritis, follow up, and therapy appointments. We have audited the case mix of our new patient referrals 3 times over 7 years.

Methods

All new patient referrals, to a single hospital trust, seen in a 3-6-month period in 2011, 2015 and 2018 were audited. Data was collected on primary rheumatological diagnosis (by rheumatologist), outcome (discharge/follow-up), if it was a re-referral for the same problem within 12 months, and onwards referrals (AHPs, injection clinic, ultrasound). In 2018, additional data captured included GP reason for referral. Data was entered onto an electronic proforma and analysed with descriptive statistics.

Results

Data was collected on 547 patients in 2011, 335 patients in 2015 and 305 patients in 2018. The primary diagnosis made by the rheumatologist in 2011, 2015 and 2018 respectively was: inflammatory arthritis (18%, 15%, 13%); gout (9%, 4%, 2%); osteoarthritis (19%, 19%, 17%); fibromyalgia (6%, 15%, 19%); spondyloarthropathy (4%, 4%, 3%); PMR (6%, 3%, 4%); soft tissue (9%, 6%, 3%). In 2018, comparison between GP reason for referral, and diagnosis by rheumatologist was, respectively, 33% and 13% for inflammatory arthritis; 2% and 17% for OA; 23% and 19% for fibromyalgia. Discharge at first appointment was 33% (2011), 38% (2015) and 39% (2018). Re-referral rates were 4.1% (2015) and 3% (2018). Onward referrals in 2011, 2015 and 2018 were, respectively 26.5%, 28.1% and 41% for physiotherapy; 23.4%, 20.9% and 10% for joint injection clinics; 10.1%, 17.3% and 21% for ultrasound.

Conclusion

Detailed case mix audit can help with service planning and delivery; suspected inflammatory arthritis (< 3 weeks) requires a third of the new patient capacity. Over the 7 years, the proportion of patients diagnosed with an inflammatory arthritis has remained stable, as has the two-thirds of new patients who are followed up; capacity in early arthritis and follow-up clinics is required to match this demand. Demand for ultrasound has significantly increased, and units may need to consider local ways to meet his demand. Local therapy teams will find this audit helpful to ensure capacity can match demand. Over the 7 years there has been a tripling of the proportion of patients diagnosed with fibromyalgia, such that it now represents a fifth of all new patient referrals. Seeing these patients 'in the right place, by the right person' could include developing community clinics and the role of a GP with a specialist interest.

Disclosures

M. Ford None. S. Panchal None. H. John None.