bluuebunny/crossref_metadata_2025 huggingface dataset:
P08 The impact of patient’s compliance and delivery delays: a cost-saving audit on biologics
Authors: Pookarnjanamorakot Patra , Suresh Resmy , Webb Paul
Published: April 2020

Background

Inflammatory arthritis or ankylosing spondylitis patients who are qualified for biologics treatment will have their medications delivered to their homes by Healthcare at Home (HaH). HaH sends rheumatology department the requests for repeat prescriptions in which the drug delivery due date should be within two weeks of the faxed date on the prescription. Anti-TNF is costly and if the patient already has excess stocks of medications at home then future delivery should be postponed in order to reduce the economic impact on the Trust. This audit aims to investigate the amount of money that could be saved by checking patient’s available medications at home and delay future deliveries.

Methods

168 patients were contacted at Croydon University Hospital between 1 - 19 November 2018 by telephone before signing the biologics repeat prescriptions. Patients were asked regarding the number of injections/tablets they have left and whether they had missed any and their reasons for non-adherence. Number of weeks the next prescriptions could be delayed due to the excess amount of injections/medications patients have was calculated and the amount of money saved by delaying the prescription was calculated.

Results

133 out of 168 patients answered the phone. Among patients who answered the phone, 59 of them were on etanercept, 6 were on secukinumab, 13 were on etanercept, 24 were on adalimumab, 9 were on methotrexate, 17 were on baricitinib and 5 were on golimumab. Their drug stock at home varied between 0 to 12 weeks. There are various reasons for their excess drug stock in the last 2 months including previous delivery delays or double-delivery (3 patients), infection (20 patients), simply forgotten (7 patients), high liver function tests (1 patient), holiday (6 patients), underwent surgery (1 patient), and underwent a dental procedure (1 patient). By analysing the number of injections/tablets patients have left, we were able to delay repeat prescriptions in 62 patients by 1 to 8 weeks. Theoretically, by delaying sending prescription out to Healthcare at Home for all 62 patients, we would be able to save £13,546.585 for the Trust during the month of November. This made up 6.5% of the monthly cost of anti-TNF inflicted on the Trust in November 2018 (£208,099.94).

Conclusion

This is a cost-saving audit concerning patient’s adherence to biologics. By verifying the number of excess biologics at patients’ home prior to requesting the repeat prescription, we would be able to reduce the cost inflicted on the Trust greatly. This calls for an improvement in patient education and compliance monitoring. We have launched a biologic patient education programme at Croydon University Hospital which enhances patient’s understanding of biologic treatment. Patients are also encouraged to contact our biologic coordinator if they are non-compliant for any reasons.

Disclosures

P. Pookarnjanamorakot None. R. Suresh None. P. Webb None.
P29 Use of novel biologic therapies for arthropathy affecting common variable immunodeficiency patients
Authors: Henneberry Robert , Burns Siobhan , Stratton Richard , Lowe David M
Published: April 2020

Background

CVID is the most common adult immunodeficiency with an incidence of 1:25000. It is characterised by hypogammaglobulinaemia and recurrent bacterial infections. Patients also develop granulomatous interstitial lung disease and are at increased risk of lymphoma. Autoimmune disease, most commonly AIHA, ITP and thyroiditis, occurs at a rate of 25%. Previous studies suggested that 3% of patients have inflammatory arthritis, but from our experience a higher proportion complain of chronic arthralgias. Treating arthropathy in CVID is challenging; examination and inflammatory markers may be normal and there is concern about the risk of infections if using methotrexate or biologics.

Methods

We present a series of 7 patients with arthropathy in CVID. We chose DMARDs based on the individual case, tailor-made to the patients clinical and immunologic status.

Results

Patients had longstanding symptoms, with a median duration of 11 years. All patients had disabling joint pain, in three it was the most prominent symptom of their illness. All patients had pain/swelling in a typical symmetrical small joint polyarthritis distribution. Fatigue was also prominent. On examination three patients had clear evidence of synovitis, one had tenderness but no swelling, and three had no evidence of synovitis; there was no deformity. No patient had positive autoantibodies. Three had chronically raised CRP/ESR, one had raised inflammatory markers during flares, but the other three had normal markers. Prednisolone (10-15 mg) controlled arthritic symptoms. There was little response to conventional DMARDS or rituximab. Two patients treated with abatacept showed improvement in symptoms, but one died from PJP pneumonia. Two patients treated with baricitinib showed improvement in symptoms but one relapsed after 5 months (Table 1).

Conclusion

Arthopathy is a common, and probably under-diagnosed, feature of CVID. It is difficult to treat, with a poor response seen to most DMARDs. We have seen promising results with Baricitinib and propose using it first line in patients with disabling rheumatic symptoms. There may be a role for abatacept in co-existent severe joint and lung disease. A striking proportion, 4/7 (versus 10% in general CVID population), of patients had a causal genetic mutation identified. Arthropathy may, therefore, push immunologists towards genetic testing.

Disclosures

R. Henneberry None. S. Burns None. R. Stratton None. D.M. Lowe None.
P38 A rare case of rheumatoid arthritis with perforating collagenosis
Authors: Deb Subhasish , Srirangan Srinivasan
Published: April 2020

Background

Rheumatoid arthritis has multiple cutaneous manifestations with rheumatoid nodule being the commonest one. A maculopapular rash in setting of rheumatoid arthritis has a varied list of differentials including rheumatoid vasculitis, pyoderma gangrenosum, rheumatoid neutrophilic dermatosis, interstitial granulomatous dermatitis and palisaded neutrophilic granulomatous dermatitis. We present a rare case of patient with rheumatoid arthritis with perforating collagenosis.

Methods

A case report is presented in the results section.

Results

A 64 year old lady known to have seropositive rheumatoid arthritis for the past 6 years with poor compliance to treatment presented with maculopapular lesions on both her legs and abdomen. The lesions were itchy in nature and later became ulcerative. The lesions spread to various parts of the body over the next 4 weeks and patient was seen by a dermatologist who initially prescribed topical therapy and the patient came off her disease modifying anti rheumatic agents. She underwent a skin biopsy as initial investigations were otherwise unremarkable. Skin biopsy revealed a diagnosis of perforating collagenosis. She was given topical steroids and counselled regarding the need to take her disease modifying anti rheumatic drugs regularly. There was 95% resolution of skin lesions within 6 months.

Conclusion

Perforating collagenosis is a skin disorder characterised by transepithelial expulsion of dermal tissue which presents as a papulonodular rash with central keratin plugs. It is usually associated with diabetes mellitus and chronic kidney disease but rarely been reported in association with rheumatoid arthritis. Literature review revealed that there have been only 2 cases reported previously. The first case has been described in 2010 in a man from Singapore on treatment for RA for 2 years. Second case has been described by Ikeda et al in 2019 in a case of rheumatoid vasculitis. Clinically it presents as umbilicated, hyperkeratotic papules with a central white keratotic crust. Koebnerization may be seen and itching of surrounding regions may lead to papules to coalesce and form plaques. A biopsy will reveal features similar to those seen in the primary disease where perforating collagenosis shows cup shaped invagination of the epidermis filled with a plug consisting of keratin and cellular debris. There have been no trials and treatment is based on case reports. We believe that better compliance to her disease modifying anti rheumatic agent therapy, leading to improved treatment of the systemic cause had a significant role in resolving her skin lesions.

Disclosures

S. Deb None. S. Srirangan None.
P40 Spontaneous pneumomediastinum in mixed connective tissue disease
Authors: Hasan Fuad , Kumar Vinod , Silburn Suzy , Thomson Rosanna
Published: April 2020

Background

Spontaneous pneumomediastinum refers to dissection of free air from the airways on lung parenchyma into the mediastinal structures without any antecedent thoracic trauma or surgical intervention. Pneumomediastinum has been described as a rare complication of connective tissue disease, most commonly in dermatomyositis and polymyositis. Here we report 2 cases of mixed connective tissue disease (MCTD) who developed pneumomediastinum.

Methods

The first case was a 76 year old male undergoing assessment for MCTD. During assessment, he was found to have bi-basal crepitations without any obvious respiratory symptom. He was on steroids for last 4 weeks for proteinuria. His High- resolution CT scan (HRCT) showed pneumomediastinum with evidence of Interstitial lung disease (ILD) without any complication. He was monitored closely and his pneumomediastinum resolved without any intervention. The second case was a 49 year old female with known MCTD & was on steroids for 5 months. She was admitted to the hospital with weight loss and dysphagia. This was a long hospital stay during which she developed pneumomediastinum with pneumothorax and surgical emphysema around the neck. She required ICU admission and was transferred to cardiothoracic centre where she underwent bronchoscopy, VATS inspection and required chest drains.

Results

In both cases there were similarities where both patients with MCTD were on variable duration of steroids & had ILD. They then developed pneumomediastinum with surgical emphysema, however their course was quite contrasting where the first case was relatively benign & resolved without any intervention while the second one required long ITU stay with multiple complications and interventions.

Conclusion

Spontaneous pneumomediastinum is an uncommon manifestation of CTD and only few cases have been reported with MCTD. Although spontaneous mediastinum seems to be associated with a relatively benign short-term course, one should be wary of complications and have low threshold for investigating for any new lung symptoms in context of CTD. It is uncertain whether severity of MCTD or duration of steroids use impacts the progress of spontaneous pneumomediastinum as there are very limited number of cases.

Disclosures

F. Hasan None. V. Kumar None. S. Silburn None. R. Thomson None.
P51 Serious pathology mimicking GCA: two cases of carcinoma tongue
Authors: kayani Abdul , Sebastian Alwin , Borukhson Liubov , Whitlock Madeline , Dasgupta Bhaskar
Published: April 2020

Background

Jaw and tongue pain with constitutional symptoms and raised inflammatory markers are considered pathognomonic ischemic features of giant cell arteritis (GCA). Temporal artery ultrasound (US) (or biopsy) available in GCA fast-track clinics (FTC) for a rapid assessment of patients with suspected GCA. Atypical presentation and negative US or biopsy require further workup to look for an alternative diagnosis. ENT pathology can occur as a mimic of GCA. Herein we discuss two clinical cases of squamous cell cancer tongue presenting with signs and symptoms that resemble GCA.

Methods

We have put together a case report.

Results

Case-1: A 58-year-old male with a recent presumed diagnosis of relapsing GCA was referred with worsening visual symptoms and right eye pain despite ongoing steroid treatment (60mg), for consideration of Tocilizumab (TCZ). His initial presentation was 5 months ago with a right parietal and retro-orbital headache and blurred vision. He had a normal eye examination. His C-reactive protein (CRP) was raised (24). He was started on prednisolone 40 mg for GCA with complete resolution of symptoms with normalised CRP within weeks. Several weeks later, symptoms reoccurred. CT brain, abdomen and pelvis was normal and temporal artery biopsy negative. His prednisolone was increased to 60 mg. 6 months later, his jaw and tongue pain worsened, and he was treated with pulsed methylprednisolone. Due to partial response to steroids, he was referred to consider TCZ. He had tender left TMJ with normal temporal artery US. Urgent MRI head and neck revealed a left posterior tongue mass with the histology confirmed poorly differentiated squamous cell carcinoma. He was managed with chemo and radiotherapy.

Case-2: A 75 years old female, presented with right scalp pain, tongue pain, painful swallowing and chewing. Her blood investigations were normal except a raised ESR (48) and presumed GCA she was started on steroids (60 mg). she had initially good response but, within a few weeks, her symptoms returned. She was then referred to our FTC. Temporal artery US and biopsy were normal. MRI of the head and neck showed a large mass seen in the right half of the posterior tongue extending into the deep aspect of the anterior tongue. Histology confirmed poorly differentiated Squamous cell carcinoma. She was treated with a combination of chemotherapy and radiotherapy.

Conclusion

GCA mimics represent a major diagnostic dilemma. FTC helps to stratify the GCA from mimics. Careful evaluation of the history, examination as well as a temporal artery US helps to exclude GCA and aids prompt requesting of appropriate tests to find an alternative diagnosis such as tongue cancers as in our cases. We have now introduced negative weightage for consideration of alternative diagnoses in our GCA probability score.

Disclosures

A. Kayani None. A. Sebastian None. L. Borukhson None. M. Whitlock None. B. Dasgupta Consultancies; Roche, Sanofi. Grants/research support; Roche.
P64 Does pain peak at night? The daily rhythm of musculoskeletal searches on the NHS website
Authors: Fuggle Nicholas R , Masefield Nicola , Dennison Elaine M , Cooper Cyrus
Published: April 2020

Background

With the advent of smartphone technology and the constant availability of information on the internet, it is suspected that searches for clinical symptoms or medical conditions could be a real time indication of the timing of these symptoms. Therefore, we aimed to investigate the daily timing of visits to musculoskeletal pages compared to mental health pages on the NHS website (a major source of online health information in the UK).

Methods

In collaboration with NHS Digital we acquired 6 months of data on visits to the NHS website and visits to individual webpages relevant to pain management (“Managing chronic pain”, “10 ways to ease pain”) musculoskeletal conditions (Rheumatoid arthritis, Osteoarthritis, Arthritis”), anatomical pain (Neck, Back, Shoulder, Elbow or Arm, Foot, Hip, Knee, and Hand pain) and an assortment of mental health pages, (Clinical depression, Generalised Anxiety Disorder). In order to adjust for the overall traffic to the NHS website (which peaks strongly at 9-10pm) the mean numbers of webpage visits per hour of the day over the 6 month period were calculated and divided by the mean number of NHS website visits per hour of the day over the 6 month period. Fourier analysis was used to shape appropriate models and assess daily rhythm. Analysis were performed using STATA version 15.

Results

There were a total of 400 million visits to the NHS website over the 6-month period of data collection. The overall trends for traffic to the website included a marked peak in visits in the evening at 9-10pm and a distinct trough overnight. Visits to ‘pain management’ pages peaked at 11-4am, whereas visits to ‘musculoskeletal conditions’ pages had a bimodal distribution with the largest peak at 6-7am (and a lesser peak at 9-10pm). This bimodal distribution was echoed on the ‘anatomical pain’ pages with a greater peak at 6-7am and lesser peak at 9-10pm, except for ‘neck pain’ and ‘back pain’ which had higher peaks at 9-10pm and lesser peak at 6-7am. In comparison, visits to ‘mental health’ pages peaked clearly at 12-1am.

Conclusion

Through this investigation of visits to the NHS website we saw clear differences in the distribution of visits relating to ‘musculoskeletal conditions’, ‘anatomical pain’ and ‘pain management’. These profiles differed substantially to the distribution of ‘mental health’ page visits. It is interesting that searches for pain management (including the page “10 ways to ease pain” which is the top NHS webpage listed on Google when searching the word “pain”) peaked overnight between 11-4am, as this replicates our previous finding from Google search data. These findings provide an insight into the circadian rhythm of interactions with online health data and may even hint at patterns of symptom experience over a 24-hour period.

Disclosures

N.R. Fuggle None. N. Masefield None. E.M. Dennison None. C. Cooper None.
P72 Muscle weakness affects function differently in males and females in inclusion body myositis: providing results for focused clinical care and clinical trial design
Authors: Williams Jacob , Oldroyd Alexander , Lilleker James , Chinoy Hector , Miller James
Published: April 2020

Background

Sporadic inclusion body myositis (IBM) is a muscle wasting disorder usually affecting those aged over 50 years, characterised by slowly progressive weakness of the distal upper limbs and proximal lower limbs. Particular weakness of pinch, knee extension and ankle dorsiflexion result in functional decline and disability. Weakness-associated functional decline differences between genders has not previously been investigated. This study aimed to investigate for differences of functional decline in men and women with IBM.

Methods

A cohort of verified adult IBM patients were followed at a single specialist neuromuscular clinic (Royal Victoria Infirmary, Newcastle-upon-Tyne, UK) between 2004-15, with data collected at each clinic visit. Strength of 11 movements was measured via dynamometry at each clinic visit. Patient-reported function was measured via the Neuromuscular Symptom Score (NSS). Generalised linear modelling, adjusted for disease duration, was carried out to identify associations between strength and function (NSS). Pinch, knee extension and ankle dorsiflexion strength measurements were analysed. Modelling was carried out separately for male and female cohorts.

Results

Data of 75 participants (47% female) was analysed. A total of 591 measurements were taken. Median age at time of IBM diagnosis was 68.8 years. Median baseline NSS score was 45 (IQR 37, 54) for the male cohort and 40 (IQR 29, 45) for the female cohort. The median disease duration of the study cohort was 2.6 years. Reduced function (NSS) was significantly associated with reduced pinch, knee extension and ankle dorsiflexion strength in the male cohort only (Table 1). No significant associations were observed in the female cohort.

Conclusion

This is the first study to demonstrate that the progression of weakness, in the characteristic muscle groups affected in IBM, impacts on function differently in men and women. These results illustrate the importance of functional assessment in patients with IBM and the importance of focused physiotherapy upon function-dependent muscle groups. Further, potential gender-based differences of weakness-related function in IBM should be considered when designing clinical trials.

Disclosures

J. Williams None. A. Oldroyd None. J. Lilleker None. H. Chinoy None. J. Miller None.
P95 “Why do we have to lose this too?”: an exploration into the conversations around intimacy that individuals with Sjögren's syndrome have on an online forum
Authors: McCready Jemma L , McCarty Kristofor , Deary Vincent , Collins Tracy L , Hackett Katie L
Published: April 2020

Background

Sjögren’s syndrome (SS) is an autoimmune disease that predominantly affects women (by a ratio of 9:1), and age at onset is typically between 40-60 years. Symptoms of dryness of the vagina and vulva can cause painful sexual intercourse and can result in diminished levels of sexual arousal and desire. This can lead to a lack of understanding by their partner, which can place an immense strain on their relationship. Furthermore, intimacy issues can be a particularly sensitive subject and often go undiscussed, even between partners, which can leave them feeling isolated and without an adequate support network. Many patient groups turn to online support forums and use these sites to discuss sensitive issues under the cloak of anonymity. Analysing this source of data allows us to explore the conversations pertaining to intimacy issues that individuals with SS may not feel comfortable discussing in person.

Methods

The forum data was scraped using the automated Web Scraper tool, accessed from the developer tools within Google Chrome. The Computer-Assisted Qualitative Data Analysis (CAQDAS) software tool ATLAS.ti was used to facilitate the data analysis process. The process of analysis was conducted in accordance with both Braun and Clarke’s Thematic Analysis (TA) framework and Freise, Sorrato and Pires guidelines for applying the phases of TA within the ATLAS.ti software.

Results

A total of 3,557 posts were identified as being pertinent to the topic of intimacy. Conversations were centred around the lack of sexual activity with their partners, with users revealing they had been abstaining for years as a result of vaginal dryness, dyspareunia, fatigue and widespread pain. Numerous users discussed being unable to engage in intimate activities like handholding and hugging due to allodynia and issues with temperature regulation, as well as refraining from kissing as they perceived others kisses to be too wet and sloppy. One conversation theme was centred around increased cognitive effort and behaviour changes, with many users revealing that they plan sexual activity around symptoms, regularly implement self-management strategies before, during, and after sexual activity, and use smaller gestures to show emotion. There was also a body of conversation focused around the emotional impacts of sexual dysfunction with users unanimously discussing their experience with feelings of guilt, burden, fear of intimacy and pain, and saudade - a deep emotional state of longing for the past and their previous selves.

Conclusion

Individuals with SS experience alterations in their sexual activity and relationship dynamics, with symptoms of vaginal dryness, fatigue and pain being discussed as the most debilitating of symptoms.

Disclosures

J.L. McCready None. K. McCarty None. V. Deary None. T.L. Collins None. K.L. Hackett None.
P96 Evaluation of the 1st AStretch Digital Conference
Authors: Gregory William J , Martindale Jane , Martin Melanie , McDonald MT
Published: April 2020

Background

The physiotherapy AStretch committee promote excellence and education in axial spondyloarthritis. One channel for providing this is though the bi-annual conference. An average of 50 delegates attend these conferences. The planned 2018 conference was deferred and we took the opportunity to replace this with a digital version. A mid-November date was agreed for 'go live' of the digital conference; this was advertised on the AStretch website and on our social media channels in advance. Digital resources in the form of presentations and interviews were accessed via our website with some resources additionally held on our YouTube page. Conference access was open for a month from the 'go live' date. This papers aim is to evaluate engagement with our first digital AStretch Conference.

Methods

Qualitative and quantitative data was captured from YouTube, Twitter, Facebook and our AStretch emails from the 'go live' date until 1 month after. The quantitative data captured were the numbers of YouTube watches, twitter impressions, twitter engagements and the numbers of Facebook likes, comments and shares. In addition, qualitative data by means of free-text comments were recorded.

Results

We had several live questions on the night; answered across the team. There were 7,600 impressions on twitter with a 4.7% engagement rate, 137 link clicks, 41 retweets and 105 likes. The YouTube channel averaged 80 watches per video. Facebook had 54 likes, 6 comments and 18 shares. Examples of comments: “this has been excellent, well done to all involved”, “absolutely brilliant...a great CPD event”, “EULAR talk was great...interviews were good too”, “my NASS physios loved it”, and “what a great evening”.

Conclusion

We have shown that there is a high level of interest in a digital version of our AStretch conference. We have reached more people via this digital version of the conference than our average attendance at the in-person conference. We have observed far reaching engagement and sharing of knowledge in a cost-neutral and user-convenient method, which has the potential to ultimately improve patient care nationally and internationally.

Disclosures

W.J. Gregory: Honoraria; W.G. has received speaker fees from Novartis and received Conference attendance fees from Pfizer. J. Martindale: Honoraria; JM has received honoraria from Abbvie Ltd, Novartis, Pfizer and UCB. Grants/research support; JM has received a research grant from Pfizer. M. Martin: Honoraria; MM has received honoraria from Novartis and Abbvie. Grants/research support; MM has received a research grant from NASS. M. McDonald: None.
P114 Which antibody is more important for radiographic erosions in RA?
Authors: Minocha Amal , Kukran Sebi , Yee Philip , Nisar Muhammad K
Published: April 2020

Background

The presence of bony erosions in patients with RA is a marker of disease severity and once present they are largely irreversible. Previous studies have shown that those who are RF positive have more erosions than RF negative group. Likewise, ACPA is associated with increased bone loss and rapid erosive changes. The aim of our study was to determine which of these two antibodies is more strongly associated with erosive disease and whether being double +ve confers higher risk than single positive antibody status.

Methods

A retrospective study of 774 patients diagnosed with RA at large university teaching hospital during the period of January 1981 and December 2018. Clinical records were reviewed to determine antibody status, date of diagnosis, duration of symptoms, DAS-28, age, ethnicity and whether the 1987 Rheumatoid Arthritis criteria was met. The presence of radiographic erosions at diagnosis were determined from reports of plain film radiographs of hands and feet of all patients. Chi square model was utilised to ascertain if there was a significant relationship among the four groups. Mann Whitney two-tailed U test was employed to determine the significance of relationship between the double negative group and other arms for all variables including disease duration and delta change in DAS28. Significance level was predefined at 0.05.

Results

All patients fulfilled the 2010 ACR/EULAR criteria. 240 (31%) patients were male and 534 (69%) were female with an age range of 17 to 90 years for the cohort. The duration of symptoms ranged for the patient cohort from 0.5 to 250 months with a median of 6 months while the duration of disease ranged from 4 to 455 months with a median of 49 months. DAS 28 ranged from 1.19 to 8.4 with a median of 4.4. 367 (47%) were positive for both RF and ACPAs, 87 (11%) were positive for RF alone, 66 (9%) were positive for ACPA alone and 254 (33%) were antibody negative. There were a total of 127 patients with erosions at the time of diagnosis. Patients in the double positive group had a significantly higher (p = 0.003) erosion burden compared to the double negative group i.e. 21.5% in RF+/ACPA+ versus 11.0% in RF-/ACPA- group. The erosion burdens in RF+/ACPA- and RF-/ACPA+ groups were 13.7% and 12.1% respectively.

Conclusion

This is the first real world study to demonstrate the radiographic erosive burden in the RA cohort with respect to RF/ACPA status. Our results show that patients RF+/ACPA+ have nearly two-fold higher incidence of radiographic erosions than patients who are RF-/ACPA-. Patients with single antibody positivity have a trend towards higher erosive burden compared to the double antibody negative group however it’s the combination of two antibodies which is strongly associated with erosive disease.

Disclosures

A. Minocha None. S. Kukran None. P. Yee None. M.K. Nisar None.
P116 A systematic review of the safety of non-tumour necrosis factor inhibitor and targeted synthetic drugs in rheumatic disease in pregnancy
Authors: Nguyen Hanh , Ahmed Kawser , Flint Julia , Giles Ian
Published: April 2020

Background

Despite increasing evidence to support safe use of tumour necrosis factor inhibitor (TNFi) drugs in pregnancy, there remains a paucity of evidence regarding non-TNFi and targeted synthetic disease modifying anti-rheumatic drugs (tsDMARDs) in pregnancy. Therefore, we conducted a systematic review to summarise use of these drugs in pregnancy and breastfeeding.

Methods

Systematic search of databases including; EMBASE, Pubmed (MEDLINE), and Cochrane up to December 2018 using keywords including; commonly prescribed non-TNFi and tsDMARDs, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection.

Results

From an initial screen of 700 papers, n = 92 full text papers were included in the final analysis. A summary of findings from known outcomes of pregnancy and breastfeeding exposures as well as long-term follow-up of infants where available are shown in Table 1. Overall, this data does not identify an increased risk of adverse pregnancy outcomes with these drugs in this population of patients.

Conclusion

These findings do not suggest an increased risk of non-TNFi and tsDMARDs in pregnancy. Given that the total number of exposures, however, remain limited these drugs should only be considered in pregnancy if the benefit of maintaining disease control in the mother justifies any potential risk to the fetus. This body of evidence will be useful when counselling women about the potential risks of using these types of drugs during pregnancy and breastfeeding period as well as following accidental exposure to drugs at conception.

Disclosures

H. Nguyen None. K. Ahmed None. J. Flint None. I. Giles None.
P145 A review of vitamin D testing in primary care: significant savings to be made
Authors: Riding Emily , MacPhie Elizabeth
Published: April 2020

Background

Vitamin D deficiency is common in the UK due to a lack of sunlight over the winter months. Risk factors include darker skin and reduced exposure to sunlight (e.g. housebound/institutionalised patients or those who cover skin for religious reasons). As part of the Choosing Wisely campaign, the British Society for Rheumatology recommend that vitamin D testing should be reserved for people at high risk of deficiency and avoided as part of routine investigation of widespread pain alone. They also recommend that repeat testing isn’t usually necessary in patients who are taking vitamin D supplements. The aim of this project was to review the testing of Vitamin D in a Primary Care setting.

Methods

An EMIS search was conducted for patients who had their vitamin D levels tested in September and October 2017. The following information was collected for each patient: indication for testing, vitamin D level, whether vitamin D had been tested previously or subsequently, treatment offered and the patient’s residence.

Results

96 patients had their vitamin D levels checked. Of these, 8 were excluded as they had been tested on the advice of secondary care. Of the remaining 88 patients, 6 (6%) were vitamin D deficient and 34 (38%) had insufficient vitamin D levels. The most common indication for testing was tiredness in 26 patients (30%) followed by generalised aching/lower limb pain 19 (22%). 8 (9%) patients were tested due to pain at specific sites including a single joint or abdominal pain, 5 (6%) due to neurological symptoms, 4 (5%) due to a diagnosis of CKD and 3 (3%) due to skin and hair problems. There was no clearly documented indication for testing levels in the remaining 3 (3%) patients. 35 (40%) patients had previously had their vitamin D levels tested and 19 (22%) patients had subsequent testing. Of the patients with abnormal vitamin D levels, 22 (25%) were prescribed treatment, 16 (18%) advised to buy over the counter and no advice was documented in 16 (18%) patients. None of the patients lived in residential or nursing homes.

Conclusion

This project identified a range of indications for vitamin D testing and a large number of patients who had repeated testing. This highlights a potential area for education in primary care surrounding the value in both initial and repeated testing of vitamin D levels. The findings show a need for an improvement in documentation as some patients had no clear linked reason for testing and no evidence that abnormal levels were actioned. However, there were limitations to determining whether BSR guidelines were followed as some factors that would lead to patients being at high risk of deficiency (such as skin colour) could not be collected from EMIS.

Disclosures

E. Riding None. E. MacPhie Other; EM is the secretary of the North West Rheumatology Club; meetings are supported by an unrestricted educational grant from UCB.
P148 Gastrointestinal symptoms and proton pump inhibitor use in patients with polymyalgia rheumatica: results from the PMR Cohort study
Authors: Feddah Hamzeh , Muller Sara , Hider Samantha , Hay Charles , Mallen Christian
Published: April 2020

Background

Polymyalgia Rheumatica (PMR) is a common disorder of older adults, characterised by pain and stiffness in the shoulders and hips. PMR is one of the commonest indications for long-term glucocorticoid use. Because of the well-recognised side effects of glucocorticoids including gastrointestinal disturbances and bleeding, guidelines recommend consideration of gastrointestinal prophylaxis. The aim of this study was to assess the proportion of PMR patients who report 1) gastrointestinal disturbances; and 2) appropriate prophylactic treatment, and to investigate other factors that may be associated with the development of gastrointestinal disturbances.

Methods

652 people diagnosed in primary care with incident PMR were recruited. Participants all responded to a baseline postal survey and were followed up postally at 1, 4, 8, 12, 18 and 24 months. At each time point, participants answered a range of questions relating sociodemographic, general health and their PMR. At baseline, respondents reported proton pump inhibitors (PPI) use and at 4, 12 and 24 months the presence and extent of any gastrointestinal symptoms (ulcer, wind, indigestion, heartburn; not bothered, bothered a little, bothered a lot). The association of gastrointestinal symptoms with age, gender and PPI use was quantified using proportional odds regression.

Results

Overall, 51% of people reported PPI use at baseline. Reporting of gastrointestinal symptoms was commoner at all time points in people prescribed a PPI at baseline (Table 1). There was no association between age and bothersomeness of gastrointestinal symptoms (odds ratio 0.98 (0.96, 1.00)), but more bothersome symptoms were more likely in females (2.44 (1.72, 3.45)). PPI use at baseline was significantly associated with a high level of bothersomeness compared to no/little bother (2.45 (13.39, 4.36)), but not with being bothered compared to not being bothered (1.23 (0.87, 1.74)).

Conclusion

Around half of patients with PMR report gastrointestinal symptoms. Symptoms are more prevalent in females and those prescribed a PPI. This suggests that GPs are prescribing PPIs in those they consider at higher risk of experiencing gastrointestinal symptoms. However, almost half of those without a PPI reported such symptoms within 4 months. Clinicians should be more aware of the potential for gastrointestinal symptoms in PMR.

Disclosures

H. Feddah None. S. Muller None. S. Hider None. C. Hay None. C. Mallen None.
P152 Skin score trajectory associates with survival and pulmonary outcome in diffuse cutaneous systemic sclerosis
Authors: Nihtyanova Svetlana I , Derrett-Smith Emma C , Fonseca Carmen , Ong Voon H , Denton Christopher P
Published: April 2020

Background

Skin thickness improves over time in most diffuse cutaneous systemic sclerosis (dcSSc) patients and the use of group level skin score (mRss) as an endpoint is clinical trials can be challenging. We explore the association between individual mRss trajectories and outcome in early dcSSc patients.

Methods

Subjects with at least one mRss assessment within the first 5 years from onset were included. Random effects models were fitted to evaluate changes in mRss over time and model-predicted individual patient intercepts and slopes were included in Cox regression to assess associations with outcome.

Results

Of the 467 patients, 22.7% were male and mean age of disease onset was 45.5 years. Most frequent autoantibodies were anti-Scl70 in 30.2% and anti-RNA polymerase (ARA) in 30.0% of subjects. Average mRss at 12 months from onset was 25 and this declined over time, slowing down with longer disease duration (3.4, 2.7, 1.9 and 1.2 units at years 2, 3, 4 and 5). Higher initial mRss associated with greater subsequent decline (correlation coefficient -0.3). Both higher baseline mRSS (intercept) and slower decline (higher slope) predicted increased risk of death with 8% increase in hazard for every unit higher baseline mRss and 4% increase for every unit higher slope (Table 1). Adjusting for autoantibodies did not change the estimates. ANA+ENA- subjects had the highest risk of death, followed by ATA + (HR 0.91, p = 0.677 v ANA+ENA-), while risk was lowest among ARA+ subjects (HR 0.47, p = 0.002 v ANA+ENA-). Risk of pulmonary complications was associated with rate of change in mRss but not with baseline absolute value. A unit slower yearly decline in mRss increased the hazard of pulmonary fibrosis (PF) by 3.5% and pulmonary hypertension (PH) by 7% (Table 1). The association between mRss and PF disappeared after adjusting for antibody specificities, while the association between skin and PH did not change. Autoantibodies did not show significant association with PH development within this dcSSc cohort.

Conclusion

Although at a group level there is an improvement in skin over the initial 5 years, for individual patients, poor outcome for skin predicts increased risk of pulmonary complications and higher mortality.

Disclosures

S.I. Nihtyanova None. E.C. Derrett-Smith None. C. Fonseca None. V.H. Ong None. C.P. Denton None.
P155 Co-existence of scleroderma hallmark autoantibodies associates with distinct clinical phenotype
Authors: Campochiaro Corrado , Clark Kristina E. N , Host Lauren , Sari Alper , Denton Christopher P , Ong Voon H
Published: April 2020

Background

Systemic sclerosis (SSc) is typically manifests with SSc-specific antibodies (SSc-Abs): anti-topoisomerase I (ATA), anti-centromere (ACA), anti-RNA polymerase III (ARA), anti-U3RNP (u3RNP), anti-U1RNP (U1RNP), anti-PmScl (PmScl), anti-Ku (Ku) and anti-Th/T0 (Th/T0), each being characterised by distinct clinical features and prognosis. The presence of > 1 SSc-Abs is rare with minimum data about these patients’ clinical phenotype in SSc

Methods

The autoantibody profiles of 2,799 SSc patients from February 2001 to June 2017 were retrospectively reviewed. Patients with >1 SSc-Abs were identified. Clinical features were collected and compared to historical cohorts of SSc patients with single SSc-Ab positivity. Patients were excluded if treated prior to their immunology test with rituximab, iv immunoglobulins or stem cell transplantation. Statistical analysis was performed using Fisher exact test.

Results

72 patients (2.6%) with >1 SSc-Ab were identified. Full clinical data were available for 63 patients. 60 patients (2.1%) had double Ab positivity and 3 patients had triple Ab positivity (0.1%). 13 Ab combinations were present. U1RNP and ATA was the most frequent combination (35%), these patients were significantly younger(51.38 years) than both U1RNP (58.64 years,p=0.050) and ATA (62.03 years,p=0.002) patients and more commonly of diffuse subset (dcSSc)(p = 0.001 and p = 0.041 respectively). Compared to ATA patients overlap features were more frequent (43% vs 15%, p = 0.004) including inflammatory arthritis (p = 0.025) and myositis (p = 0.013) (Table 1). U1RNP and ACA had a significantly higher prevalence of pulmonary arterial hypertension compared to U1RNP (p = 0.039) and ACA (p = 0.022) patients, and compared to ACA patients they were younger (57.88 vs 68.75,p=0.015) with a higher frequency of myositis (p = 0.001). U1RNP and ARA patients were more frequently dcSSc subtype compared to U1RNP patients (75% vs 21%, p = 0.040). U1RNP and PmScl patients had a higher prevalence of myositis compared to U1RNP patients (p = 0.006). ATA and ACA patients behaved similarly to ATA patients with a significantly higher prevalence of lung fibrosis (p = 0.006) and myositis (p = 0.041) compared to ACA. ACA and PmScl (7%) had higher prevalence of myositis compared to ACA patients (p = 0.04).

Conclusion

Coexistence of hallmark autoantibodies is exceedingly rare in SSc patients. When combined, both SSc-Abs have the potential to synergistically interact and modify the clinical phenotype.

Disclosures

C. Campochiaro None. K.E.N. Clark None. L. Host None. A. Sari None. C.P. Denton None. V.H. Ong None.
P158 Severity of hand vascular involvement as assessed by MRI Digital Artery Volume Index (DAVIX©) predicts worsening of clinical parameters and patient reported outcomes in scleroderma
Authors: Danzo Fiammetta , Gjeloshi Klodian , Lettieri Giovanni , Abignano Giuseppina , Hinton Mark , Dean Anne-Maree , Cuomo Giovanna , Kubassova Olga , del Galdo Francesco
Published: April 2020

Background

Neointima proliferation is a key pathologic feature of systemic sclerosis (SSc), causing arterial vessel narrowing and being the recognised culprit pathological lesion in digital ulcers (DUs), pulmonary artery hypertension and renal crisis. Nevertheless, there are no validated imaging techniques to assess the severity of vascular involvement in SSc. We have previously shown digital artery volume index (DAVIX©) assessed with time of right MRI angiography, is a reliable measure of neointima proliferation in the hands. The purpose of our study was to identify the value of DAVIX© in predicting worsening of patient reported outcomes (PROs) and clinical parameters in SSc.

Methods

Cross-sectional data were available for 91 patients and complete 12 months follow-up data for 68 patients. Data collected included: modfied Rodnan skin score (mRSS), pulmonary function tests (PFTs), echocardiography, nailfold capillaroscopy, Health Assessment Questionnaire Disability Index (HAQ-DI), and Scleroderma Health Assessment Questionnaire (sHAQ). DAVIX© of the dominant hand was calculated as the % mean of the 4 fingers, employing MeVisLab software. Following analysis of distribution, Spearman or Pearson test were used to determine correlation coefficients, as appropriate (Prism 7).

Results

56/68 were female and median of disease duration was 4 years (IQR 1.91-9). As previously reported DAVIX© correlated with the presence of DUs (p = 0.0093). Considering all patients, DAVIX© correlated with mRSS (r=-0.258, p = 0.017), DLCO% (r = 0.338, p = 0.008) and the pattern of capillaroscopy (r=-0.388, p = 0.001). In patients with DUs, DAVIX© showed a stronger correlation with DLCO% (r = 0.786, p = 0.048). Most importantly, DAVIX© predicted the worsening of HAQ-DI (r=-0.295, p = 0.029), sHAQ (r =-0.333, p = 0.029) and VAS pain (r=-0.269, p = 0.038) independently of the presence of DUs.

Conclusion

The quantitative assessment of neointima proliferation in the hand by DAVIX© is a useful imaging biomarker of vascular disease activity. The value of DAVIX© in predicting the worsening of PROs and clinical parameters in overall patients, may offer insights on the role of vascular disease activity in the global progression of SSc. The validation of our data in an independent cohort and the sensitivity to change over time of DAVIX© may aid to the implementation of hand MRI as imaging outcome measure of vascular severity in SSc.

Disclosures

F. Danzo None. K. Gjeloshi None. G. Lettieri None. G. Abignano None. M. Hinton None. A. Dean None. G. Cuomo None. O. Kubassova None. F. del Galdo None.
P172 Anti-domain I positivity in SLE at diagnosis is predictive of atherosclerotic plaque development
Authors: McDonnell Thomas C. R , Farinha Filipa , Pericleous Charis , Griffin Maura , Nicolaides Andrew , Croca Sara , Giles Ian , Rahman Anisur
Published: April 2020

Background

Cardiovascular disease is a significant burden on SLE patients, and no satisfactory markers exist to predict atherosclerotic development in patients. This study utilised an orthogonal approach to develop a marker of cardiovascular progression with predictive value in SLE patients.

Methods

The earliest available sample from a cohort of 92 SLE patients was tested for anti-Domain I (aDI), anti Beta-2-Glycoprotein-I, and anti-Cardiolipin antibodies. Persistent positivity was not assessed. These patients then had vascular ultrasound scans (carotid and femoral arteries) (mean 10 years later) to assess subclinical atherosclerotic plaque. A range of demographic, clinical and serological markers were recorded at the time of the scan. Predictors of plaque presence were investigated using binary logistic regression.

Results

A total of 34 patients from the cohort of 92 had atherosclerotic plaque (37%). A total of 32 patients had aDI positivity, of which 20 (62.5%) also had Plaque, this is reflected by the significantly higher levels of aDI antibodies seen in Plaque patients (p < 0.01). Anti-DI positivity was predictive of the development of plaque in the future (Odds Ratio (OR) 5.476, p < 0.001). No association was seen for any other antibody tested. Multiple binary logistic regression showed aDI positivity had as much predictive value as triglyceride levels on the day of the scan (OR 3.5 vs 3.9, Table 1) for predicting plaque in patients. Age at scan was a third independent variable associated with atherogenic plaque.

Conclusion

Early aDI positivity may be a good marker of atherogenesis in SLE patients in the long term.

Disclosures

T.C.R. McDonnell: Other; I am an inventor on the patent for Domain I. F. Farinha: None. C. Pericleous: Other; This Author is an Inventor on the Patent for Domain I. M. Griffin: None. A. Nicolaides: None. S. Croca: None. I. Giles: Other; This Author is an Inventor on the Domain I Patent. A. Rahman: Other; This Author is an Inventor on the Domain I Patent..