bluuebunny/crossref_metadata_2025_split huggingface dataset:
EP34 Assessing the ability of anti-C1q antibody measurement to predict a flare of lupus nephritis
Authors: Bahal Sameer , Pyne Dev , Rajakariar Ravindra , Lewis Myles , Pakozdi Angela , Cove-Smith Andrea 
Published: April 2020

Abstract

Background
Systemic lupus erythematous (SLE) is a multi-system autoimmune disease which has a relapsing and remitting course. Patients with lupus nephritis (LN) are at risk of relapse and hence long term follow up and disease monitoring are of particular importance. Anti-C1q antibodies (C1Q Ab) are observed in 30-60% of patients with SLE. It has been postulated that the presence of C1Q Ab can predict a flare of LN. Here we undertook a prospective follow up of patients after having a C1Q Ab measurement to determine whether the result predicted a flare of LN.

Methods
SLE patients attending an Inner-City Lupus Center, were involved in the study. All fulfilled the 2012 SLICC criteria for SLE. A point-in-time measurement of C1Q Ab was made using an ELISA kit (Orgentec Diagnostika GmbH). A positive test defined by the manufacturer is a level above 10 U/ml. Medical records of patients were reviewed over the following 1 year to identify LN flares. A renal flare was defined as a doubling of the protein creatinine ratio with a subsequent decision to escalate immunosuppressive therapy. Chi Squared tests were used to assess statistical significance. 9 patients who were being treated for a flare of LN at the time of C1Q Ab were excluded from the analysis.

Results
116 lupus patients were included in the study. Of those, 52 had biopsy proven LN (45%). Positive C1Q ab was more common in patients with a history of biopsy proven LN (n = 17, 32.7%) compared to those with non-renal SLE (n = 10, 15.6%),(p = 0.03). Renal flares tended to be more common in C1q ab positive LN patients (n = 4, 26.7%) compared to those without C1q ab (n = 2, 7.14%). (p = 0.782). Of the 64 patients with non-renal SLE, 1 (10%) C1Q Ab positive patient subsequently developed LN compared with 1 (1.85%) C1Q Ab negative patient (p = 0.173).There was no correlation between the level of C1Q Ab and the rate of LN flares. Having a positive dsDNA antibody level at the time of sampling also did not appear to predict a flare.

Conclusion
C1Q Ab has a known correlation with LN, however its ability to predict flares has been less well characterised. Our prospective analysis shows that although the C1Q Ab positive patients were more likely to have a flare of LN in the following year, there was not a statistically significant difference between the C1Q Ab positive and negative groups. In addition, only a relatively small proportion of C1Q Ab positive patients went on to have a flare (20%). Our data therefore does not support the use of C1Q Ab as a predicting factor for a subsequent flare of LN.

Disclosures
S. Bahal None. D. Pyne None. R. Rajakariar None. M. Lewis None. A. Pakozdi None. A. Cove-Smith None.
O10 Combining clinical and ultrasound assessment to taper biologic therapies in patients with RA in routine clinical practice
Authors: Pillai Harikrishnan , Nolkha Nilesh , Yau Augustus , Matthews Susan , Hall Alison , Hirsch George , Venkatachalam S 
Published: April 2020

Abstract

Background
There is growing evidence for tapering biologic therapies in patients with rheumatoid arthritis in sustained clinical remission to avoid overtreatment and minimise side-effects. Ultrasound assessment for subclinical synovitis adds to clinical assessment of patients with rheumatoid arthritis suitable for tapering biologic therapies. Our primary objective was to combine clinical and ultrasound assessment to select patients with rheumatoid arthritis for tapering biologic therapies in routine clinical practice. The secondary objectives were to identify predictors for successful tapering and assess the cost savings to the local health economy by optimising the use of high cost drugs.

Methods
All patients with rheumatoid arthritis on a biologic therapy for 2 years and in sustained clinical remission (DAS28≤2.6) over the previous year were seen in the remission clinic. They had an Ultrasound scan of the small joints of the hands, wrists and other symptomatic joints. Patients with no activity on Power Doppler were advised to lengthen the interval of their biologic therapy gradually and were followed once every 3 months. Patients were not on oral steroids but continued conventional DMARDs. Patients had a dedicated helpline if they had a flare.

Results
Ninety-three of the 120 patients with rheumatoid arthritis on biologic therapy seen in the biologic remission clinic between January and October 2019 were eligible and all but one agreed to taper. They were 70% female with a mean age of 62.8 years and mean duration of disease 14.6 years. Their mean duration of biologic therapy was 6.3 years; mean baseline DAS28 was 6.3 pre-biologic therapy and 1.7 before tapering. Fifty-seven of the patients were on a TNF inhibitor and 35 were on other biologic therapies. Forty of the ninety-two patients were co-prescribed DMARDs. Screening failure was due to clinical activity in 13 patients, Ultrasound Power Doppler activity in 23 patients, interstitial lung disease in 2 patients and shoulder surgery in one. Only two of the 40 patients who had completed 6 months had a flare and reverted to the baseline frequency. Of the remaining 52 patients, 22 patients had completed 3 months at the tapered dose and 3 patients who were in the initial 3 months had a flare and reverted to the baseline frequency. Initial drug-cost savings at 6 months was approximately £45,000.

Conclusion
Tapering of biologic therapies in patients with rheumatoid arthritis is feasible in routine clinical practice. Ultrasound is helpful to stratify patients for biologic tapering and has enabled a higher proportion of patients to remain in remission after tapering.

Disclosures
H. Pillai: None. N. Nolkha: None. A. Yau: None. S. Matthews: None. A. Hall: None. G. Hirsch: None. S. Venkatachalam: None.
O16 Incidence, prevalence and associated comorbidity of axSpA within the UK: a retrospective database analysis
Authors: Morgan Christopher L. I , White Abigail , Tomlinson Mark , Scott Amie , Tian Haijun 
Published: April 2020

Abstract

Background
This study reports the incidence and prevalence of axial spondyloarthritis (axSpA) in the UK, and describes the baseline characteristics and comorbidities associated with the condition.

Methods
This study was conducted using the Clinical Practice Research Datalink, a large routine primary care database in the UK. Approximately 60% of contributing English primary care practices are linked to Hospital Episode Statistics (HES) secondary care data. AxSpA and relevant comorbidities were identified from Read or International Statistical Classification of Diseases and Related Health Problems-10 codes in primary care or HES datasets, respectively. The date of first axSpA diagnosis defined the index date. Patients with ≥90 days between practice registration and first axSpA diagnosis were classified as incident cases. The incidence and prevalence of axSpA were calculated annually from 2003-2017 for the UK as a whole, each constituent nation and English practices linked to HES data, to maximise case ascertainment. Comorbidities occurring prior to the index date (inclusive) were reported and compared with non-axSpA patients matched for age, sex, primary care practice and concurrent practice registration.

Results
Overall, 20,199 axSpA patients were identified, of whom 8,387 (41.5%) were classified as incident cases. Of the incident cases, 2,600 (31.0%) were female. Mean age at first diagnosis was 45.5 years (standard deviation [SD]: 17.2), mean body mass index was 27.2 kg/m2 (SD: 5.9) and 2,481 (29.6%) patients were current smokers. In 2017, the incidence of axSpA was 8.0 per 100,000 person-years and the prevalence was 15.8 per 10,000 population, an increase from 12.7 per 10,000 population in 2003. For patients from English practices linked to HES data, the incidence was 10.8 per 100,000 person-years and the prevalence was 17.5 per 10,000 population. 8,385 (∼100.0%) axSpA patients could be matched to non-axSpA controls. At baseline, all selected comorbidities were significantly increased in axSpA cases vs controls (Table).

Conclusion
This study reports an increasing prevalence of axSpA over the study period and higher rates of specific comorbidities in patients with axSpA vs matched controls. Caveats related to routine database studies, including secular changes in case ascertainment and observation bias, should be considered when interpreting these results.

Disclosures
C.L.I. Morgan: Other; Employee of: Pharmatelligence. A. White: Shareholder/stock ownership; Novartis. Other; Employee of: Novartis. M. Tomlinson: Consultancies; Novartis. A. Scott: Consultancies; Novartis. H. Tian: Other; Employee of: Novartis.
O37 Utility of RA classification criteria in early inflammatory arthritis referral prioritisation
Authors: Imaduddin Syed M , O'Biern Patrick 
Published: April 2020

Abstract

Background
Early arthritis clinics are increasingly utilised as a method of ensuring patients suspected of disease are assessed promptly to enable suitable treatment. Early recognition with treat to target has been demonstrated in systematic reviews to significantly improve mortality and morbidity outcomes. The United Kingdom’s National Institute for Health and Care Excellence (NICE) recommend potentially affected patients are referred from primary care within 3 days and seen in secondary care within 3 weeks. We hypothesised that utilising the ACR/EULAR 2010 rheumatoid arthritis classification criteria we could identify variables within the primary care referral which make an early arthritis more or less likely.

Methods
A retrospective study of all the patients seen in early inflammatory arthritis (EIA) Clinic from September 2017 to August 2018 in Aneurin Bevan University Health Board. EULAR scores of 145 patients were calculated based on the data provided in the primary care referral. These scores and their components were then compared to the eventual diagnosis.

Results
EULAR score of ≥ 5 had specificity of &gt; 78% and sensitivity of &lt; 30% in predicting EIA. EULAR score of 8 or more was 100% specific for EIA with positive likelihood ratio of infinity. Whereas EULAR score &lt; 3 had a specificity of &gt; 70% and sensitivity of &lt; 45% for Non EIA with a positive likelihood ratio of 1.59. Considering individual EULAR components a high positive Rheumatoid Factor (RF) or Anti-citrullinated peptide antibody (ACPA) and involvement of greater than 10 joints had a positive likelihood ratio of ≥ 3.00 for EIA. A low positive RF or ACPA had a specificity of 66.67% and sensitivity of 27.59% for EIA with a positive likelihood ratio of 0.83. Surprisingly involvement of 4-10 small joints or 2-10 large joints or just 1 large joint had a specificity of ≥ 75% for EIA and a positive likelihood ratio of greater than 1.00. A positive ESR or CRP had a specificity of 36.84% and sensitivity of 67.92% with a positive likelihood ratio for EIA of 1.08. A negative ESR and CRP had a specificity of 67.92% and a sensitivity of 35.00% for Non EIA with a positive likelihood ratio of 1.09. The duration of symptoms of &lt; 6 weeks had a specificity of 77.55% and sensitivity of 24.39% with positive likelihood ratio for Non EIA of 1.08, however duration of &gt; 6 weeks had a positive likelihood ratio of 0.97 for EIA with a lower specificity of 22.45% .

Conclusion
The total EULAR score and individual components can be used to prioritize primary care referrals. A EULAR score of less than 3, duration of symptoms of &lt; 6 weeks, a negative ESR and CRP, a low positive RF or ACPA makes EIA less likely.

Disclosures
S.M. Imaduddin None. P. O'Biern None.
P15 An audit of the management of Behçet's disease in a tertiary referral centre against guidelines from EULAR and the National Centres of Excellence
Authors: Weightman Jessica , Griffiths Bridget , Pandit Ranjeet , Stroud Catherine , Price Ashleigh D , Lorenzi Alice R 
Published: April 2020

Abstract

Background
BD patients are managed equivalently by multiple medical specialties in our trust. Failure to switch from IV to s/c antiTNFalpha therapies was noted and our use of methotrexate, hydroxychloroquine and cyclophosphamide deviates from guidelines. Whether this effects outcome is unknown it but seems likely to be considered clinically useful. A national audit would determine if our management is an anomaly or in keeping with standard practice in the UK prompting review of our treatment algorithm.

Methods
Involved specialities provided details of BD patients in their care. Electronic case records from January 2009 to July 2019 were reviewed. Data were extracted using standard pro-forma classifying patients into 3 groups determined by their most severe manifestation: less severe (predominant musculoskeletal, mucocutaneous); ophthalmic (all eye disease) and severe disease (predominant CNS and vascular disease). Medication was assessed against guidelines for escalation and de-escalation protocols.

Results
50 patients (representing approximately 7% of the national BD population) were identified from 4 specialties (Table 1). 23 were female; 45 identified as White British. 26 were regularly reviewed by 2 or more specialties, 4 had discontinued follow up. 26/50 had used antiTNFalpha therapies and 9/50 had received IV cyclophosphamide. Adherence to guidelines was determined by specialty and disease severity (Table 1). The EULAR guideline was followed least well by Rheumatology; low rates of adherence to the national guideline reflected frequent use of methotrexate and hydroxychloroquine in the less severe group and failure to switch to from IV to sub-cutaneous antiTNFalpha therapies. Deviations from national and EULAR guidelines in the ‘severe’ category related to the first line use of IV cyclophosphamide for acute organ/sight threatening disease.

Conclusion
BD patients are managed equivalently by multiple medical specialties in our Trust. Failure to switch from IV to s/c antiTNFalpha therapies was noted and our use of methotrexate, hydroxychloroquine and cyclophosphamide deviates from guidelines. Whether this effects outcome is unknown it but seems likely to be considered clinically useful. A national audit would determine if our management is an anomaly or in keeping with standard practice in the UK prompting review of our treatment algorithm.

Disclosures
J. Weightman None. B. Griffiths None. R. Pandit None. C. Stroud None. A.D. Price None. A.R. Lorenzi None.
P46 Takotsubo cardiomyopathy in a GPA patient receiving rituximab therapy
Authors: Jayanti Santhosh P , Nair Sulfi , Makkuni Damodar 
Published: April 2020

Abstract

Background
Cardiac involvement in GPA is quite rare. Patients with GPA are two times more likely to die of cardiovascular complications as compared to the general population due to accelerated atherosclerosis. Cardiac involvement in GPA is secondary to necrotising vasculitis with granulomatous infiltrates, usually resulting in coronary artery thrombosis. We present a case of Takotsubo cardiomyopathy in a patient of GPA treated with rituximab. There has previously only been one case report of a patient on rituximab therapy developing Takotsubo cardiomyopathy.

Methods
This 67-year-old woman was diagnosed with GPA in January 2018 when she presented with a necrotic lung lesion along with nasal crusting and leg ulcers. Her ANCA was 102 i.u./ml at the time. We treated with cyclophosphamide and azathioprine to good effect. Then she had a relapse six months later and presented to the hospital with stridor due to subglottic stenosis. At this point we switched to rituximab and methotrexate to induce remission, her ANCA titres settled to 3.4 i.u./ml at this point. After her second cycle of rituximab, she presented to the hospital with shortness of breath, chest pain and stridor in November 2018.

Results
At her presentation with chest pain in November 2018, an ECG was performed, which showed an incomplete LBBB with ST elevation in anterior leads with a troponin level of 550ng/ml. A repeat ECG after 2 hours, showed ST elevations in anterolateral leads with a troponin level of 1259ng/ml. We treated this as an acute myocardial infarction. An echocardiogram was obtained, which was remarkable in that it showed no new regional wall motion abnormalities. A subsequent coronary angiogram confirmed that there was no coronary artery disease raising the possibility of Takotsubo cardiomyopathy.

Conclusion
Rituximab is implicated in cardiac arrhythmia and coronary vasospasm during the infusion, reduction in LVEF, non-ischaemic cardiomyopathy, cardiogenic shock after. Our patient had a myocardial infarction with normal coronaries, and she was going through a very emotionally stressful period with her husband’s illness at the time of her presentation, which makes Takatsubo cardiomyopathy a very likely diagnosis. There are few case reports in the literature and, clinicians should be aware of this rare complication.

Disclosures
S.P. Jayanti None. S. Nair None. D. Makkuni None.
P65 Exploring ethnic disparities in early arthritis care
Authors: James Lija , Clarke Benjamin D , Salerno Rosaria , Audu Aderonke , Steer Sophia , Galloway James B 
Published: April 2020

Abstract

Background
The National Health Service caters to a variety of rheumatology patients from increasingly diverse multi-ethnic backgrounds. Despite this, societal, organisational and personal barriers remain across the UK. These are known to directly and indirectly influence access to care although no inference can be generalised at a local level. Our south London trust has one of the highest non-white patient bases in the UK, hence our interest in wanting to explore the cultural differences around delivery of care. We set out to use the national inflammatory arthritis audit (NEIAA) data from our department to ensure equitable service provision and delivery using quality improvement methodology.

Methods
The NEIAA data for our trust observes performance across the seven NICE quality indicators for rheumatoid arthritis. Of interest was evaluation of standards 1 to 6, as too few data existed for standard 7. Ethnicity was coded according to the NEIAA categories as white or non-white. Differences by disease severity indicators were analysed. A descriptive analysis was performed with an understanding that no assumptions or statistical interpretations could be made to these observed differences.

Results
A total of 471 patients had data available. Of these, 124 (26%) had a diagnosis of early inflammatory arthritis, of whom 34 (27%) were non-white and 80 (73%) were white. Non-white patients were younger, more were seropositive, had a higher baseline DAS28, worse MSK-HQ scores, worse mental health scores and worse HAQ scores. Non-white patients were less likely to have a patient reported outcome recorded. Attainment of quality standards 1, 2, 3 and 6 had equiproportionate representation of non-white and white patients. Standards 4 (provision of education) and 5 (agreement of treatment target) demonstrated fewer non-white patients meeting the target. Standard 5 demonstrated the most disparity. 83% of white patients had an agreed target compared to 47% of non-white (Odds ratio 5.6 (CI 2.2-14.1)). To describe this, our non-white patients were more than 5 times less likely to have an agreed treatment target.

Conclusion
Cultural differences exist in health-seeking behaviour, verbal language, written comprehension and in unconscious bias. The NEIAA results within our trust suggest differences exist by ethnic groupings in early arthritis care. Although challenges and taboos remain in discussing these variations, more work needs to be undertaken to explore healthcare disparities and why these occur. Research within this field is limited to date. We plan to adopt a quality improvement approach using stakeholder engagement meetings, process-mapping and driver diagrams to evaluate how best to achieve change.

Disclosures
L. James None. B.D. Clarke None. R. Salerno None. A. Audu None. S. Steer None. J.B. Galloway None.
P67 Risk factors for musculoskeletal pain amongst health and social care workers in the UK: results from the Health and Employment After Fifty (HEAF) study
Authors: D'Angelo Stefania , Ntani Georgia , Syddall Holly , Harris E C , Linaker Cathy , Stevens Martin , Walker-Bone Karen 
Published: April 2020

Abstract

Background
Musculoskeletal disorders are one of the main causes of sickness absence in the UK and their prevalence is likely to increase in workers, with the rise of state pension age. Previous research has shown that these conditions are common among health and social care workers. Therefore, we aimed to describe the prevalence of musculoskeletal pain among health and social care workers and to explore personal and occupational risk factors for pain at specific anatomical sites and for multi-site pain.

Methods
We used data from the second year of follow up of the Health and Employment After Fifty (HEAF) study, a cohort study of 8,134 adults aged 50-64, recruited through 24 English general practices. Health and social care workers, identified through the Standard Occupational Classification 2010, were the focus of this cross-sectional analysis.
The outcome under investigation was self-reported pain lasting more than a day in the past month, at one or more of eight anatomical sites: neck, low back, mid-back, shoulder, elbow, wrist/hand, knee, foot/ankle. Socio-demographic variables, self-reported health measures, psychosocial work factors (job dissatisfaction, lack of appreciation, lack of support) and occupational activities (kneeling or squatting for more than 1 hr/day, standing for most of the day) were ascertained through postal questionnaire, and associations with pain at specific anatomical sites and multi-site (≥2 anatomical sites) pain were explored with logistic regression, firstly adjusted for age and sex and then adjusted for additional confounders.

Results
A total of 282 participants were working in health and social care at second year follow up. Mean age was 59 years and 90% of them were women. Of these workers, n = 199 (71%) reported pain in at least one site, while n = 147 (52%) reported multi-site pain. The most reported anatomical sites with pain were knee and low back, with a prevalence of 39% and 34% respectively. Significant risk factors for knee pain were poor self-rated health (OR = 4.2; 95%CI 2.1 to 8.2) and being exposed to kneeling for longer than an hour/day at work (OR = 2.0; 95%CI 1.2 to 3.4). Similar results were found for low back pain, while for multi-site pain mental exhaustion also appeared to have an effect. None of the socio-demographic variables or psychosocial work factors influenced the outcomes.

Conclusion
In a sample of health and social care workers in the UK, the prevalence of low back, neck and multi-site pain is high. The common risk factors were being exposed to kneeling at work and reporting poor/fair health.

Disclosures
S. D'Angelo: None. G. Ntani: None. H. Syddall: None. E.C. Harris: None. C. Linaker: None. M. Stevens: None. K. Walker-Bone: None.