bluuebunny/crossref_metadata_2025_split huggingface dataset:
P14 Using NHS resources wisely: A Snapshot of biologic and small molecule agent prescribing at the Peter Maddison Rheumatology Centre
Authors: Jones Alaw R , Batty Ann , Lloyd Lois A , Breslin Anne , Owen Catherine , Ahmad Yasmeen 
Published: April 2020

Abstract

Background
Pharmacological management of rheumatological conditions has transformed in the past two decades. A range of targeted therapies are available to manage conditions such as rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Careful governance and management is required to ensure patients receive the most appropriate drug and dose for their condition.

Methods
Patients diagnosed with RA, PsA and SpA/AS treated with a biologic or small molecule agent during the period of April 2018 - March 2019 for &gt;6 months duration were eligible for inclusion. Patients were identified using biologic patient registers maintained by the Rheumatology department.

Results
One hundred and eighty-one patients were eligible for inclusion. Ninety-two patients (51%) were female, age range: 21 - 85 years, median = 54 years. The most prescribed biologic was etanercept (n = 71, 39.2%) followed by rituximab (n = 31, 17.1%) and adalimumab (n = 23, 12.7%) of which 98.4% were prescribed a biosimilar formulation. A breakdown of prescribing is illustrated below.
Over a third of patients were maintained on a reduced dose of biologic, resulting in significant cost efficiencies (£20,000 cost avoidance with etanercept dose reduction). Twenty-eight patients in the RA cohort were not on a DMARD; of these 25 patients (89.2%) had achieved remission/ low disease activity. Average annual drug cost per patient was higher for psoriatic arthritis (£6,719.33 vs. £4731.00 for RA and £3,417.27 for SpA). Patients treated with rituximab had a dosing interval of 12 months or longer between cycles, as dosing was influenced by clinical symptoms. As a result, the percentage of patients in low disease activity is lower.

Conclusion
This study has shown marked variance in cost per head (range= £1,769- £9,303) depending on the disease, type of targeted therapy and disease response rate. The PMRC multidisciplinary team approach to introducing biosimilar medicine prescribing and actively maintaining patients in remission/low disease activity on reduced biologic therapy, has enabled patients to access medicines and deliver value-based healthcare with positive patient outcomes in line with NICE guidelines and clinical reasoning.

Disclosures
A.R. Jones None. A. Batty None. L.A. Lloyd None. A. Breslin None. C. Owen None. Y. Ahmad: None.
P32 Should we continue to test for latent tuberculosis infection in patients treated with biologics?
Authors: Sidhu Arslan A , Nandagudi Anupama 
Published: April 2020

Abstract

Background
Timely diagnosis of tuberculosis (TB) infection is important in patients receiving biologics. Current BSR guidelines on biologic safety in inflammatory arthritis (2018) advise to screen all patients for TB before starting treatment. Due to limitations of tuberculin skin test (TST), IFN-γ release assay (IGRA) is frequently used in addition to clinical examination, risk assessment and chest x-ray (CXR). There are no clear guidelines whether IGRA should be part of follow up assessments. The Royal College of Nursing suggest patients on biologics should have repeat CXR in 3 months after starting biologics and then annually. The American College of Rheumatology suggest an annual TST or IGRA for high-risk individuals receiving biologics. Centers for disease control and prevention guidelines allows to use TST and IGRA for surveillance in selected population.

Methods
We present two cases in which patients developed TB after starting biologics. Both patients had negative IGRA, normal CXR and low risk of developing TB on prebiologic screening.

Results
First patient was a 64-year-old female with rheumatoid arthritis diagnosed in 2001. She failed multiple conventional DMARDs and was started on Certolizumab in 2014. Prebiologic screen showed a negative IGRA (T Spot) and CXR was clear. She was a smoker and her mother had pulmonary TB when she was a child. After 4 years she presented with weight loss and cough. CXR showed 1.4 cm round opacity in right upper lobe. She underwent surgical resection and histology showed acid fast bacilli on ZN stain with superimposed aspergilloma. She was started on quadruple therapy and we switched Certolizumab to Etanercept due to its shorter half-life. Second patient was a 27-year-old man with ankylosing spondylitis diagnosed in 2015. He was a smoker and had no past medical history. He was started on Adalimumab in 2016. T Spot was negative and CXR was clear. There were no risk factors for TB. Two years later he presented with multiple tender subcutaneous nodules over thighs and lower abdomen. Skin biopsy after dermatology assessment showed superficial and deep perivascular inflammation with lymphocytes and small number of eosinophils. Differential were granulomatous infection or panniculitis due to injection site reaction. TB cultures came back negative but repeat T Spot was positive. He was treated as latent TB infection for 3 months and Adalimumab was restarted without any problems.

Conclusion
Current BSR guidelines advise to monitor patient clinically for any signs of TB while receiving biologics. We suggest that there is a need to review whether TST or IGRA should be done annually on high risk patients along with CXR.

Disclosures
A.A. Sidhu None. A. Nandagudi None.
P45 Interstitial pneumonitis induced by secukinumab therapy in a patient with psoriatic arthritis
Authors: Saleh Christopher , Bilgrami Syed , Gatheral Timothy , Ottewell Lesley 
Published: April 2020

Abstract

Background
Inhibition of pro-inflammatory interleukin-17A (IL-17A) with secukinumab (an anti-IL-17A antibody) has been utilised in patients with chronic autoimmune disease such as psoriasis seronegative spondyloarthopathies. In mouse models, IL-17A was involved in the development of pulmonary inflammation and progression of fibrosis, with blockade of IL-17A implicated as a potential therapeutic target in such conditions. Here we report a case of, seemingly paradoxical, interstitial lung disease (ILD) secondary to secukinumab therapy in a 61-year-old patient with psoriatic arthritis.

Methods
Please refer to the results section.

Results
Initial therapy was with adalimumab achieving good disease control for 9 years, at which point his arthritis began to progress. Secukinumab was commenced with good clinical response from his arthritis, however he developed a persistent cough with blood-stained secretions, and shortness of breath on exertion. A CT thorax was arranged at 21 weeks after initiation of secukinumab, and showed florid bibasal, lingula and middle lobe ground glass density air space opacification. He went on to have bronchoscopy with bronchoalveolar lavage (BAL) and differential cell count. BAL was negative for atypical infection including P. jirovecii, growing upper respiratory tract flora only. Microscopy of BAL showed lymphocytosis in keeping with the diagnosis of drug induced ILD, with no atypical cells. The patient made a significant improvement on withdrawal of secukinumab therapy within 7-8 weeks of cessation - both clinically and radiologically.

Conclusion
A review of the current literature at this time indicates this is now a third case of secukinumab induced ILD. Given this potentially idiosyncratic reaction we suggest further work may be necessary to understand the underlying immunogenic potential of secukinumab, and an increased awareness as well as vigilance in reporting, to determine those at-risk populations of this phenomenon.

Disclosures
C. Saleh None. S. Bilgrami None. T. Gatheral None. L. Ottewell None.
P61 Trajectories of foot pain severity over seven years and relationship to potential prognostic factors: the clinical assessment study of the foot
Authors: Marshall Michelle , Blagojevic-Bucknall Milica , Rathod-Mistry Trishna , Thomas Martin J , Edwards John J , Peat George , Menz Hylton B , Roddy Edward 
Published: April 2020

Abstract

Background
Foot pain is common and disabling in older adults however little is known about its course. The objective of this study was to identify foot pain trajectories over seven years and examine the associations between progressive symptom trajectories and potential prognostic factors.

Methods
All adults aged ≥50 years registered with four general practices in North Staffordshire, UK were mailed a health survey at baseline. Those reporting foot pain in the previous 12 months were invited to attend a research clinic that included a standardised interview, physical examination, and plain radiographs of the feet. Follow-up was by repeated postal surveys at 18 months, three years, 54 months, and seven years. Trajectories of repeated measures of foot pain severity in the previous month (10-point numerical rating scale) were identified using Latent Class Growth Analysis (LCGA). Logistic regression was undertaken to explore the relationship between these trajectories and both person-level and foot-level prognostic factors adjusted for covariates (age, gender, and body mass index).

Results
Of 560 adults with foot pain attending baseline research clinics, 425 (76%) provided data at baseline and ≥two follow-up time-points and were included in the analysis. The optimum LGCA model for foot pain severity was a 4-class model with the following trajectories: mild improving pain (n = 109, 26%); moderate improving pain (n = 179, 42%); moderate persistent pain (n = 122, 29%); severe persistent pain (n = 15, 4%). Compared with individuals with mild/moderate improving pain trajectories, those with moderate/severe persistent pain trajectories over 7 years did not differ significantly by age, sex, foot posture or radiographic foot OA phenotype at baseline, but were more likely to be overweight/obese. After adjustment for covariates, these less favourable long-term trajectories were associated with lower socioeconomic position, poorer physical and mental health, catastrophising, greater foot-specific functional limitation (Manchester Foot Pain and Disability Index), and self-reported hallux valgus at baseline (Table 1).

Conclusion
Over a 7-year period, one-third of individuals had persistent moderate to severe pain. Targeting interventions to modifiable prognostic factors such as obesity and hallux valgus may have the potential to improve long-term outcomes in people with foot pain.

Disclosures
M. Marshall None. M. Blagojevic-Bucknall None. T. Rathod-Mistry None. M.J. Thomas None. J.J. Edwards Other; JJE is part of The Keele Academic General Practice which has received funding from Bristol-Myers Squibb to develop and evaluate a quality improvement tool in anticoagulation. G. Peat None. H.B. Menz None. E. Roddy None.
P80 Value of the clinical nurse specialist role in the care of patients with systemic lupus erythematosus: the patient experience
Authors: Culshaw Alison N , Roychowdhury Dr. Bijaya 
Published: April 2020

Abstract

Background
Systemic lupus erythematosus (SLE) is a complex, multi-system, chronic disease that is predominantly managed by rheumatologists in a clinical setting. Clinical Nurse Specialist (CNS) access and support for patients can be variable and mostly lacking. The value of the CNS role in supporting patients with SLE has not previously been explored in depth from the patient’s perspective. This service evaluation investigates the role of the SLE CNS in supporting patients with SLE, with the aim to further develop the CNS role in SLE care to support patients locally in North Wales.

Methods
Seven SLE participants, who had access to a dedicated SLE CNS, were selected from connective tissue disease clinics at a district general hospital. The age range was 33-69 years with a disease duration from 4-20 years. Participants took part in a one to one semi-structured interview using open ended questions. Interviews were digitally recorded, transcribed verbatim, and analysed using thematic analysis.

Results
The analysis of the interviews highlighted the value of a specific SLE CNS role to SLE patients. Overall, responses were positive with participants feeling reassured knowing they could contact the CNS for support via the telephone nurse advice line during flares of disease activity: “It’s like a lifeline”. Owing to the complex nature of SLE, participants valued having a nurse to monitor their condition, enabling them to feel supported between routine appointments: “I think of the nurse as my safety blanket”. Validation of symptoms led participants to feel in control, as they appreciated having a nurse to discuss their concerns with, who took the time to listen: “It’s about not putting it all down to lupus”. All respondents valued receiving information about SLE from the CNS, who was perceived as having specialist knowledge of SLE: “The specialist nurse knows the ins and outs”. This expert knowledge of SLE was fundamental to participants at diagnosis and throughout their disease trajectory, as those without support from a CNS soon after diagnosis felt isolated and ill informed: “I didn't even know what I had”. The majority of participants reported a lack of empathy and understanding of SLE among primary care specialists, and experiences of misdiagnosis were not uncommon: ‘“They said I had scarlet fever, psoriasis and various other things”.

Conclusion
Though the number of participants was small, the study has revealed that the SLE CNS provides an important and unique role in the care of patients with SLE. Continued support from SLE CNS roles, and improved knowledge of SLE within primary care, is fundamental so that SLE patients have enhanced support soon after diagnosis and throughout their journey with SLE.

Disclosures
A.N. Culshaw None. D. Roychowdhury None.
P131 Patients with hand osteoarthritis have a long duration of symptoms and significant pain scores at the time of referral to rheumatology services
Authors: Ghaffar Muhammad Tauseef , O'Sullivan Miriam , Silke Carmel , Whelan Bryan 
Published: April 2020

Abstract

Background
Osteoarthritis is the most common arthritic condition worldwide affecting 9.6% of men and 18% of women aged &gt;60 years with an Irish prevalence &gt;50 years of age is 17.3% for women and 9.4% for men. It can occur in any joint but is most common in the hip, knee and spine. It is also prevalent in the hand and can lead to significant pain and disability. The aim of this study was to examine the pattern and severity of hand osteoarthritis in patients referred to a regional rheumatology service.

Methods
Consecutive patients seen in general rheumatology clinics of all ages and gender who had confirmed diagnosis of hand osteoarthritis based on the ACR criteria were recruited (patients with RA, psoriatic arthritis, gout and haemochromatosis were excluded). All gave written informed consent to participate and had a single assessment performed including demographic details, symptom assessment using the AUSCAN Osteoarthritis Hand Index. In addition, measures of functional ability, grip strength and pincer strength were performed in the OT department. All patients also had an up to date hand X-ray performed. For the purposes of this paper we will report the initial assessments including the demographic details and pain scores.

Results
103 consecutive patients were included in this analysis. M:F ratio 1:5.25. Mean age was 66.13 years. Mean duration of symptoms 74.63 months (8-422). At assessment the mean pain scores (0-10 VAS) were 4.53 (at rest), 6.09 (when gripping), 6.06 (when lifting) and 6.42 (when turning objects). The mean tender joint count was 7.14 and the mean score for objective soft tissue swelling in the joints was 1.36.
Subject Average VAS (0-10) Pain Score at presentation by Gender

Conclusion
From these analyses, we can see that patients are referred very late with no one being seen within 6 months of symptoms onset. This is despite patients having pain scores which are comparable to those with inflammatory arthritis and in a small minority evidence of soft tissue swelling in joints at the time of presentation. In addition, it is noticeable that men are under-represented in the cohort of referred patients based on estimates of prevalence.

Disclosures
M. Ghaffar None. M. O'Sullivan None. C. Silke None. B. Whelan None.
P134 Collaborating with the National Congenital Anomaly and Rare Disease Registration Service to estimate national incidence of Kawasaki disease in England
Authors: Rutter Megan , Lanyon Peter C , Bythell Mary , Stevens Sarah , Aston Jeanette , Pearce Fiona A 
Published: April 2020

Abstract

Background
The true incidence of Kawasaki disease (KD) in England is unknown. In KD treatment with intravenous immunoglobulin (IVIG) can be lifesaving, but it is both expensive and in limited supply. In collaboration with Public Health England’s National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) we aimed to determine the incidence of KD in England.

Methods
We worked within NCARDRS to access patient-identifiable Hospital Episode Statistics (HES) data, enabled by their legal permissions (CAG 10-02(d)/2015). We extracted all patients receiving a primary or additional diagnostic code for KD between April 2003 -March 2017. For patients identified in Nottingham University Hospitals Trust, we reviewed the coding accuracy in their medical records. We calculated incidence with 95% Poisson confidence intervals among children in England using the total number of cases newly diagnosed in the study period. We used the ONS mid-year estimates for 2016 for the denominator.

Results
37 patients were coded as having KD in our Trust. All had a clinical diagnosis of KD (positive predictive value 100%). 32 patients were paediatric cases treated for KD; the remaining 5 patients were diagnosed in adult life on the basis of pathognomonic angiogram findings. It was not possible to apply classification criteria because the required information was not always available. During the 13-year study period we identified 3345 cases in children aged &lt;5, and 4234 cases in children &lt;16 in England. The incidence in children aged &lt;5 years was 7.50 (95% CI: 7.25-7.76)/100,000 person-years, and 40.7% of cases were female. Incidence in children aged &lt;16 was 3.09 (95% CI: 3.00-3.19)/100,000 person-years, and 41% of cases were female.

Conclusion
Analysis of HES data within NCARDRS has provided population-based estimates of incidence of KD for the whole of England. Our estimates are higher than in previous studies. Validation of coding accuracy has shown our methods were specific, and they are likely to be sensitive given KD is always treated in hospital. Accurate incidence estimates are essential for appropriate resource allocation, given the limited availability of lifesaving IVIG treatment.

Disclosures
M. Rutter None. P.C. Lanyon None. M. Bythell None. S. Stevens None. J. Aston None. F.A. Pearce None.
P150 Influence of patient reported arthritis activity in determining sHAQ, HAQ-DI and Cochin scores in systemic sclerosis
Authors: Gjeloshi Klodian , Danzo Fiammetta , Abignano Giuseppina , Dean Anne-Maree , Masini Francesco , Cuomo Giovanna , del Galdo Francesco 
Published: April 2020

Abstract

Background
Arthritic involvement is a common manifestation in systemic sclerosis (SSc). The aim of this study is to assess the weight of patient reported arthritis activity in determining Patient Reported Outcome Measures (PROMs) in an observational cohort of SSc patients.

Methods
We conducted a retrospective study of 330 clinic episodes from 121 unselected patients diagnosed with SSc according to EULAR/ACR 2013 classification criteria, in annual follow-up (for a total of 165 patients/year) with Pulmonary Function Tests (PFTs), Health Assessment Questionnaire - Disability Index (HAQ-DI), Scleroderma Health Assessment Questionnaire (sHAQ) and Cochin Hand Function Score (CHFS). Hand disability index was assessed by CHFS and global disability index was assessed by HAQ and sHAQ. Patient reported arthritis activity was assessed by Visual Analogical Scale for Arthritis Activity (VAS3). Based on the median of VAS3, patients were classified in two groups and the evaluation of global and hand disability index was performed for each group. Furthermore, we assessed the correlation between the change of VAS3 and the modification of disability scores (ΔHAQ, ΔSHAQ, ΔCHFS) over 12 months of follow-up. Following analysis of distribution, Spearman or Pearson Test were used to determine correlation coefficients, as appropriate (Prism 7).

Results
The median disease duration was 5 years (IQR 3-10). The median of VAS3 was 35 (IQR 2 - 66). In patients with VAS3 &lt;35 and VAS ≥35 the HAQ-DI medians were 0.625 (IQR 0.25 - 1.5) and 1.75 (IQR 1.125-2.25) respectively, (p &lt; 0.0001); the sHAQ medians were 0.628 (IQR 0.255 - 1.114) and 1.701 (IQR 1.234-2.059), respectively, (p &lt; 0.0001); and the CHFS medians were 4 (IQR 0 - 19) and 28 (IQR 10 - 46) respectively, (p &lt; 0.0001). A significant correlation was observed between VAS3 and HAQ (r = 0.463, p &lt; 0.0001), SHAQ (r = 0.651, p &lt; 0.0001), CHFS (r = 0.497, p &lt; 0.0001); between ΔVAS3 and ΔSHAQ (r = 0.493, p &lt; 0.0001).

Conclusion
This analysis of a monocentric non-selected population supports the key role of joint involvement in determining global patient reported functional and hand disability in SSc. Severity of musculoskeletal involvement should be carefully considered when interpreting PROs in patients with SSc.

Disclosures
K. Gjeloshi: None. F. Danzo: None. G. Abignano: None. A. Dean: None. F. Masini: None. G. Cuomo: None. F. del Galdo: None.