bluuebunny/crossref_metadata_2025_split huggingface dataset:
P180 External validation of the Southend GCA Probability Score (GCAPS) as a screening tool for referrals with possible GCA
Authors: Quick Vanessa , Hughes Mark , Mothojakan Nadira , Fishman Daniel 
Published: April 2020

Abstract

Background
We run a rheumatologist-led, ultrasound-driven giant cell arteritis (GCA) fast track pathway (FTP). Currently, no specific referral criteria are required. Sensitive referral criteria are now needed to safely reduce referrals, which have risen year-on-year (92 in Year 3, 84% greater than Year 1).

Methods
The following were collected for all patients referred to our GCA-FTP from 1/4/2018-31/3/2019 (Year 3): Final diagnosis of imaging/biopsy confirmed-GCA, unconfirmed clinical-GCA or not-GCA using the electronic patient record to September 2019; Rheumatologist-determined clinical probability of GCA (low, moderate, high) before imaging/biopsy; Presence of ≥ 3 ACR 1990 GCA Classification Criteria (biopsy excluded, adapted to increase sensitivity, see table); Presence of Southend GCAPS≥10 (Based on our clinical experience, polymyalgic symptoms were also counted if patients had recently taken prednisolone for PMR).

Results
88 consecutive patients were analysed (total 92: 2 missing data; 2 passed through twice). 25/88 (27%) were diagnosed with GCA 24 were imaging/biopsy confirmed. The single patient with unconfirmed clinical-GCA had high clinical probability, indeterminate ultrasound and biopsy after &gt;1-week glucocorticoid. GCA patients were mean age 77.3y (range 63-94), 76% female, all White, with mean GCAPS 15.3 (range 10-25).
Our adaptations of the ACR criteria increased ACR-criteria sensitivity: 24% GCA patients had new generalised headache and 16% had ESR&lt;50, but CRP&gt;10. 14% referrals were non-White, although GCA is rare in this group. GCAPS was based on a largely White population. If GCAPS did not remove 3 points for alternative diagnoses, then 5 additional non-White patients would have scored ≥10.

Conclusion
This study externally validates GCAPS≥10 as a screening tool for referrals with possible GCA. It captured all GCA patients and screened out 44% referrals. For this indication, it performed better than a consultant rheumatologist. Despite adaptations to improve sensitivity, ACR criteria missed a quarter of cases. To improve GCAPS specificity when scored by a non-rheumatologist, GCAPS should be adapted to reflect the low likelihood of GCA in non-Whites. We plan to only accept patients with GCAPS≥10, where 3 points are removed for non-Whites if not already removed for alternative diagnoses. We predict referrals will reduce but anticipate referrers will need education to limit over-scoring.

Disclosures
V. Quick None. M. Hughes None. N. Mothojakan None. D. Fishman None.
P191 Real life experience of tocilizumab for the management of giant cell arteritis in Fife, Scotland
Authors: Allcoat Paul , Hart Stephanie , Hailwood Sarah J , McLaren John S 
Published: April 2020

Abstract

Background
Tocilizumab was accepted by the Scottish Medicines Consortium for use in the management of Giant Cell Arteritis (GCA) on 10.09.18. The Fife Rheumatic Diseases Unit is the first Rheumatology unit in Scotland to introduce a structured process for the management of GCA patients with tocilizumab. We describe here our experience of this new service for NHS Fife.

Methods
All GCA patients considered for tocilizumab are discussed at our weekly Medication Review Meeting by the Consultant Rheumatologists (JSM & SJH) and Rheumatology Pharmacist (SH). By consensus decision, GCA patients deemed appropriate for tocilizumab treatment are then referred to the Vasculitis Nurse Specialist (VNS; PA) for counselling. We have prospectively recorded data on all GCA patients counselled on tocilizumab from 08.11.18 onwards. Patients are followed up closely in a structured manner by the VNS on a fortnightly basis, with both clinical and laboratory assessment at each visit. The VNS ensures that GCA patients follow a rapid steroid taper in line with that used in the GiACTA Trial. Patients also have laboratory assessments performed between each VNS visit at their GP's surgery (to monitor the ESR) to assist in decision making in view of the rapid steroid taper. The VNS also records the cumulative steroid dose along with drug-related side effects (both from steroids and tocilizumab).

Results
14 GCA patients have been counselled and commenced on tocilizumab between 08.11.18 and 18.09.19. We have another 2 GCA patients awaiting counselling and due to start tocilizumab soon. Twelve patients have newly diagnosed GCA (5 with unilateral visual loss), 5 with Large vessel vasculitis and 3 patients have refractory GCA. Of the newly diagnosed patients, the reasons for initiating tocilizumab were as follows: poor control of diabetes mellitus on high dose steroids; large vessel vasculitis confirmed on PET scan; previous long-term steroid exposure due to past history of polymyositis; high osteoporotic risk.

Conclusion
We have successfully introduced a structured process for the use of tocilizumab in Fife GCA patients via a VNS-led GCA clinic. This ensures robust clinical governance around the issues of safety, efficacy and cost. In addition, by collecting real life prospective data, we will add to the existing information available regarding use of this new therapeutic advance for GCA management in routine clinical practice. This initiative is the first of its kind in Scotland and a new service development for NHS Fife.

Disclosures
P. Allcoat None. S. Hart None. S.J. Hailwood None. J.S. McLaren Honoraria; J.S.M. has received Speaker fees from Roche.
P197 Analgesic prescribing in patients with inflammatory arthritis in the NHS
Authors: Scott Ian C , Bailey James , White Christopher , Mallen Christian D , Muller Sara 
Published: April 2020

Abstract

Background
There is little evidence analgesics improve pain in inflammatory arthritis (IA), and substantial evidence they have significant harms. Excepting NSAIDs in ankylosing spondylitis (AS), their long-term use is not recommended in guidelines. Despite this, international data suggest pain management in IA involves the substantial and sustained use of opioids (∼40% of North American patients with rheumatoid arthritis [RA] are chronic opioid users). We evaluated analgesic prescribing practice in NHS-managed patients with IA.

Methods
This study was undertaken in the Consultations in Primary Care Archive (CiPCA), containing primary care consultation/prescription data from 9 general practices (∼200,000 patients) in North Staffordshire (UK) from 2000-2015. Repeated cross-sectional analyses evaluated annual prevalence of analgesic prescriptions in (a) patients with IA (RA; psoriatic arthritis [PsA]; AS), and (b) five age, sex, and practice-matched controls without inflammatory rheumatic conditions. Patients without full calendar-years of data were excluded. The numerator was the number of patients receiving oral analgesic prescriptions in a calendar-year; the denominator was the number of patients contributing data within that calendar-year. Analgesic prescriptions were classified into basic, opioids, gabapentinoids, and NSAIDs. Patients were grouped into users, or non-users of analgesics. Users were sub-classified into chronic (≥3 prescriptions across a calendar year), or intermittent (1-2 prescriptions) users.

Results
In all years, the majority (65.1-77.8%) of patients with IA received analgesics, compared with the minority (38.1-42.0%) of controls (Table). Opioid prescribing in IA fell slightly between 2000-2015, but remained common with 45.0% receiving an opioid, and 32.5% being chronic opioid users in 2015. The proportion of patients with IA prescribed gabapentinoids increased from 0% in 2000, to 9.4% in 2015. In contrast, the proportion prescribed NSAIDs fell from 53.3% in 2000, to 24.9% in 2015. In all years, analgesic use was commoner in patients with RA, compared to PsA and AS, and 2-4 times higher in IA than controls.

Conclusion
Analgesic prescribing - particularly opioids - in IA is commonplace, with most prescribed long-term. This is at variance with existing evidence, and guidelines. Interventions are needed to improve analgesic prescribing in this population.

Disclosures
I.C. Scott None. J. Bailey None. C. White None. C.D. Mallen None. S. Muller None.
P207 A quality improvement intervention to increase pneumococcal and influenza vaccination rates in immunosuppressed inflammatory arthritis patients
Authors: Murray Kieran , Low Candice , Young Francis , O'Rourke Anna , Callanan Ian , Feeney Eoin , Veale Douglas J 
Published: April 2020

Abstract

Background
Pneumococcal and influenza vaccination rates have been suboptimal in studies of immunosuppressed patients. We aimed to assess barriers to and increase rates of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and influenza vaccination in this group.

Methods
In 2017, Rheumatology outpatients completed an anonymous questionnaire recording vaccination knowledge, status and barriers. Simultaneously, a low-cost multifaceted quality improvement (QI) intervention was performed. All outpatients on oral steroids, immunosuppressant conventional synthetic disease modifying antirheumatic drugs (csDMARDs) or biologics (bDMARDs) were included in the study. In 2018, post-intervention, the clinic was re-assessed. Demographics, diagnosis, medications, smart phone access and willingness to use this for vaccination reminders were assessed for independent vaccination predictors using binary logistic regression analysis.

Results
425 patients were included (72.6% rheumatoid arthritis, 74% women, 45.6% ≥60 years old). From 2017-2018, vaccination rates increased for PPSV23 {41.0% to 47.2% (p = 0.29)} and influenza {61.8% to 62.1% (p = 0.95)}. The most common reason for non-vaccination was lack of awareness. Following the intervention, this decreased for influenza (36.7% to 34.2%) and PPSV23 (82.1% to 76.4%). General Practitioners performed most vaccinations, only 3.6% were delivered in hospital. Significant predictors of PPSV23 vaccination were older age {≥80 years had an OR 41.66 (95% CI 3.69-469.8, P = 0.003), compared to ≤ 39 years}, bDMARD use (OR 2.80, 95% CI 1.24-6.32, P = 0.013) and adequate influenza vaccination (OR 9.01, 95% CI 4.40-18.42, P &lt; 0.001). Up to date PPSV23 vaccination (OR 8.93, 95% CI 4.39-18.17, P &lt; 0.001) predicted influenza vaccination.

Conclusion
PPSV23 and influenza vaccination rates were suboptimal and increased marginally. Point-of-care vaccination may be more effective.

Disclosures
K. Murray: None. C. Low: None. F. Young: None. A. O'Rourke: None. I. Callanan: None. E. Feeney: None. D. Veale: None.
P237 Utility of diagnostic ultrasound in a rheumatology podiatry clinic
Authors: Newcombe Lisa , Tougher John , Woodburn James , Barn Ruth 
Published: April 2020

Abstract

Background
The use of musculoskeletal ultrasound (MSUS) is increasing with diagnostic, prognostic and treatment advantages for inflammatory disease. However, further work is required to determine its utility in podiatry clinics regarding diagnosis and management of lower limb pathology. The overall objective was to investigate the agreement between clinical and MSUS diagnoses and the impact of MSUS on treatment planning.

Methods
Consecutive patients attending a rheumatology clinic at the Queen Elizabeth University Hospital Podiatry Department, Glasgow were invited to participate. Clinical diagnosis of foot problems and structures affected was conducted by a single experienced podiatrist (JT). MSUS assessment of affected structures was then conducted by a single podiatrist with US training (LN) using an Esaote MyLabAlpha portable US machine using two linear array transducers (IH6-18 and SL2325) with a range of 6-18MHz. Ultrasound findings were made available to the podiatrist responsible for diagnosis and management (JT) and any amendments to the diagnosis or treatment plan were recorded.

Results
A total of 23 participants were recruited, 7 male and 16 female with a mean (SD) age of 54 (14) years. Across a range of pathologies, agreement between clinical examination and MSUS was 55% (Table 1). Where disagreement occurred, a range of additional findings were reported from MSUS including bursae, osteomyelitis, active inflammation (joint and tendon) and gout. MSUS assessment confirmed the treatment plan for 15 patients (65%) and altered the treatment plan for 8 patients (35%). The alterations included: 2 onward referrals for further imaging/antibiotic therapy; 4 rehabilitation programme adjustments (based on presence or absence of active inflammation); 2 orthotic plan adjustments; and 2 where corticosteroid injection was no longer indicated.

Conclusion
When compared with an experienced clinician’s clinical diagnosis of foot pathology, MSUS agreed in just over half of the cases. Additional diagnostic findings from MSUS were reported in 45% of the sample. One third of the management plans were amended due to MSUS findings. Further work is required in a larger sample, but these findings provide provisional evidence of the utility of MSUS for enhancing the accuracy of diagnosis and the tailored management of lower limb pathology in rheumatology.

Disclosures
L. Newcombe None. J. Tougher None. J. Woodburn None. R. Barn None.
P241 Associations between clinical variables and psychological symptoms in RA: a network science perspective
Authors: Tung Hsiu Yen , Norton Sam , Galloway James , Matcham Faith , Hotopf Matthew 
Published: April 2020

Abstract

Background
This study tests the feasibility of a network analysis approach to examine associations between clinical variables and mental health symptoms in rheumatoid arthritis (RA).

Methods
Over 1,000 patients completed patient reported outcomes. A sub-sample of 211 was extracted where psychological screening (using two-item versions of the Patient Health Questionnaire (PHQ2) and the Generalised Anxiety Disorder scale (GAD2)) and inflammatory markers were recorded concurrently (&lt;14days). Inflammatory markers, joint counts, pain, fatigue, and global disease activity were also recorded. Network analysis was conducted based on egularised correlations between variables.

Results
The network highlights pain and PHQ2 (low mood) as having the highest degree (3.9 & 3.8) and betweenness centrality (22 & 10), indicating that they have the highest number of connections and provide the shortest pathway between symptoms, therefore act as key variables linking inflammation and mental health. Pain and global disease activity had the highest closeness centrality (0.033 & 0.032), illustrating that they have the shortest path with other symptoms, and capture the influence of both inflammation and mental health. Tender and swollen joints have weak connections with mental health variables, suggesting that extra-articular aspects of pain may be important.

Conclusion
Inflammation in RA does not have a strong influence on mental health, but pain appears to be the biggest influencing factor. Symptoms of mental health were all strongly connected, but low mood provides the main connection between clinical and psychological variables. This indicates mood as potentially a key variable, which is easy to monitor in routine care.

Disclosures
H. Tung None. S. Norton None. J. Galloway None. F. Matcham None. M. Hotopf None.
P254 Secukinumab provides rapid and sustained improvement in joint tenderness and swelling in patients with PsA: 2-year results from the Phase 3 FUTURE 5 study
Authors: McInnes Iain , Chinoy Hector , Asquith Darren , White Abigail , Gaillez Corine 
Published: April 2020

Abstract

Background
Tender joint count (TJC) and swollen joint count (SJC) are components of composite measures used to assess treatment response, which may be impacted by confounding factors. TJC and SJC used in psoriatic arthritis (PsA), which can affect small joints of the feet, assess 78 and 76 joints. TJC and SJC are effective measures of synovitis, a key measure of disease activity. We report 16-week through 2-year effects of secukinumab upon 78 TJC and 76 SJC in PsA patients in FUTURE 5.

Methods
996 patients with active PsA were randomised to subcutaneous secukinumab 300 mg with loading dose (LD), 150 mg with LD, 150 mg without LD or placebo. All patients received secukinumab or placebo at baseline, Weeks 1, 2, 3 and 4, and every 4 weeks thereafter. Placebo-treated patients were re-randomised to secukinumab 300 or 150 mg at Week 16 (non-responders) or 24 (responders). Secukinumab dose was escalated from 150 to 300 mg starting at Week 60 and maintained thereafter, if active signs of disease were observed by the physician. 78 TJC and 76 SJC were assessed at baseline, Weeks 1, 2, 3 and 4, every 4 weeks until Week 52, every 8 weeks until Week 92 and at Week 104. ACR20 response, 78 TJC and 76 SJC results are reported for the overall population over 2 years of treatment. Data are reported as observed.

Results
Baseline characteristics were comparable across treatment arms (Table 1). 783/996 (78.6%) patients completed 104 weeks of treatment. All secukinumab dose regimens (300 mg with LD, 150 mg with LD and 150 mg without LD) demonstrated rapid-onset ACR20 responses that were superior to placebo at Week 16 (adjusted P values: P &lt; 0.0001 for all secukinumab regimens) and increased to 77.0%, 79.4% and 82.4% at Week 104, respectively. Adjusted 78 TJC and adjusted 76 SJC improved in all secukinumab groups vs placebo by Week 4 through Week 16 and were sustained after 2 years of treatment (Table). Numerical differences were comparable between secukinumab doses.

Conclusion
Secukinumab provided rapid and sustained improvements in 78 TJC and 76 SJC over 2 years of treatment in patients with active PsA.

Disclosures
I. McInnes: Consultancies; AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, UCB. Honoraria; AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, UCB. Grants/research support; AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, UCB. H. Chinoy: Honoraria; Novartis. D. Asquith: Shareholder/stock ownership; Novartis. Other; Employee of Novartis. A. White: Shareholder/stock ownership; Novartis. Other; Employee of Novartis. C. Gaillez: Shareholder/stock ownership; Novartis, Bristol-Myers Squibb. Other; Employee of Novartis.
P283 Clinical predictors of switching biologic treatment in patients PsA: data from a single centre over 17 years
Authors: Naja Meena , Santos Liliana R , Greenwood Mandy , Castelino Madhura 
Published: April 2020

Abstract

Background
Management of PsA has included biologic agents (bDMARDs) since the early 2000s, in addition to conventional disease-modifying antirheumatic drugs (csDMARDs). Switching of bDMARD treatment is currently common clinical practice in treatment failure. Our aims were to determine the most prescribed first line bDMARDs, reasons for switching and any clinical factors at baseline that may predict switching in PsA.

Methods
Data was analysed retrospectively from a cohort of 400 PsA patients followed through from 2002-2019. Statistical analysis was carried out (logistic regression, analysis of variance and descriptive statistics) using SPSS version 22.

Results
The median age at baseline was 38.4 years (interquartile range [IQR] 29.8 - 53.3 years), 52.5% were female. bDMARDs were started in 220 of the 400 patients (55.0%). Initial therapy was a TNFi in 212 patients (96.3%). The median age of those started on bDMARDs was 33.7 years (IQR 27.5 - 48.2 years), 52.5% were female. The most frequently prescribed was adalimumab (59.5%), followed by etanercept (33.2 %) and infliximab (3.2%). 106 out of the 220 patients (48.2%) were on at least one concomitant csDMARD. 83 patients (37.8%) switched to a second bDMARD; 69 of these (83.1%) switched to a second TNFi. The commonest reasons for switching were primary or secondary inefficacy (61.0%) and adverse events (33.7%). The median duration on the first bDMARD was 11.6 months (IQR 3.8 - 30.1 months). Of the 83 patients who commenced a second bDMARD, 45 (54.2%) switched to a third bDMARD. The median duration on the second bDMARD was 10.0 months (IQR 3.0 - 33.0 months). The main reasons for the second switch were primary or secondary inefficacy (44.4%), adverse events (42.2%) and a combination of the two (11.1%). Patients who switched onto a second bDMARD were more frequently female (57.8%), had longer disease duration (14.01 versus 13.2 years), higher pain scores (84.2 versus 66.0) and higher tender/swollen joint counts compared to non-switchers at baseline. Patients using csDMARDs at baseline were more often responsive to initial bDMARD treatment than those on bDMARD alone (63.2% response versus 45.1%), but this was not statistically significant (p value &gt;0.05). There was no significant change in drug survival of the first bDMARD if the patient was concurrently taking csDMARDS. A high ESR at baseline was associated with increased risk of switching from a second bDMARD to a third (odds ratio 1.20, p = 0.036).

Conclusion
We found that females, those with longer disease duration, higher subjective elements to disease activity at baseline were more likely to switch from initial bDMARD therapy. A high baseline ESR was associated with switching onto a third line bDMARD. Interestingly, the concurrent use of csDMARDs had no significant effect on the drug survival or efficacy of bDMARD therapy.

Disclosures
M. Naja None. L. R. Santos None. M. Greenwood None. M. Castelino None.
Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis
Authors: Zhao Sizheng Steven , Robertson Selina , Reich Tzvi , Harrison Nicolas L , Moots Robert J , Goodson Nicola J 
Published: April 2020

AbstractObjectivesComorbidities are common in people with axial spondyloarthritis (axSpA). In this systematic review and meta-analysis, we aimed to: (i) describe the prevalence of commonly reported comorbidities, (ii) compare comorbidities between axSpA and control populations, and (iii) examine the impact of comorbidity burden on axSpA outcomes.MethodsWe systematically searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We excluded studies of only one comorbid condition or a few closely related diseases within one organ system. Where possible, meta-analysis was performed using random-effects models.ResultsA total of 40 studies were included for analysis. 36 studies reported prevalence of comorbidities, amounting to a combined sample size of 119 427 patients. The number of comorbidities studied ranged from 3 to 43. The most prevalent individual comorbidities were hypertension (pooled prevalence 23%), hyperlipidaemia (17%) and obesity (14%). Eleven studies consistently showed higher prevalence of comorbidities in axSpA than controls, particularly large differences were seen for depression [pooled odds ratio (OR) 1.80] and heart failure (OR 1.84). Comorbidities (total number of and individual conditions) were also associated with axSpA disease activity, functional impairment, quality of life, work productivity and mortality.ConclusionsComorbidities are common in axSpA, particularly cardiovascular diseases and risk factors. Most comorbidities were more prevalent in axSpA patients than in control populations. Overall comorbidity burden, and many individual conditions, were associated with axSpA outcomes including worse disease severity, work productivity and mortality.