British Society Of Rheumatology Research Articles

P033 Online educational resources in paediatric and adolescent rheumatology- what’s new?

Abstract Background/Aims Paediatric and adolescent rheumatology (PAR) is a small sub-specialty, and due to the rarity of some conditions, UK trainees find it difficult to access relevant educational materials. Furthermore, due to the wide geographical distribution of paediatric rheumatology centres, regional educational opportunities are limited. A 2022 survey of the UK PAR trainee group confirmed that the creation of more PAR specific online educational materials and signposting of current guidelines/ resources was needed. Survey participants were supportive of a range of delivery methods, including webinars, e-learning, case studies and podcasts. Methods A PAR trainee education team was formed in 2022, with the aim of promoting learning opportunities, by developing and collating educational resources. The PAR trainee education team has been working both independently and in conjunction with the British Society of Rheumatology (BSR) education team and Digital Learning Board (DLB) to achieve this aim. Activities have included the following: a) Creation of a BSR hosted Teams channel to store PAR specific educational information; b) PAR trainee inclusion on the BSR DLB, which creates digital education resources including podcasts and the monthly blended learning Spotlight topic series; c) Creation of PAR focused podcasts within the BSR Talking Rheumatology podcast series; d) Organisation of webinars on PAR relevant topics; e) Creation of a PAR podcast playlist on the Spotify platform; f) Production of a resource list and education newsletter to signpost relevant existing/upcoming learning opportunities and events. Results A 2023 follow up survey of the PAR trainee group (n = 16 respondents), showed the most used resources were podcasts (69%), the newsletter (63%) and resource list (43%). Webinars (38%), the Teams channel (38%) and the BSR Spotlight series (31%) had been accessed less. BSR podcast download data illustrated that PAR relevant podcasts from the Talking Rheumatology/ Talking Rheumatology Spotlight series have a UK and international audience. There have been over 2500 downloads from six PAR relevant podcasts covering myositis guidelines, biologics in PAR, HLH, antiphospholipid syndrome and ultrasound in PAR. Feedback from those who have used the various educational resources has been extremely positive, although comments have indicated a barrier in terms of awareness of the materials and how to access them. Conclusion Good progress has been made, however maximising means and opportunities to disseminate available resources within the PAR community is vital. Work to develop, collate and signpost more PAR educational content is ongoing. A project is in progress to create condition-specific lists of classification criteria, guidelines and key studies. The PAR trainee group are very grateful to all of those who have supported this work including the professionals who have shared their knowledge and expertise via podcasts and webinars, members of the BSR DLB and the education team at BSR. Disclosure J. Lemon: Other; Unpaid member of the BSR Digital Learning Board. R. Close: None. G. Dobson: None. K. Maxey: Other; Works for the BSR as Events and Education Officer. J. May: None. D. McLaughlin: None. I. Rajarathinam: None. S. Saadalla: None. L. Yeo: None. P.A. Watson: Other; Works for the BSR in a paid role (2PA per week ) as digital learning editor.

P089 Comprehensive comparison of current guidelines in the management of Systemic Lupus Erythematosus in children, with a focus on Lupus Nephritis

Abstract Background/Aims Lupus nephritis (LN) is a common complication of systemic lupus erythematosus (SLE); LN affects 50-60% of those with a diagnosis of childhood-SLE (cSLE). Currently one set of paediatric recommendations exists for the diagnosis and treatment of LN, published by the Single Hub and Access point for Paediatric Rheumatology in Europe (SHARE). This paper compares SHARE recommendations against two current sets of adult guidelines, published by the British Society of Rheumatology (BSR) and the European Alliance of associations for Rheumatology (EULAR). This paper aims to identify similarities and differences between the three sets of guidelines, and to evaluate the evidence base used to formulate them. Methods Paediatric SHARE recommendations were recorded within a spreadsheet. The recommendations were separated into recommendations for diagnosis and recommendations for treatment. The BSR paper was then examined for equivalent guidelines. The evidence level was recorded for each guideline. In the second phase, the EULAR 2019 guidelines were assessed for corresponding guidelines to the SHARE recommendations. EULAR levels of evidence were recorded. A Likert score of similarity (0-10) was assigned to each trio of guidelines (the trio consisting of one each from SHARE, BSR and EULAR). If a comparable guideline couldn’t be found in either the BSR or EULAR papers, this is made clear in the table. Results When comparing six diagnostic SHARE recommendations for paediatric LN with equivalent BSR and EULAR guidelines, the Likert similarity score ranged between 0-9. Only 50% of the 20 treatment SHARE recommendations had a Likert score ≥5 with their equivalent BSR and EULAR guidelines. Three SHARE treatment recommendations had no comparable guidelines, these are clearly identified in the results tables. All SHARE recommendations were based on level 3 or 4 evidence. Level 3 evidence comes from descriptive studies, whilst level 4 evidence comes from expert opinion and is considered the lowest level of evidence. Conclusion The quantity of differences noted in this paper leads to questioning whether transitional guidelines should be developed for care of young adults with LN to ensure safe transition as they move from paediatric to adult medical care. LN is a chronic condition that will impact a child’s entire life. Optimising care from as early in life as possible and continuing this into the future is essential to maximising quality of life and reducing adverse outcomes associated with renal involvement. Disclosure J.A. Day: None. M.W. Beresford: None.

P037 Rheum for more? A systematic literature review on undergraduate exposure to rheumatology

Abstract Background/Aims Since the introduction of Modernising Medical Careers by the General Medical Council in the United Kingdom (UK) in 2007, newly-qualified doctors are expected to choose their specialty much sooner than previously. A recent report published by the British Society of Rheumatology (BSR) in 2021 demonstrated a lack of exposure to the specialty for medical students. We conducted a systematic literature review on the quantity and quality of rheumatology teaching amongst undergraduate medical students. Methods Articles published until June 2023 were included. Eligible articles were: case reports and series, observational studies, qualitative studies and randomised control trials. Medline, Embase, PyscINFO, Cochrane library and WHO international clinical trial registry were searched, restricted to English language articles only. Articles including postgraduate trainees and those pertaining to a single intervention or single student cohort were excluded. Information was extracted on demographics, method of teaching, hours dedicated to rheumatology and students’ and educators’ feedback where mentioned. Results After deduplication, 1195 article were identified. After screening title and abstract, 1156 papers were excluded, with 39 proceeding to full text screening. Ultimately, seven articles (all cross-sectional surveys) were included. Publication year of included articles ranged from 1981 to 2018. The countries of included studies were UK (3), USA (2), Australian (1) and Pan-European (1). Year of rheumatology teaching at medical school was reported in four studies (3 UK and 1 USA). The three UK studies were all taught in the latter years (4-6), whereas in the USA study the students were taught at every single year. Where reported, data on the number of hours of exposure to rheumatology were variable, ranging from 15 to 96 hours per medical student. Reported method of teaching included lecture-based, rheumatology inpatient service and shadowing consultations. Student feedback was only provided in one (UK-based) study, from 49 students of whom two regarded rheumatology as “fascinating”, four felt that they had limited exposure and eight considered it as “a niche specialty of no interest”. No feedback from educators were collected in any of the included studies. Factors identified by the included studies for overall poor exposure to rheumatology included: lack of having full-time rheumatologists on the school’s faculty, lack of specialty training programme in their local teaching hospital and greater emphasis on general medical/ acute specialties (e.g. general practice and emergency medicine). Conclusion Overall, there are significant limitations in recording the amount and quality of rheumatology teaching amongst undergraduate medical students. Exposure to clinical rheumatology has markedly decreased over time, with variable student awareness of the speciality. Given the ageing UK population and increase in multimorbidity, there is a need to increase exposure and entry to the specialty, which may be partly facilitated by improved incorporation of rheumatology in the undergraduate curriculum. Disclosure K. Kouranloo: None. N. Myall: None. J. Christie: None.

OA27 Growth of the UK and Ireland paediatric rheumatology nurses’ group

OA27 Growth of the UK and Ireland paediatric rheumatology nurses’ group

P025 Do referrals to rheumatology meet the new British Society of Rheumatology (BSR) guidelines for adult patients with osteoporosis? A retrospective audit of a tertiary osteoporosis service

Abstract Background/Aims British Society of Rheumatology (BSR) released national guidance in September 2021 outlining appropriate referrals to adult rheumatology departments from primary care. Our tertiary metabolic bone service accepts referrals from primary care, secondary care and internal referrals. Methods We retrospectively audited the new patient referrals for 50 patients with osteoporosis seen in our clinic over the 6 months prior to the guidance publication. 86% were referred from primary care, 6% from secondary care and 8% from our orthopaedic colleagues. 92% patients were female and 8% patients were male. Mean age was 61.7 years (range 17- 85 years). Results: We found that the majority of patients with osteoporosis referred to our specialist service were within the new BSR guidance (45/50 patients or 90% of patients). Reasons for referring patients outside of the BSR guidance included deterioration in bone mineral density without fracture and a family history of osteoporosis. Of these patients, four were referred from primary care and one from secondary care (another rheumatology department). Of the 50 patients seen in our clinic, 48% were advised to commence parenteral bone protection medication. 2% were advised to start hormone replacement therapy (HRT) only. 6% were advised to either start or continue oral bisphosphonates. 38% of patients were advised to remain without bone protection treatment and monitor. 2% were given an alternate diagnosis other than osteoporosis. Conclusion We plan to undertake a further audit for a period of 6 months after the release of the guidance. No funding to declare Disclosure F. Baldeweg: None. J. Bubbear: None. R. Keen: None.

OA25 Is it time for patient-initiated methotrexate monitoring?

Abstract Background/Aims Regular blood monitoring is recommended to ensure safety in patients on methotrexate (MTX). During the COVID pandemic, British Society of Rheumatology (BSR) sanctioned a reduction in monitoring for patients stable on MTX for 12 months. In accordance Devon CCG approved changing local Shared Care Guidelines (SCG), reducing the frequency to six monthly in stable MTX patients. Our aim was to assess whether monitoring frequency changed during the pandemic, and if so whether any patients came to harm. Methods Patients stable on MTX monotherapy for at least a year to 31.3.2020 were identified via hospital pathology. 854 patients identified; the mean number of days between monitoring requests was calculated for the year to April 2020, and year to April 2021, respectively. A sub-analysis of 229 patients who had reduced from monthly to three monthly blood tests at similar time points was undertaken. Tests included: platelets (PLT), mean cell volume (MCV), neutrophils (NEUT), estimated glomerular filtration rate (eGFR), and alanine aminotransferase (ALT). Confidence intervals evaluated any differences in the results between monthly and three-monthly frequencies, in terms of overall distribution as well as at an individual patient level. Additionally, the numbers of ‘catastrophic' test results, as defined by the Royal College of Pathologists, were calculated for the higher frequency and reduced frequency years. Results Testing frequency in the year to April 2020 approximated to monthly, and three-monthly in the year to April 2021. Sub-analysis in 229 patients showed the overall distributions of PLT, MCV, NEUT, eGFR and ALT results were no more likely to be outside normal laboratory parameters when tested less frequently. Furthermore, individual patients were no more likely to have results outside normal laboratory parameters with less frequent testing. Overall, our analysis indicated that reduced monitoring did not lead to more abnormal results. Additionally, ‘catastrophic’ results were extremely uncommon, and did not increase with reduced testing. Routine MTX monitoring revealed no catastrophic results, these only occurred in patients being managed for co-existing morbidities. Conclusion MTX monitoring reduced during the pandemic but not in adherence to updated SCG. We evidence that reducing frequency of routine blood monitoring did not increase abnormal results or cause harm in stable MTX patients. Significant blood abnormalities were rare and universally occurred only with co-existing morbidities. Across primary and secondary care workloads are increasing, resources are limited, and cost efficiencies needed. These findings support a review of the frequency of routine blood monitoring; is now the time to shift to patient-initiated testing in those stable on MTX monotherapy? Disclosure N.A.E. Wood: None. L. Farmer: None. R. Manhas: None. T. Lewis: None. S. Kyle: None.

P001 Audit on giant cell arteritis fast track clinic in Tayside

Abstract Background/Aims Giant cell arteritis (GCA) is a systemic inflammatory disease of medium to large sized arteries. Diagnosis of GCA is a medical emergency due to the consequence of permanent blindness if not treated early with glucocorticoids. The objective of this audit was to assess the effectiveness of the GCA fast track clinic (FTC) in NHS Tayside. The current practice was compared with British Society of Rheumatology (BSR) standards. Methods This was a retrospective audit from March 2019 to May 2021. All patients referred with suspicion of GCA were included. Main outcomes measured were referral time, investigations and management. Data were collected through electronic records. Results 120 patients were included (median age 71 years; F71.7%). 35% of patients were diagnosed with GCA. Most common symptoms were headache (94.2%), jaw claudication (26.7%), visual symptoms (36.7%), PMR symptoms (21.7%), systemic symptoms (50%). As seen in Table 1, 50% with visual symptoms were seen by ophthalmology within 24 hours. 70.8% were seen by rheumatology within 24 hours. 89% were given steroids within 24 hours from suspicion. 80.8% were investigated with ultrasound or biopsy. Comparing with expected standards, provision of written information, advice on recurrence of symptoms, calculation of CRP, documentation of bone protection was achieved at 100%. Immediate follow-up time was 6 weeks. One patient lost vision while on steroids. Conclusion Early recognition and prompt management of GCA is crucial for a good prognosis. NHS Tayside’s FTC has allowed for quick evaluation for most patients within 24 hours and has improved prognosis in patients. Disclosure D. Subramanian: None. S. Bhat: None.

P157 Poverty and paediatric rheumatology

Abstract Background/Aims 30% of UK children live in poverty, which is associated with a multitude of long-lasting adverse outcomes. Healthcare workers have a vital role in addressing the psychosocial wellbeing of children, which extends to identifying children living in poverty and how this impacts upon their health. Navigating this is challenging. This project reviews the literature to present how poverty impacts child health, with particular reference to patients with juvenile idiopathic arthritis (JIA). Practical suggestions are outlined to signpost and support children and families in need. Methods Information was sought from resources such as the Royal College of Paediatricians, British society of Rheumatology and Child Poverty Action Group. Further literature was sought via sequential PubMed searches with relevant terms. This project provides a report, rather than systematic review, of the literature. Results Poverty disproportionately affects children with JIA from diagnosis to adulthood. A US study demonstrated that children living in deprived areas were significantly more likely to experience delays in presenting to a paediatric rheumatologist. In the UK poorer children are more likely to present via the emergency department, reflecting potential areas to improve the patient journey. Low socioeconomic status is a strong predictor of poor medication adherence and appliance poverty may prevent appropriate drug storage. Families that are experiencing in-work poverty may also be ‘time poor’, which could result in suboptimal appointment attendance and engagement. JIA places an additional financial stressor on families in poverty due to the cost of travel, parking, childcare and loss of income. Additionally, JIA may impact on the earning potential of young people themselves. JIA impacts school attendance and achievement and is associated with reduced employment. The impact of JIA on education is likely to be amplified for children living in poverty, which has a strong link with absenteeism. Children with JIA from low socioeconomic groups experience more severe disease outcomes and are more likely to have a poorer health reported quality life. Lower socioeconomic status in childhood is also associated with higher prevalence of chronic pain in both childhood and adulthood. Conclusion It is vital that we think beyond the investigations we order and drugs we prescribe, and consider social investigation and prescribing as part of our practice. An ‘Ask, Action, Advocate’ strategy is recommended. Evidence suggests that families welcome healthcare staff asking about financial difficulty during consultations. Professionals can take action by signposting families to the wealth of resources available to help meet basic needs, increase income, and provide social and emotional support. Advocating for the most vulnerable families by considering where your service could be improved for those in financial hardship is crucial. Professionals are encouraged to learn more, and share knowledge. Disclosure L. Crosby: None.

P015 Rheumatology Patient Initiated Follow-Up (PIFU) in a busy urban district general hospital - a scoping exercise

Abstract Background/Aims A recent report from British Society of Rheumatology (2021) highlighted severe national shortages in the rheumatology workforce. Patient Initiated Follow-Up (PIFU) is an innovative strategy for stable patients, reducing the need for “routine follow-up”. PIFU allows patients to contact their local department and organise a clinical review if they have a disease flare. In our model, a back-up appointment is made to allow ongoing future management such as drug de-escalation. PIFU has been trialled successfully in other trusts, where 20% of follow-up patients were deemed suitable. Our aim was to perform a scoping exercise to determine if PIFU would be suitable for our multi-ethnic diverse cohort in a busy urban district general hospital. Methods PIFU inclusion, exclusion and disease-related criteria were developed with input from departments already running PIFU. Patients were considered for PIFU if over 18 years old with a diagnosis of stable inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, axial spondyloarthropathy) evidenced by low disease scores, no change in disease modifying drugs or steroid use in the last 12 months. Our criteria were applied retrospectively to all patients who attended consultant and registrar General Rheumatology clinics from 20th-31st January 2020. Data were collected on demographics, rheumatological diagnosis and suitability of eligible patients for PIFU. Results 340 follow-up patients attended clinic during the 2-week period, of which 136 did not have a rheumatological condition suitable for PIFU (including osteoporosis, osteoarthritis and connective tissue disease). 42 (20.6%) of the 204 patients with eligible conditions were deemed suitable for PIFU. This represented 12.4% of our total follow-ups. In our current practice, the routine follow-up for the 42 suitable patients was arranged for a median time of 9 months (IQR: 7.75-12 months). If PIFU patients were allocated a back-up appointment at 3 years, PIFU would represent a saving of 3 routine appointments per patient over 3 years. For a full-time consultant, seeing 40 follow-ups per week, this would save 4.9 appointments per week or 198 appointments per year. Conclusion 12.4% of our follow-up patients were deemed eligible for PIFU, which was lower than other trusts. This may be due to the low sample size or increased diversity and social complexity of our local population. Even with this lower percentage of eligible patients, PIFU may allow freeing of nearly five appointments per full-time consultant per week. PIFU may also empower patients to take ownership of their condition and enable confidence in self-management. If a PIFU service was set up locally, a robust pathway would be needed to ensure that patients could contact the department when required. The need for annual disease review would also need to be considered using primary care or IT solutions. Disclosure N. Mothojakan: None. L. St.Aimee: None. C. Quieros: None. N. Horwood: None. S. Levy: None. R. Sathananthan: None.

O03 Continuation of golimumab (anti-TNF) in a patient with SpA and low-risk prostate cancer, what is the right decision?

Case report - IntroductionGolimumab is an anti-TNF alpha drug used in the treatment of inflammatory arthritis including spondyloarthritis (SpA). The introduction of this drug class has revolutionised the treatment of SpA over the last 20 years with significantly improved patient outcomes.Despite their treatment benefits multiple adverse effects of TNF-alpha inhibition have been reported through clinical trials including a possible increased risk of malignancy.We describe a case of a patient with known ankylosing spondylitis (AS) on golimumab who was diagnosed with low-grade prostate carcinoma and discuss the factors taken into consideration in guiding our decision-making process regarding ongoing treatment. Case report - Case descriptionA 57-year-old gentleman with known AS presented to the rheumatology clinic for routine review. His AS was well controlled, and he had been taking golimumab for the past 3 years. Upon review he was in clinical remission with a CRP <1 and ESR 5. Prior to the initiation of anti-TNF therapy his disease had been poorly controlled. However, following commencement his symptoms had significantly improved and he was able to work as a professional sports coach whilst bringing up a young family.On review he had recently been diagnosed with low-risk cancer of the prostate by his urologist. A prostate biopsy found Gleason 3 + 3 adenocarcinoma involving 2 out of 22 cores on each side, with a prostate specific antigen (PSA) of 3.95ng/ml. An MRI had shown chronic prostatitis. He was in the lowest risk category of grade group 1 prostate cancer and no treatment for his prostate cancer was indicated. The plan from his urology team was active surveillance with PSA monitoring.Whilst being investigated for possible malignancy his golimumab had been held for six months and during this period he had a significant flare in symptoms. He experienced severe back pain that forced him to stop working. Following his prostate cancer diagnosis, golimumab was restarted by his urologist with a subsequent improvement in his AS symptoms.To guide ongoing treatment his case was reviewed in the local biologics multi-disciplinary team meeting, alongside close communication with his urologist. The patient was informed of the risks of continuing golimumab in relation to his malignancy. Despite this he was reluctant to stop anti-TNF therapy or switch to another treatment, citing concerns about the impact it might have on his symptoms and ability to work.Case report - Discussion This case highlights the complexities involved in the management of a patient on anti-TNF therapy, who receives a diagnosis of malignancy, particularly when the diagnosis is classed as low risk. Traditionally anti-TNF therapy was contraindicated for patients with a history of a solid organ tumour within the previous five years. The British Society of Rheumatology (BSR) guidelines recommends that patients should be advised that there is no conclusive evidence for an increased risk of solid organ tumours but that on-going vigilance is required.A holistic patient-centred approach needs to be taken in these contexts, and consideration of cases on an individual basis is needed. Inter-disciplinary and multi-speciality team input, with the effective use of a biologics MDT, is crucial. The patient was understandably reluctant to stop his treatment due to the significant impact this may have on his quality of life.On liaison with his urologist his prostate cancer was in the lowest risk category with 99% 5-year survival rates with low risk of disease progression or spread.Evidence in this field to date has been conflicting and studies have predominantly focused on the safety of anti-TNFs in rheumatoid arthritis patients. Recent large national registry data has been reassuring. Few studies have looked at the AS and psoriatic arthritis anti-TNF treated population; however, a meta-analysis of RCTs found no evidence of increased incidence of malignancy.Taking into account his low-risk cancer, the patient’s wishes and clinical evidence in this field we have made to decision to continue anti-TNF treatment for now but with ongoing surveillance for any tumour progression. The patient will undergo urology follow up alongside regular PSA monitoring, and there will be a low threshold to stop or switch treatment in the futureCase report - Key learning pointsTreatment with anti-TNF therapy in patients with concomitant inflammatory arthritis and malignancy pose a specific challenge that require close co-ordination of care between rheumatologists, oncologists, other relevant teams and may benefit from the use of local biologics MDT to guide ongoing drug therapy.It is important to take a patient centred approach and consider cases on an individual basis taking into account their cancer diagnosis, extent of disease, histology findings and their response to TNF treatment.Patients must always be counselled on the risk of continuing anti-TNF and be involved in the decision-making process.Further research is required to look at the safety of anti-TNF particularly in SpA and if there is an increased risk of malignancy.

Rheumatologists rapidly adjust patient care during COVID-19 pandemic.

Rheumatologists rapidly adjust patient care during COVID-19 pandemic.

Temporal artery biopsy harvesting length audit, patient satisfaction with post op management. A guide for clinical commissioning group planning

Introduction Giant cell or temporal arteritis (GCA) is a vasculitis mainly affecting patients over 50yrs. Diagnosis is facilitated by a temporal artery biopsy (TAB). Due to the increased risk loss of visual loss, patients are started on high dose steroids to reduce this risk. However, a timely diagnosis with the aid from a TAB can help steer the patient into a more medically directed pathway of an appropriate reduction or prolonged use of steroids. We used British Society of Rheumatology (BSR) guidelines to audit our harvest length (recommend > 20 mm) and a telephone questionnaire to follow up patients.

Guidelines and Recommendations Towards Evidence-Based Management of Systemic Sclerosis

The preferred treatment of systemic sclerosis (SSc) is unclear due to an incomplete understanding of disease pathogenesis, variations in disease manifestations and variable quality of evidence to support treatment decisions. The objectives of this article are to discuss the value of clinical practice guidelines, critique guideline development and uptake, compare SSc-specific guidelines and highlight consensus-based treatment algorithms to complement guidelines when recommendations and/or high-quality evidence are lacking. Thirty-nine guidelines or recommendations for the screening, diagnosis, treatment and conduct of trials in SSc have been published. Four publications contained guidance on the treatment of multiple domains. The European League Against Rheumatism and the EULAR Scleroderma Trial and Research group guidelines were published in 2009 and updated in 2017. The British Society of Rheumatology and the British Health Professionals in Rheumatology published guidelines in 2016. The Brazilian Society of Rheumatology published SSc guidelines in 2013. The absence of recommendations for the preferred order of therapy is a limitation of all published guidelines. Treatment algorithms, based on SSc expert consensus, were proposed in 2012 and updated in 2018. These algorithms are complementary to the guidelines, as they provide expert consensus in areas of uncertainty. SSc-specific guidelines and treatment algorithms provide evidence-based and/or expert consensus-based recommendations on how to treat patients with the intention of reducing inappropriate practice variability and improving patient outcomes.

An update on the management of gout

Gout is the most common form of inflammatory arthritis and its incidence in the UK has steadily increased from 1.5% in 1997 to 2.5% in 2012.1,2 It is characterised by...

Temporal artery biopsy in the diagnosis of giant cell arteritis: Does the end justify the means?

BackgroundEarly temporal artery biopsy is recommended in all patients with suspected cranial GCA (Giant Cell Arteritis) by the BSR (British Society of Rheumatology) and BHPR (British Health Professionals in Rheumatology) guidelines. This should be performed within one week ideally.AimTo assess ACR (American College of Rheumatology) score at presentation and whether temporal artery biopsy result affects clinical management of the clinically suspected GCA patient.MethodCase records of all temporal artery biopsies performed within January 2012 until December 2014 were analysed for size and result of biopsy and this was correlated to clinical management following result.Results129 temporal arteries were biopsied with a total of 17 positive biopsy results. 10 biopsy samples were insufficient to confirm or refute GCA. 8 patients within the biopsies negative for GCA had their prednisolone therapy stopped. 5 patients had unknown follow up, with the remainder (89, 87.3%) of the patients continued prednisolone management for treatment of GCA for at least 6 weeks.ConclusionOverall 13.2% of our biopsies were positive for GCA and 87.3% of biopsy negative patients continued prednisolone therapy on clinical grounds. In the face of new diagnostic tests (high resolution MRI (Magnetic Resonance Imaging), colour duplex USS (Ultra Sound Scan) and PET (Positive Emission Topography) can we justify invasive surgery to all patients on histological grounds when the results may not alter management? Further investigation is needed directly comparing newer imaging modalities to histology.

Evidence-based management of systemic sclerosis: Navigating recommendations and guidelines.

Systemic sclerosis (SSc) is a rare heterogeneous connective tissue disease. Recommendations addressing the major issues in the management of SSc including screening and treatment of organ complications are needed. The updated European League Against Rheumatism/European Scleroderma Trial and Research (EULAR/EUSTAR) and the British Society of Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guidelines were compared and contrasted. The updated EULAR/EUSTAR guidelines focus specifically on the management of SSc features and include data on newer therapeutic modalities and mention a research agenda. These recommendations are pharmacologic, with few guidelines regarding investigations and non-pharmacologic management. Recommendations from BSR/BHPR are similar to the organ manifestations mentioned in the EULAR/EUSTAR recommendations, and expand on several domains of treatment, including general measures, non-pharmacologic treatment, cardiac involvement, calcinosis, and musculoskeletal features. The guidelines usually agree with one another. Limitations include the lack of guidance for combination or second-line therapy, algorithmic suggestions, the absence of evidence-based recommendations regarding the treatment of specific complications (i.e., gastric antral ectasia and erectile dysfunction). Consensus for when to treat interstitial lung disease in SSc is lacking. There are differences between Europe and North American experts due to access and indications for certain therapies. Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc and future updates of these recommendations. Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc.

SYSTEMIC VASCULITIS: NOVELTY IN CLASSIFICATION, DIAGNOSIS, AND TREATMENT

Systemic vasculitides (SV) are a heterogeneous group of acute and chronic diseases, the most important pathomorphological sign of which is inflammation and necrosis of the vascular wall. The basis for the classification of SV is their etiology and pathogenesis, the type of affected vessels and the pattern of inflammation, predominant organ involvements, clinical manifestations, a genetic predisposition, and demographic characteristics. To diagnose vasculitis is a difficult task due to a broad spectrum of its clinical manifestations that depend on the predominant size of affected vessels, the involved organs and systems, and the magnitude of the inflammatory process. There are no specific laboratory tests for most forms of SV; nonspecific inflammatory measures and activated autoimmune reactions are noted to be higher. Screening for SV determines the levels of anti-neutrophil cytoplasmic antibodies (ANCA), cryoglobulins, anti-glomerular basement membrane antibodies, and anti-complement C1q antibodies. However, biopsy with its specimen being pathomorphologically characterized, as well as current noninvasive or minimally invasive diagnostic techniques remain relevant because of a large number of seronegative variants of vasculitis. The ANCA-associated vasculitis management algorithm developed by the British Society of Rheumatology has been presented in 2015. The timely diagnosis and treatment at the onset of SV is the basis for quality of life and survival improvement.

Management of Gout in Primary Care is Suboptimal- Audit

Introduction: The soaring incidence of gout in the United Kingdom suggests that medical practitioners should be increasingly aware of optimizing management of gout, which is aimed at pain relief, preservation of joint function and preventing recurrent attacks. Recent guidelines published by the British Society of Rheumatology (BSR), have provided clinicians with a framework for achieving these aims. Aims : To evaluate the management of gout in a primary care centre in North West England against recognized standards. Methods : An electronic search on EMIS Web using the Read codes “gout” and “gouty arthritis”, with a specified period of 2010–2013, generated a cohort of patients who were categorized into 2 groups: those prescribed urate-lowering therapy (allopurinol) and those not. Patients on febuxostat were excluded. Clinical data from the patients were extracted and retrospectively audited. Results : A total of 112 patients were identified, of which only 46% ( n = 52) of patients were reviewed after an acute attack. Among those who were prescribed allopurinol, only 19% ( n = 12) achieved target serum urate levels while only 67% ( n = 42) had their serum urate levels checked regularly and 31% ( n = 20) had dosage adjustments. Comparatively, in patients not prescribed allopurinol, a few indications for initiating allopurinol were detected: 29% ( n = 12) had more than one attack of gout in a year, 27% ( n = 11) suffered from renal insufficiency, 2% ( n = 1) presented with tophi, and 17% ( n = 7) were on diuretics. Conclusion : Gout management in this primary care centre is not fully concordant to the BSR guidelines. Clearly, there is a need to improve adherence, particularly in the tight monitoring of serum uric acid levels, medications review, appropriate use of allopurinol, where indicated, and patient follow-up.

Proposed PMR Guidelines Aim to Standardize Therapy

Proposed PMR Guidelines Aim to Standardize Therapy

FRI0180 Do Shared Care Schemes Work for Methotrexate Monitoring?

BackgroundMethotrexate (MTX) is widely used as a disease modifying agent in rheumatic disease.1 The National Patient Safety Agency (UK) have previously highlighted the potential hazards of MTX therapy and requested...