Rheumatology Department Research Articles

Immunogenicity of Covishield vaccine in patients with autoimmune rheumatic diseases.

The Coronavirus disease 2019 (COVID-19) pandemic has been the biggest threat to humankind during the last 3 years. It has caused the loss of more than 6.9 million precious lives across the world. The only method by which the massacre could be stopped was by mass vaccination or mass immunization. The patients suffering from autoimmune rheumatic disorders (AIRDs) and treated with immunosuppressants were the high-priority candidates for vaccination. However, the data regarding the efficacy of COVID-19 vaccines in this group of patients are very less. Hence, this study was planned to study the immunogenicity of Covishield in patients with AIRDs attending the rheumatology OPD at DMCH, Ludhiana. It was a prospective cohort study and was planned by the Department of Biochemistry and Department of Clinical Immunology and Rheumatology at Dayanand Medical College and Hospital, Ludhiana. Fifty patients with AIRDs attending the DMCH rheumatology OPD and 52 age and sex-matched healthy controls who had received two doses of Covishield vaccine were included in this study. Patients having any other immunosuppressive conditions like uncontrolled diabetes, hepatitis, malignancy or HIV were excluded. Patients who had suffered from previous laboratory-confirmed COVID-19 infection (by RT-PCR) were also excluded. Blood samples were collected following all aseptic precautions from patients and controls on the 28th day after administration of a second dose of Covishield vaccine and total antibodies to the severe acute respiratory syndrome coronavirus 2 spike (S) protein receptor binding domain was measured using Elecsys Anti-SARS-CoV-2 S kit from Roche. It was observed that no significant difference was there in antibody titre between cases and controls (6213 ± 4418 vs. 8331 ± 7979, P = 0.1022). It was also observed that no statistically significant difference in antibody titre in cases without prednisolone and those taking treatment with prednisolone was found (P = 0.7058). A similar observation was found in terms of methotrexate also (P = 0.457). No significant difference in antibody titres was there when compared with controls (for prednisolone, P = 0.169, for methotrexate, P = 0.078). We found that only the patients receiving mycophenolate mofetil showed a statistically significant decrease in antibody titre in comparison to healthy controls (P = 0.03). Our study showed no statistically significant difference in antibody titres between patients suffering from different AIRDs. Our study supplements the fact that patients with AIRDs in India can receive Covishield as the primary vaccine against COVID-19 without concerns regarding decreased immunogenicity or increased adverse effects.

The Florida Scoring System for stratifying children with suspected Sjögren's disease: a cross-sectional machine learning study.

Childhood Sjögren's disease is a rare, underdiagnosed, and poorly-understood condition. By integrating machine learning models on a paediatric cohort in the USA, we aimed to develop a novel system (the Florida Scoring System) for stratifying symptomatic paediatric patients with suspected Sjögren's disease. This cross-sectional study was done in symptomatic patients who visited the Department of Pediatric Rheumatology at the University of Florida, FL, USA. Eligible patients were younger than 18 years or had symptom onset before 18 years of age. Patients with confirmed diagnosis of another autoimmune condition or infection with a clear aetiological microorganism were excluded. Eligible patients underwent comprehensive examinations to rule out or diagnose childhood Sjögren's disease. We used latent class analysis with clinical and laboratory variables to detect heterogeneous patient classes. Machine learning models, including random forest, gradient-boosted decision tree, partial least square discriminatory analysis, least absolute shrinkage and selection operator-penalised ordinal regression, artificial neural network, and super learner were used to predict patient classes and rank the importance of variables. Causal graph learning selected key features to build the final Florida Scoring System. The predictors for all models were the clinical and laboratory variables and the outcome was the definition of patient classes. Between Jan 16, 2018, and April 28, 2022, we screened 448 patients for inclusion. After excluding 205 patients due to symptom onset later than 18 years of age, we recruited 243 patients into our cohort. 26 patients were excluded because of confirmed diagnosis of a disorder other than Sjögren's disease, and 217 patients were included in the final analysis. Median age at diagnosis was 15 years (IQR 11-17). 155 (72%) of 216 patients were female and 61 (28%) were male, 167 (79%) of 212 were White, and 20 (9%) of 213 were Hispanic, Latino, or Spanish. The latent class analysis identified three distinct patient classes: class I (dryness dominant with positive tests, n=27), class II (high symptoms with negative tests, n=98), and class III (low symptoms with negative tests, n=92). Machine learning models accurately predicted patient class and ranked variable importance consistently. The causal graphical model discovered key features for constructing the Florida Scoring System. The Florida Scoring System is a paediatrician-friendly tool that can be used to assist classification and long-term monitoring of suspected childhood Sjögren's disease. The resulting stratification has important implications for clinical management, trial design, and pathobiological research. We found a highly symptomatic patient group with negative serology and diagnostic profiles, which warrants clinical attention. We further revealed that salivary gland ultrasonography can be a non-invasive alternative to minor salivary gland biopsy in children. The Florida Scoring System requires validation in larger prospective paediatric cohorts. National Institute of Dental and Craniofacial Research, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Heart, Lung, and Blood Institute, and Sjögren's Foundation.

Autoimmune diseases (AIDs) in Côte d’Ivoire West Africa

Abstract Introduction Autoimmune diseases (AIDs) are until now very well unknown in Africa and particularly in subsaharien countries. They were even considered non-existent . The objective of this work is to estimate the prevalence, describe the epidemiological, clinical and biological aspects of AID in our country. Methods This was a descriptive retrospective study conducted from January 1, 2010 to December 31, 2020, on the files of patients hospitalized in the rheumatology department of the University Hospital of Cocody in Abidjan, Côte d’Ivoire. Results We studied 116 patients including 104 female patients (90%) and 12 male patients (10%). Most systemic autoimmune diseases have been observed in patients aged from 31 to 45 years. The average age was 40.02 +/- 15.07 years (extreme 12 and 72 years). The main diagnoses retained were systemic lupus erythematosus (34%), rheumatoid arthritis (22%), mixed connectivites (27%), sclerodermia(13%) . Of the 116 patients, 82% were not tested, 4% were negative and 14% were found positive for antinuclear antibodies, the most common biomarker in autoimmunity. Conclusion AIDs are prevalent in our countries with various presentation in our patients and they occur in young adults. Autoimmune disease are prevalent in our country and increasing. Further studies and a national regsitry of autoimmune disease need to be established to understand the disease and its increase in african environnement.

Epidemiological, clinical and paraclinical aspects of Pott's disease at Brazzaville University Hospital

Objective: Describe the epidemiological, clinical and paraclinical aspects of Pott's disease at the University Hospital Center of Brazzaville. Patients and methods: This was a descriptive, cross-sectional study with retrospective collection carried out in the Rheumatology department of Brazzaville University Hospital from January 1, 2013 to June 31, 2017, i.e. 4 years and 6 months. The diagnosis of Pott's disease was based on anamnestic, clinical and paraclinical arguments. Results: The hospital frequency of Pott's disease was 6.4%. Men predominated (56.4%) with a sex ratio of 1.3. The average age was 46 +/- 16 years (range: 20-80 years). The average time to diagnosis was 6.6 ± 5 months (range: 1-26 months). Alcoholism was the most common cause in 56 cases (50.9%). Spinal syndrome was present in 109 cases (99.1%). All patients had a standard spine x-ray performed. Computed tomography was performed in 28 patients (25.5%), magnetic resonance imaging in 23 patients (20.9%). The most common morphological aspect was spondylodiscitis in 76 cases (69.1%) associating disc pinching (60%), erosion (40%), and demineralization (19.1%). Atypical forms were found in 34 cases (30.9%), dominated by the appearance of spondylitis in 21 cases (61.8%). Conclusion: Pott's disease is a common pathology in developing countries, spondylodiscitis remains the most common morphological form.

Clinical value of high frequency ultrasound in the diagnosis of hip joint involvement in patients with ankylosing spondylitis

To analyze the correlation between hip joint musculoskeletal ultrasound score and ankylosing spondylitis (AS) disease activity, as well as to investigate the value of high frequency ultrasound in the assessment of hip joint involvement in AS. The clinical data of 244 patients with AS who were treated in the rheumatology department of from March 2019 to March 2022 were retrospectively analyzed. Among them, there 174 males and 70 females, aged from 19 to 58 years old with an average of (34.22±9.49) years old;the disease duration of AS patients ranged from 8 months to 26 years, with an average of (13.68±4.04) years.The 244 patients were divided into disease group (83 cases) and control group (161 cases) based in the presence of hip joint involuement. According to the the disease activity, patients in the disease group were further categorezed into active phase (45 cases) and stable phase (38 cases). The ultrasound scores of patients in the active and stable phases of the disease group and the control group were compared. Relevant factors of hip joint involvement in AS patients were analyzed, and analyze the correlation between ultrasound score and Bath ankylosing spondylitis disease activity score index(BASDAI), Bath ankylosing spondylitis functional index(BASFI), visual analogue score of pain (VAS), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and the correlation between hip joint capsule score and tendon attachment end score and BASDAI, BASFI, VAS, CRP and ESR. The hip joint capsule score(3.06±1.12), femoral head score(1.45±0.43), tendon attachment end score(3.28±1.30) and total ultrasound score(6.65±2.31) of the disease group were higher than those of the control group(1.51±0.48)、(0.66±0.27)、(1.61±0.53)、(3.81±1.44)scores (P<0.05). Multifactor Logstic regression analysis showed that the course of disease, hip joint capsule score and total ultrasound score were independent risk factors for hip involvement in AS patients.The hip capsule score (3.65±1.22)and total ultrasound score(8.28±2.33) in the active phase of the disease group were higher than those in the stable phase (2.48±1.04)、( 6.82±1.96)scores(P<0.05). The hip joint capsule score and total ultrasonic score of AS patients were positively correlated with BASDAI, BASFI, VAS, CRP, and ESR (P<0.05, P<0.01).The score of tendon attachment end was positively correlated with CRP (P<0.05). The score of joint capsule effusion in AS patients was positively correlated with BASDAI, BASFI and VAS (P<0.05, P<0.01). The synovial blood flow score was positively correlated with BASDAI, VAS, CRP and ESR (P<0.05, P<0.01). The synovial thickening score was positively correlated with BASDAI, BASFI, VAS, CRP and ESR (P<0.05, P<0.01). There was no correlation between the score of tendon attachment end and BASDAI, BASFI, VAS, CRP and ESR. There is a correlation between hip joint ultrasonic score of hip joint and clinical indexes in AS patients.Hip joint capsule score and total ultrasonic score were independent risk factors for hip involvement in AS patients. High frequency ultrasound exhibits clinical value in the diagnosis of hip joint involvement in AS patients.

E020 Osteoporosis service improvement audit

Abstract Background/Aims Osteoporosis referrals are sent to rheumatology departments for consideration of parenteral treatments in those who are unable to tolerate oral bisphosphonates or have failed treatment. The rheumatology services at Croydon University Hospital (CUH) are oversubscribed which results in long waiting times for appointments and increased workload on clinicians. The aim of this audit is to identify the scope of osteoporosis workload, the source of referrals, to improve distribution of the osteoporosis workload in CUH and redesign the pathway for osteoporosis referrals. A secondary aim is to identify patients that could be managed without referral enabling more consultation slots within the rheumatology department for patients that present with early inflammatory arthritis. Methods Data was collected retrospectively from all the patients that had been referred to the rheumatology department, either internally or externally and offered a new osteoporosis appointment from June to mid-September 2022 (104 patients in total). A data collection sheet was created from electronic patient records. The data included the patients’ hospital number, age, sex, height, weight, BMI, race, source of referral, reason for referral, fractures sustained, admissions for fracture, prior treatment with IV/ oral bisphosphonates, which oral bisphosphonate treatment and reasons for stopping, co-prescription of calcium/ vitamin D and the follow up plan. Results Among patients who were surveyed, 33 were internal referrals. Referring departments were as follows: 18 from fracture liaison service (FLS), 7 from care of the elderly (COTE), 3 from orthopaedics, 1 from rheumatology, 1 from nephrology, 1 from endocrinology, 1 from haematology and 1 from respiratory. In the GP cohort (71 patients), many were intolerant to oral bisphosphonates due to gastrointestinal upset. Reasons for referral were as follows: 36 for intolerance to oral medication, 14 for declining BMD, 11 for restarting medication after drug holding, 9 for complexity of cases (including young age/ male/ anorexia/ osteogenesis imperfecta), 8 unspecified, 7 had sustained a fracture on treatment, 6 received breast cancer treatment, 6 had renal impairment, 6 for a second opinion and 1 for considering a drug holiday. Conclusion This audit highlights the issues associated with osteoporosis workload and suggests improvements for managing the referrals both internally and externally. GP education is important for managing patients not tolerating oral bisphosphonates before accepting referrals. We have started recommending GP to try alternative oral bisphosphonates or effervescent alendronic acid prior to referral. Some internal workload can be managed by the referring team with advice being provided by the rheumatology team in order to reallocate rheumatology appointments for other conditions. The rheumatology department at Croydon University Hospital met with stakeholders from COTE and FLS and discussed the audit results. The COTE team agreed to initiate and continue IV zoledronate to reduce the osteoporosis burden on the rheumatology department. Disclosure S. Taheri: None. R. Suresh: None. J. Burton: None. S. Adil: None. T. Ahmed: None. N. Horwood: None. R. Sathananthan: None.

P083 Introduction of a gout pathway in a London NHS trust

Abstract Background/Aims Gout is a major cause of morbidity with a significant increase in UK hospitalisation identified over the last decade due to acute flare. Patient and physician education alongside a treat-to-target approach with urate-lowering therapy (ULT) are fundamental in its management. Despite being commonly encountered by clinicians, a survey conducted at Imperial College Healthcare NHS trust (ICHNT) demonstrated 49% of responders did not feel confident managing the condition. This project aimed to create a guideline for the management of acute gout at ICHNT to aid prompt diagnosis and effective management. Increasing the proportion of patients commencing ULT through engagement with local primary care networks was prioritised to improve patient outcomes and reduce subsequent hospital attendances. Methods A trust wide guideline for the management of acute gout was created with input from stakeholders (including emergency and acute medicine physicians) and informed by rheumatology clinicians and current guidelines. Latest recommendations from NICE, BSR and EULAR were consulted alongside local guidelines in place across London. An emphasis was placed upon education and initiation of ULT to improve management of acute and chronic gout to prevent future hospital attendances. Staff within the rheumatology department were consulted to agree on timing of ULT initiation and an effective pathway for implementation. Results Through review of local, national and international guidelines, discrepancies in gout management were identified, most notably variation in the timing of ULT initiation (e.g. during the acute presentation, after flare resolution or after subsequent flare). This was reflected in the practice of clinicians within the rheumatology department at ICHNT. Agreed consensus brought the trust guideline predominantly in line with current NICE guidance for management of acute gout with ULT commenced in patients 2-4 weeks after resolution of flare. Initially, this led to delegation of ULT initiation to general practitioners, however, this resulted in concerns over treatment delays and added pressure on an already stretched service. Follow-up within secondary care was also considered, but capacity issues exist. As a next step, a pilot for a pharmacy-led follow-up service within primary care is planned using standardised protocols supported by secondary care. Conclusion The implementation of a local guideline on the management of acute gout is helpful for clinicians from a non-rheumatology background to facilitate prompt diagnosis and effective management of this common, but often poorly treated, condition. A successful pathway to prevent future flares is more challenging, not only due to discrepancies in current guidelines on timing of ULT initiation but also in creating capacity for follow-up and treatment implementation. This continuing project aims to explore alternative pathways such as a pharmacy-led service that improves patient outcomes and reduces future burden upon healthcare services. Disclosure E. Mabey: None. H. Wilson-Morkeh: None. B. Ellis: None.

P062 Trust performance in managing inflammatory arthritis over time in England and Wales: a latent class analysis approach

Abstract Background/Aims To evaluate trust-level performance in time to initiation of disease-modifying antirheumatic drug (DMARD) therapy in patients with early inflammatory arthritis (EIA), with identification of change in performance trajectories over time and investigation of trust characteristics associated with this change. Methods We included 130 trusts from the UK contributing to the National Early Inflammatory Arthritis Audit (NEIAA) from 2018 to 2020. The primary outcome was days from referral to initiation of DMARD therapy in patients with EIA. Latent class growth mixture models were applied to identify distinct groups of trusts with similar trajectories of performance change over time. We used mixed-effects linear and multinomial logistic regression models to evaluate the association between delay in treatment and trust-level characteristics. Results The mean (SD) time to DMARD initiation was 53 (18) days, with an average 0.3-day decrease with each month over time. Four latent trajectories were identified in our cohort, with over 77% of individual trusts showing ongoing improvements in decreasing treatment waiting times. Prior to separating by latent class, time to DMARD initiation was shorter in trusts with higher rheumatology staffing, a local EIA treatment pathway and those with access to musculoskeletal ultrasound. Trusts with more nurses in the rheumatology department were less likely to be in the worse performance group (OR = 0.69 [95%CI 0.49, 0.93]). Conclusion In this cohort study, we observed a reduction in treatment waiting time over time. Trusts with better staffed and improved EIA clinical structure are likely to initiate definitive treatment earlier in patients with EIA. Disclosure Z. Yang: None. N. Arumalla: None. M.D. Russell: Honoraria; Lilly, Menarini, Galapagos. Grants/research support; NIHR. Other; Pfizer, Janssen, Biogen, and UCB. K. Bechman: Honoraria; Menarini, Galapagos. Grants/research support; NIHR,Versus Arthritis and Pfizer Global Medical Grants for Quality Improvement in Rheumatology Practice. Other; UCB. E. Alveyn: Other; UCB. S. Gallagher: None. E. Price: None. S. Norton: None. J. Galloway: Honoraria; AbbVie, Biovitrum, BMS, Celgene, Chugai, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB.

E016 An audit on patient initiated follow up in rheumatology in Manchester Royal Infirmary

Abstract Background/Aims PIFU is not a new concept in rheumatology. Instead of arranging regular routine appointments for patients with stable diseases, PIFU empowers patients to seek help when needed, enabling them to take control of their care and reduce pressure on rheumatology services. NHS England recommends PIFU for rheumatology patients with stable inflammatory arthritis. They should also have a good understanding of their disease management and be able to contact the service promptly. If patients on PIFU contact the service and require face-to face appointments, they should be seen within 2-4 weeks. Despite existing recommendations, there appears to be wide variation between clinicians and managers on the understanding of PIFU. The aim of this audit is to compare diagnoses of rheumatology patients for PIFU in a single rheumatology department, and the waiting time for review once patients placed on PIFU have made contact, to NHS England standards. Methods A list of rheumatology patients placed on PIFU between October 2022 and July 2023 at Manchester Royal Infirmary was obtained. Data were collected from electronic patient records. Results A total of 130 (1.5%) patients were listed on PIFU by 18 clinicians. The table outlines the demographics and detailed breakdown of diagnoses1. 1 (1%) was put on PIFU after patient declined biologic treatment for active inflammatory arthritis. 3 patients contacted the department whilst on PIFU, 2 of them required face-face review. Median time from start of PIFU to patient-initiated contact was 60 days (IQR 47.5-107.5). One with palindromic rheumatism was seen at 6 weeks and one with osteoarthritis had no appointment date yet 8 weeks after initial contact. Conclusion The audit confirmed that only 22 (17%) patients followed NHS England guidelines and 0% was seen as recommended once the patient contacted the department. Currently, 1.5% of patients in the rheumatology department are placed on PIFU, which is below 5% as per NHS England guidelines. This audit highlights the urgency to educate clinicians and managers on the cohort of patients listed on PIFU and to ensure all these patients are seen within the recommended time. Work is being done in the department to address these issues. Disclosure A. Cheung: None. G. Nowell: None. S. Ling: None. Y. Chiu: None. P. Ho: None.

P009 Improving axial spondyloarthritis time to diagnosis: a quality improvement project

Abstract Background/Aims The average UK time to diagnosis for axial spondyloarthritis (axSpA) remains unacceptably long, i.e., 8.3 years, with high economic costs and impact on patients' outcomes. Until October 2021, the Rheumatology department at Ipswich Hospital did not have an axSpA service, no specific referral pathways, no dedicated clinics, and no standardized patient journey. The main objective was to develop an axSpA service from scratch and to raise awareness on axSpA amongst health professionals. A more specific quantifiable objective was to reduce the time from patient presentation in primary and secondary care to axSpA diagnosis in rheumatology. Methods For the first year since service inception (November 2021 to February 2022), we have set up the ambitious aim of developing an axSpA service, focusing on designing a referral pathway, on establishing connections with primary and secondary care, and on providing education on axSpA. To evaluate improvement in time from patient presentation in primary/ secondary care to axSpA diagnosis, we have audited all new suspected axSpA cases in the first three months of service inception (November 2021 - February 2022) and compared data from the same period of time, a year later (October 2022 - February 2023). The Plan-Do-Study-Act (PDSA) methodology was used. The quality improvement project is part of Aspiring to Excellence programme (endorsed by National Axial Spondyloarthritis Society/NASS). Results Our axSpA service was established in November 2021. We initially established connections with primary and secondary care. Within a year, we have developed an axSpA referral pathway for primary care which was designed to reflect NICE guidelines. All suspected axSpA referrals were triaged in rheumatology as urgent rather than routine and booked into a dedicated axSpA clinic running once weekly. All patients benefited from a specialized physiotherapy review. Formal and informal referral patwhays were also developed with secondary care. Additionally, we have established monthly multidisciplinary team meetings with dermatology, ophthalmology, spinal team, as well as community physiotherapy. Regular education sessions were delivered to primary care. A specific radiology- MRI pathway was also established. The audit on time until diagnosis included a total of 94 patients with suspected axSpA. The waiting time from initial presentation in primary/ secondary care to rheumatology first appointment decreased from a median of 17 weeks to 5 weeks; the time from first rheumatology appointment to diagnosis decreased from 17 weeks to 7 weeks. Overall, patients with axSpA had to wait a median of 13 weeks from initial presentation to diagnosis in rheumatology versus 29 weeks at service inception. Conclusion In only a year, we have established an axSpA service de novo with clear and standardized pathways. There was a significant improvement in waiting times for patients waiting to be referred and diagnosed with axSpA. Disclosure S. Voules: None. C. Kelly: None. M. Alcala: None. S. Premraj: None. T. Gudu: None.

P057 Scoping the role of the physiotherapist in the axial spondyloarthritis new patient clinic

Abstract Background/Aims Early diagnosis of Axial Spondyloarthritis (Axial SpA) is crucial to reduce negative impacts and support better patient outcomes through early intervention. There are a number of challenges contributing to delayed diagnosis, the focus of this report relates to the capacity pressures limiting timely assessment and diagnosis. There are a number of well-established, and more recently initiated, physiotherapist-led Axial SpA new patient clinics across UK Rheumatology. These clinics have been locally reported to reduce delays in diagnosis. There is growing interest from other rheumatology services to establish these clinics. A working group of physiotherapists providing physiotherapist-led Axial SpA clinics were supported by a BRITSpA Travelling Fellowship Grant to meet to share service experiences and to develop a consensus-driven best-practice set of recommendations to guide planning and implementing physiotherapist-led Axial SpA new patient assessment clinics in rheumatology departments across the UK. The aim of this report is to provide an overview of the two day Travelling Fellowship project process and the key initial outcomes from the workshop. Methods A two-day workshop attended by ten physiotherapists meeting in person and four joining virtually, all with expertise in providing physiotherapist-led new and review Axial SpA clinics. The workshop programme included presentations from national and international experts, encompassing GIRFT input, exemplar consensus development examples and an opportunity for all fellows to share their experience in setting up and delivering physiotherapist-led Axial SpA new patient clinics. Discussion time was prioritised to allow shared learning, discussion of similarities and local variations to support information gathering and the development of expert consensus-driven guidelines and implementation advice. Patient and public involvement was embedded into the workshop supporting planning discussions and providing lived experience perspectives, preferences and values concerning the implementation and service delivery discussions. Results The major themes and findings identified included the variation in role description and specific responsibilities between centres, including variation in support and mentoring available as well as administration time. However, similar outcomes were found regarding levels of confidence and independence in undertaking thorough triage and assessments of inflammatory back pain referrals leading to confirming or excluding Axial SpA diagnoses, and the skillset to manage these outcomes. Conclusion Following GIRFT recommendations, and in light of the workforce crisis in rheumatology, with support from the rheumatology physiotherapy capabilities framework we have seen the expansion of the physiotherapist role. We have good levels of confidence, following our sharing of clinic data and patient experience comments, that there is a valuable contribution to the rheumatology landscape to be made by physiotherapist-led Axial SpA new patient clinics. Disclosure W.J. Gregory: Honoraria; W.G. has received honoraria for speaking and advisory board from Abbvie, Novartis, Pfizer, Sobi and UCB. R. Adshead: None. Z. Cox: None. E.E. Deeney: None. P.A. Dowie: None. S.J. Fish: None. R. Galway: None. H. Harrison: None. R.J. Hayward: Honoraria; R.H. has received honoraria for speaking from Abbive and Novartis. C. Longton: Honoraria; C.L. has received honoraria for speaking from UCB. M. Motion: None. C. Tonks: None. C. McCrum: Honoraria; C.McC. has received honoraria for professional education workshops- Novartis, Janssen.

P110 Characteristics of Difficult to treat Rheumatoid Arthritis patients in a large District Hospital in the UK

Abstract Background/Aims Difficult-to-treat rheumatoid arthritis (D2T RA) has a notably higher impact on a patient’s quality of life and is a significant cost and service pressure to the health care provision in comparison to non-D2T RA. The primary aim of this study is to delineate the major contributing factors and characteristics of patients leading to a diagnosis of D2T RA, using the criteria established by the European League Against Rheumatism (EULAR). Methods A retrospective study was conducted within the Rheumatology department in a large district general hospital, with a catchment population of over 700,000 people. A cohort of 722 patients, all of which were on biologic Disease Modifying Anti-Rheumatic Medications (DMARDs) was selected. In this study, we present our findings for the first 95 consecutive patients. Results Of the selected 95 patients, 13% met the EULAR criteria for D2T RA. The key characteristics within this subset include 75% being sero-positive (both Rheumatoid factor and anti-cyclic citrullinated peptide), 66% being categorized as obese, and 42% having concurrent fibromyalgia and osteoarthritis. Among these 13% D2T RA patients, 25% demonstrated a high disease activity index and 75% showed moderate severity. All these patients had been started on at least two conventional DMARDs including methotrexate before escalating to more advanced treatments in line with NICE guidelines. From the subgroup of high disease activity D2T RA patients, 67% had tried at least three types of biologic or targeted synthetic DMARDs (b/ts DMARDs), and 33% had been trialled on four different types of b/ts DMARDs. Similarly, out of the medium severity D2T RA subgroup, 45% had tried three and four DMARDs respectively and 10% had been given five biologic or synthetic DMARDs. Conclusion The major contributing factors leading to D2T RA within this study population appear to be seropositivity for both RF and anti-CCP, obesity, and the presence of comorbidities like fibromyalgia and osteoarthritis. The intertwined relationship between these factors emphasizes the need for a comprehensive and individualized approach to managing patients with D2T RA. Although this cohort is larger than the previous studies, the sample size is relatively small. We aim to look at the remaining 627 patients to identify trends and modifiable risk factors that could help prevent the future development of D2T RA. Disclosure K. Oo: None. M. Memon: None. P. Sharma: None. S. Dahiya: None.

E001 Pre-screen chest X-ray before starting methotrexate in autoimmune disease

Abstract Background/Aims This audit seeks to assess adherence to BSR guidelines and NICE recommendations concerning chest X-ray screening before initiating methotrexate. We also aim to evaluate the time elapsed from X-ray to radiologist reporting and the frequency of methotrexate initiations for various diagnoses. Methods We identified 127 cases from the rheumatology department (2017-2021) involving patients aged 18 or older with diagnoses of rheumatoid arthritis, psoriatic arthritis, lupus, or autoimmune connective tissue disease. We checked patient records for evidence of pre-treatment chest X-rays Results Rheumatoid arthritis was the most common diagnosis for methotrexate initiation. Out of the 127 patients, 102 underwent chest X-rays (80%), while 23 did not. For 2 patients, the status of chest X-ray performance remained unknown. The breakdown of percentages by hospital was as follows: QEQM (87%), WHH (70%), KCH (77%). The distribution of report times across the three hospitals was as follows: 1-7 days (52%), 8-14 days (4%), 15-31 days (12%), 32-62 days (11%), 63-100 days (15%), 101+ days (6%). Conclusion Urgent reporting of chest X-rays is imperative. Proposed solutions include flagging X-rays as urgent by incorporating a 'Patient starting Methotrexate?’ query. If selected 'yes’ this would flag the report as urgent on the Soliton system. This allows for prompt reporting of these X-rays with timely starting of the DMARDs treatment in various autoimmune conditions. This was done as beforehand, X-rays were not reported in a prompt manner even if they were stated as urgent in the requests. A smaller post-audit analysis involving 15 patients achieved 100% compliance of reporting within one week by implementing these changes. Disclosure M.A. Khan: None. A. Khan: None. A. Vijayan: None. A. Hajilou: None. M. Win: None.

P102 Should Fibromyalgia be Diagnosed in Primary or Secondary Care?

Abstract Background/Aims Both the Rheumatology Getting It Right First Time (GIRFT) report, published in February 2021, and the British Society for Rheumatology (BSR) referral guidelines from October 2021 recommend not referring patients with suspected Fibromyalgia to Rheumatology services. In contrast the Royal College of Physicians (RCP) guidelines on Fibromyalgia from 2022 recommend that for unequivocal cases, referral is not necessary, but that referral is appropriate if there is diagnostic uncertainty. We undertook an evaluation of our Rheumatology service to assess whether following either of these guidelines would be appropriate. Methods A prospective analysis of all patients referred to one general Rheumatologist over 18 months to assess the accuracy of suspected fibromyalgia diagnoses from primary care. The included cases were all patients referred with possible fibromyalgia on the referral letter, along with patients with an end diagnosis of fibromyalgia. Results Seventy-two patients were referred to one consultant with possible fibromyalgia on the referral letter. Of these, only 44 (61%) were confirmed as having fibromyalgia. Common other problems felt by the GP to be fibromyalgia included 2+ areas of localised soft tissue rheumatism (seven patients), localised chronic back pain (six patients) and biomechanical lower limb pains due to flat feet (three patients). Another 39 patients were diagnosed as fibromyalgia when not considered by primary care; nine of these patients were referred on the early arthritis pathway and two patients to the axial spondyloarthritis clinic. Overall this workload only constituted approximately 9% of new patients to the service, with patients with an end diagnosis of fibromyalgia making up approximately 7% of the overall new referrals. Conclusion The problems with diagnosing fibromyalgia in primary care are likely multifactorial - general practitioners (GP’s) are very busy and there is an increasing use of allied health professionals (AHP) in primary care, who do not always have the experience or training to diagnose fibromyalgia or other common musculoskeletal conditions. Some GP’s do not feel comfortable diagnosing fibromyalgia and some patients are just not happy with a primary care opinion. Overall, we do not feel that the diagnosis of fibromyalgia can be left solely in the hands of primary care; if the patients in this review had not been referred, then a significant number would have been incorrectly labelled as fibromyalgia, with all the problems that may bring. In view of this, the RCP guidelines would appear more appropriate than the BSR referral guidelines, but even then some of the patients in this review may still have ended up with an incorrect diagnosis, so overall Rheumatology departments should be very cautious about declining referrals for possible fibromyalgia and we continue to see these referrals in our department. Disclosure M.P. Sykes: None.

E018 Prophylactic co-trimoxazole prescribing practice in patients who received rituximab therapy: comparison across indications and specialties

Abstract Background/Aims Rituximab is a chimeric anti-CD20 monoclonal antibody targeting B-cells used as part of treatment algorithms for malignancy and autoimmune diseases. As is the case of other immunosuppressive agents, rituximab increases the risk of infections. Primary prophylaxis with co-trimoxazole may be considered in high-risk cohort of patients to prevent opportunistic infection, particuarly Pneumocystis jerovecii pneumonia (PJP). To investigate the prescribing practice for prophylactic co-trimoxazole in patients who received rituximab infusion in a large tertiary referral centre. To compare practices between rheumatology and nephrology department. To compare the incidence of hospitalisation for infection (particularly PJP) between those prescribed prophylactic co-trimoxazole and those who did not. Methods This was a single centre retrospective observational study over a 3 year period assessing prophylactic co-trimoxazole prescribing practice in 185 patients attending rheumatology or renal services in Cork University Hospital (CUH) and receiving rituximab. Co-trimoxazole prophylactic treatment was defined as prophylaxis dose of co-trimoxazole (either 480mg daily or 960mg three times per week) received during rituximab treatment and at least 6 months post completion of treatment. Results 185 patients’ medical charts were reviewed. Only 28 patients received prophylaxis with co-trimoxazole. The majority of patients (n = 24, 85%) who received prophylaxis with co-trimoxazole had an underlying diagnosis of small vessel vasculitis (SVV). Co-trimoxazole was more commonly prescribed by nephrologists (n = 17, 71% primarily for SVV) as compared to rheumatologist (n = 7, 29% primarily for SVV). 156 patients were not prescribed prophylactic co-trimoxazole. The primary indication for rituximab in these patients was inflammatory arthropathy (IA) (n = 72,46%), SVV (n = 26, 16%), systemic lupus erythematosus (n = 19, 12%), with the remainder accounted for by scleroderma, undifferentiated connective tissue disease, membranous nephropathy (MN), myositis, focal segmental glomerulosclerosis and amyloid renal disease. No patient was admitted over the course of the study period with PJP. 59 patients required hospital admissions due to other infections, most commonly patients with SVV. The most common infections were respiratory tract and urinary tract infections. Overall infections requiring hospitalization were more common in the group receiving prophylaxis, perhaps highlighting the vulnerable nature and greater prednisolone prescribing in the SVV cohort. No difference was seen between groups in the prevalence of UTIs. Conclusion In this cohort co-trimoxazole prophylaxis was more commonly prescribed for patient with small vessel vasculitis and differences in prescribing patterns were seen between nephrologists and rheumatologists. With greater awareness of the heightened risk of PJP in patents receiving rituximab consideration should be given to use of antibiotic prophylaxis for other indications. Disclosure S. Tio: None. J. Morrow: None. S. Cowley: None. M. Clarkson: None. G. Murphy: None.

P077 The Yorkshire Bone Network- why every region needs a Bone Network!

Abstract Background/Aims The Yorkshire Bone Network (YBN) was formalised in 2019, from a founding group of Yorkshire clinicians with a special interest in osteoporosis, meeting every four months since 1994 to discuss new drugs as they were licensed, the research underpinning them, complex clinical cases and educational topics in osteoporosis. This group was formalised into a Network in order to expand the membership and invite contributions from an increased range of specialists from different disciplines and Trusts across Yorkshire. Further aims were to reach consensus on the management of key osteoporosis issues across Yorkshire and deliver Regional guidelines. Methods The YBN now has 35 members from Rheumatology, Endocrinology, Metabolic Bone and Elderly Medicine departments from 12 different Trusts across Yorkshire. Meetings are four-monthly, continuing on Zoom during the pandemic, and now in-person again. Each meeting involves discussion of complex clinical osteoporosis cases for management decisions, alongside an educational or guidelines development session, delivered by a member of the Network or an invited guest speaker. Results We have: Agreed a consensus statement on the use of Romosozumab in Yorkshire, specifically covering cardiovascular screening for potential patients. This has given clinicians confidence in identifying appropriate patients and prescribing this new drug. This should also ensure equity of drug access to patients across the region, who are being assessed using the same framework. We have written guidelines on the role of bone densitometry in patients with coeliac disease. This has been provided to local Gastroenterologists, with the aim of reducing unnecessary bone densitometry referrals, reducing the burden on patients and radiology departments. We have provided regional recommendations for the early (before 14 days) administration of IV zoledronate for inpatients post fractured neck of femur, avoiding discharge prior to treatment. This has been adopted and is being audited to assess impact in one of our District General Hospitals. We have provided educational sessions on bone turnover markers, FRAXPlus, glucocorticoid-induced osteoporosis and renal bone disease. Conclusion The Yorkshire Bone Network is an excellent example of collaborative working. It is a valuable forum for clinical decision making for complex patients across the region. It has allowed the development of guidelines and consensus statements which are in clinical use, thus minimising variation in patient care across the region and improving clinician confidence. It continues to be an enjoyable way of forming new links between colleagues both within our own Trusts and across the region, with new members joining each year. Time is needed to co-ordinate the meetings, provide minutes and liaise with colleagues but the benefits far outweigh the effort! We would strongly recommend the formation of similar networks across the UK, given the benefits to both patients and clinicians. Disclosure C.Y.J. Vandevelde: None. S. Sultan: None. L. Hordon: None.

P081 Out-patient management of gout in secondary care: Results from the North West regional audit

Abstract Background/Aims Recommendations for gout management have significantly evolved as outlined by the latest National Institute for Health and Care Excellence (NICE), European League Against Rheumatism (EULAR), British Society for Rheumatology (BSR) and the Medicines and Healthcare products Regulatory Agency (MHRA) guidelines, with increased emphasis being placed on optimising cardiovascular risk. This regional audit aimed to assess concordance with these guidelines within rheumatology outpatient settings in the North West region of England. Methods New or follow-up patients with gout, presenting to a rheumatology outpatient setting within the Greater Manchester and Lancashire area over a five-week period between 1/3/23 and 7/4/23 were included. We collated data on demographics, co-morbidity assessment including cardiovascular risk, prescribing of febuxostat in major cardiovascular disease, diuretic use and advice, setting of treat-to-target levels, use of cardiovascular risk prediction tools and subsequent follow up arrangements. For new patients, collected data also included referral reason, and prescription recommendations for first-line urate-lowering therapy (ULT) and co-prescriptions for flare prophylaxis. Results Ninety-two patients (mean age 60 years, 80% male) were included from 13 rheumatology departments. Twenty-three patients were new referrals. Sixty-seven patients (73%) had ≥ 1 relevant comorbidity; hypertension being the most common (55%). Twenty (22%) patients were on diuretics. Twelve (55%) of these patients had a diagnosis of hypertension without heart failure; none received recommendations to reduce or stop diuretics. In line with current guidelines, no patient with major cardiovascular disease was treated with febuxostat. Treat-to-target levels were agreed in 49 (57%) applicable patients. Cardiovascular prediction tools were only calculated or known in three (3%) patients. However, clinic data collected would have allowed a risk assessment calculation in 13 (14%) patients. Sixteen (17%) patients audited had no planned follow-up. Compared to NICE guidelines, 18 (78%) new patients reviewed in clinic were referred appropriately to rheumatology services. Twenty-two (96%) new patients referred were eligible to start ULT, of which 15 (75%) were started on a NICE/ EULAR recommended first-line ULT treatment (14 patients on allopurinol including 11 patients with no major cardiovascular disease, one patient on febuxostat). Eleven (79%) patients started on allopurinol were initiated on a low dose (50-100mg), as recommended by NICE and the BSR. Ten (67%) patients of those initiated on ULT were also prescribed prophylactic colchicine. Two additional patients were prescribed NSAIDs with PPI cover and one patient was prescribed oral steroids without PPI cover. Conclusion Most new patients were referred and prescribed first-line ULT treatment appropriately, often with colchicine prophylaxis. Uptake of febuxostat as first-line therapy was limited. Cardiovascular risk assessment was rarely done; further work exploring barriers to undertaking these assessments in rheumatology clinics is likely to improve both patient care and guideline compliance. Disclosure L. Gould: Other; L.G. has received conference fees from Eli Lilly. A. Richards: None. L. Gray: Other; L.G. has received travel and conference fees from Eli Lilly. M. Badarulla: Other; M.B. has received conference fees from Eli Lilly. L. Mercer: Other; L.M. has received conference fees from Nordic Pharma and UCB. R. Farid: None. R. Heaton: Consultancies; R.H. has received consultancy fees from Galapagos. Honoraria; R.H. has received speaker honorarium from Abbvie and Nordic. Other; R.H. has received conference fees from UCB. M. Al-Attar: None. M. Whitehead: None. S. Kamath: None. L. Teh: None. A. Odekunle: None. C.A. Sharp: None. A. Babiker: None. S. Hopping: None. A. Oldroyd: None. K. Lazarewicz: None. C. Saleh: None. S. Horton: None. D. Roy: Honoraria; D.R. has an honorary University of Manchester research assistant contract. A. Opeseyitan: None. D. Das: None. S. Varughese: None. D. Yidana: None. S. Wig: None. J. Bluett: Grants/research support; J.B. has received a research grant award from Pfizer. Other; J.B. has received travel/conference fees from UCB, Fresenius Kabi, Pfizer and Eli Lilly.

E019 Management of idiopathic inflammatory myositis - a Northamptonshire audit of British Society for Rheumatology guidelines

Abstract Background/Aims The idiopathic inflammatory myopathies (IIM) are a rare group of multi-system autoimmune conditions characterised by muscle inflammation. They have an incidence of up to 19 per 1,000,000 person years in adults and a UK prevalence of 10,000 people. Last census data estimated the Northamptonshire population at approximately 785,200. The small cohort of patients reflects the limited evidence base for best practice. In March 2022, the first UK evidence guideline on IIM was published from the British Society for Rheumatology (BSR). In view of absence of prior guidance, there is expected variability in patient management within and between centres. To evaluate local practice against these standards an audit was conducted in Northampton General Hospital (NGH). Methods Using local MYOACT registry data and consultant caseload knowledge, a cohort of adult patients with IIM diagnoses consulted within the last 5 years were identified. Retrospective clinical letters were analysed for details of patient care and compared to the 26 recommendations as set out by the myositis guideline. Results A total of 12 patients were sampled as having attended the rheumatology department within the last five years at NGH. All 26 standards will be presented, but for the purposes of this abstract, key results for discussion include: • 100% of corticosteroids were tapered as the patient responded to treatment. • In presence of muscle inflammation 91% were treated with DMARDs. • In presence of active skin disease, 100% received treatment with csDMARD, IVIG or rituximab. • 100% of patients were screened for interstitial lung disease. • In presence of active muscle disease, 56% of patients received an exercise program led and monitored by therapists. • In 45% of patients’ psychological well-being and health was formally considered. Conclusion Initial service evaluation against BSR IIM recommendations reflects typical strengths and weaknesses encountered in delivering rheumatology services. There was strong concordance in diagnostic and pharmacological domains. However greater variability was encountered when considering multidisciplinary psychosocial domains involving access to therapy services and psychological support. Tools such as the 36 Item Short Form Survey, highlighted in BSR recommendations, may offer a validated method for physicians to formally consider and target psychosocial domains in management of idiopathic inflammatory myopathies. Disclosure N. Chauhan: None. S. Abushama: None. R. Jeffery: None.

E010 Impact of rheumatologist ultrasound clinic on the management of inflammatory arthritis at a tertiary centre rheumatology department

Abstract Background/Aims Musculoskeletal ultrasound plays an important role in the assessment and management of inflammatory arthritis, enabling early diagnosis and prompt initiation of disease modifying therapy, as well as escalation of therapy as part of a treat-to-target strategy. It can help clinicians distinguish between true joint inflammation and non-inflammatory causes of increased pain scores. We reviewed our weekly rheumatology ultrasound clinic service where patients are referred to aid in clinical decision making. The study aimed to evaluate the cohort of patients attending the rheumatology ultrasound clinic at University Hospitals of Leicester, a busy tertiary centre, serving a multi-ethnic population, and to assess the impact of this clinic on the management of inflammatory arthritis in these patients. Methods Data was collected retrospectively from the ultrasound clinic at University Hospitals of Leicester between June 2022 and June 2023. Outcome measures included: date of scan request, date of scan, underlying disease, C - reactive protein (CRP), anti-CCP level, presence of radiographic erosions, presence of active synovitis or erosions on ultrasound, other rheumatologic disease and how the ultrasound findings changed the patient’s management. Results The total number of patients attending the clinic during the study period was 91. Of these, 70% were female and 30% male. Over the study period, 11.8% of patients did not attend their appointment. At the time of referral, 68% of patients had a CRP&amp;lt;5, 91% had a negative anti-CCP and 83% had no radiographic erosions. Following the scan, 13% of the patients had active synovitis, and 10% received at least one steroid injection. Interestingly, 86% had no active inflammation and no indication to escalate their disease modifying drug. In our patient cohort, 16% had pre-existing fibromyalgia. In all appointments, the clinician performing the scan showed the ultrasound images to the patient and explained the findings. Conclusion This ultrasound clinic is a key part of the treat-to-target strategy for inflammatory arthritis, enabling escalation of disease modifying therapy where indicated. It allows ultrasound guided and marked injections to be given when needed and identifies patients with non-inflammatory causes of increased pain scores, preventing patients from receiving unnecessary immunosuppression. Disclosure A. Mohammed Murad: None. A. Jubber: None. A. Moorthy: None.

P059 Informal care for those with multiple longer term conditions - a hidden burden?

Abstract Background/Aims Multiple long-term conditions (MLTC) refers to the co-existence of two or more chronic conditions. Rheumatic diseases (RMDs) are important long-term conditions which are common in individuals with MLTC. The effect of rheumatic disease on disability is well known and often requires support with activities of daily living, i.e. social care. However, while the presence of MLTC is known to be associated with social care need, the role of RMDs in driving social care need is unknown. This lack of data capture of social care resource use undermines healthcare strategy. We carried out two surveys in different parts of the country to ascertain the social care burden amongst those with RMDs. Methods An online cross-sectional survey to identify and characterise formal and informal social care use was sent to two different groups of patients with rheumatic and musculoskeletal disease. The first comprised participants within Norfolk Arthritis Register, who were emailed an invitation to complete the survey between March-July 2023. As part of Assembling the Data Jigsaw programme, the second group comprised patients attending the Salford Royal Hospital Rheumatology Department with text message invitations sent between October 2022-September 2023 via the DrDoctor app. All participants answered identical questions on formal and informal care provision and demographic characteristics. Logistic regression was used to identify factors associated with needing support. Results A total of 184 participants within the NOAR cohort completed the survey, comprising 128 (70%) women with a median age of 64 years. A total of 439 participants completed the survey in the Salford Royal Hospital cohort, comprising 326 (74%) women with a median age of 58 years. Rheumatoid arthritis was reported by 93 (73%) of the NOAR recruits and 136 (31%) of the Salford Royal Hospital cohort, with osteoarthritis the next most common with 37 (20%) and 112 (34%) of each cohort reporting this condition. Using self-reported data, 47% and 64% of the respective cohorts met the criteria for MLTC. For both cohorts, 30% reported needing four hours or fewer assistance per week, and 19% reported requiring &amp;gt;10 hours a week. Although infrequent or occasional help was usually provided informally by spouses, partners, family members or friends, 42 (23%) of the NOAR cohort and 70 (16%) of the Salford Royal Hospital cohort arranged formal care provision themselves without involving the council. Multivariable logistic regression of both cohorts found that those who were younger were more likely to have reported needing assistance with ADLs in the last month. MLTC was also associated with requiring help. Conclusion The majority of individuals engage informal support or arrange care without help from local authorities. These data are important for describing social care resource use and for determining healthcare strategy. Disclosure M. Yates: None. M. Soomro: None. A. Onajole: None. A. MacGregor: None. W. Dixon: None. J. McBeth: None. J.H. Humphreys: None.