Rheumatology Patients Research Articles

P116 A quality improvement project at Bradford Teaching Foundations Hospital to reduce high-cost medication waste and improve medicines optimisation

Abstract Background/Aims Biologics and methotrexate are high-cost medications delivered to patients through a pharmacy homecare service prescribed and dispensed at 8 weekly intervals in our Trust. It is estimated nationally, £300 million of NHS prescribed medicines are wasted each year. The aim of this QiP was to investigate the extent and reasons for high-cost medication waste within the rheumatology department at BTHFT and to develop a service to overcome these issues thereby improving medicine optimisation and reducing waste. Methods Homecare data were reviewed over 12 months from Jan 2020-21 looking at high-cost medication waste within rheumatology at BTHFT. Two hundred and sixty-seven rheumatology patients were initiated on therapy in this period. Forty-four (16%) patients stopped therapy within a year of initiation. Of the 44 patients, 32 patients stopped within their first 8-week delivery resulting in £17,362 in wastage of medications. The data were further analysed to assess reasons for treatment cessation. Reasons included adverse effects, non-adherence due to lack of response or patient choice, lack of information and change in treatment plan by overseeing consultant. To overcome some of these issues we changed initial prescribing methods and dispensed 4-weeks supply of medication. We set up a pilot pharmacy telephone clinic between 9th April and 18th June 2021. Patients were phoned 8-weeks after nurse counselling when patients should have been 3-weeks into treatment with their new biologic and provided with further information and reassurance. Any clinical queries outside the pharmacist’s remit were directed to the rheumatology team. If patients were continuing medications, a further appropriate length prescription was dispensed. Results Over the 10-week period of the pilot study, 83 new patients started on therapy, 46 of these were provided with reassurance/support and of those, 9 held/stopped treatment. Through the pharmacy support line, £2,612 of medication cost was saved as these patients had received 4-weeks of medication rather than the usual 8-weeks supply. This translates to approximately £13,500 of medication waste can be saved a year through reduced initial prescription of biologics together with implementation of a pharmacy support line through the rheumatology department alone. Another unexpected benefit of the pharmacy support line was improved compliance and adherence to treatment through further counselling and guidance that was delivered to patients who may have stopped treatment without the additional support provided by the pharmacist. Conclusion The introduction of a pharmacy-led telephone support service together with a change in prescribing practice can reduce waste, save money, and improve patient outcomes through medicine optimisation. This service could be rolled out to other specialties using high-cost medication with similar intended benefits. Enhancing roles of pharmacists in this way will help meet increasing demand and improve services for patient as recommended by the recent rheumatology GIRFT review. Disclosure P. Sidhu: None. K. Nadesalingam: None. G. Quinn: None.

P002 Advice line ... of duty

Background/AimsAdvice lines in Rheumatology services are well established and supported by NICE to provide specialist support and advice to rheumatology patients. During COVID-19 the demand on this service greatly increased due to disruption in appointments, confusion regarding national advice, concerns and fears regarding condition and medication. Although patients were encouraged to refer to national guidance, many found it difficult to interpret therefore continued to access the advice line. Our advice line service largely follows the RCN 2006 guidance regarding service provision. Despite this during COVID-19 the volume of calls increased to up to 100 calls per day during the first lockdown. Support was required to effectively manage these calls with reduced clinical staff.MethodsA retrospective review of calls to the advice line compared to the previous year was undertaken from the call log database. A further review of the nature of calls was undertaken for April 2020 and January 2021 where the numbers of calls were at their peak. Data is recorded including time of call, nature of call, advice given and time call returned.ResultsThere was a 130% increase in calls during the first lockdown. This reduced by the early 2021 lockdown to 72%. The majority of calls in April 2020 were related to shielding and risk status (53%). A further 19% of calls were related to medication, these included queries regarding homecare deliveries and delays. 6% were appointment enquiries and they were passed to the administrative team. In January 2021 the majority of calls were related to medication (30%). 19% of calls were regarding the COVID-19 vaccine. There were still 8% of calls regarding shielding. 9% of calls were related to appointments. Pressure on the nursing team was increased due to staff redeployment.ConclusionThe analysis of calls during the COVID-19 pandemic highlighted that although there was extensive national guidance produced, many patients still required the support and guidance of their specialist teams to interpret these according to their condition. We believe there is a duty of care for the specialist teams to maintain this level of service during any future events and this should be factored into any decisions regarding redeployment of staff. Appointments and homecare delivery enquiries continued despite directions to alternate numbers, therefore impacted on workload for the clinical nursing team. In order to streamline the service we introduced ‘options’ to select: option 1 for appointments, option 2 for homecare and option 3 for advice line queries. Option 1 and 2 then directed to the relevant team. Future developments include audit to assess the impact of introducing telephone options; reviewing the funding and scope of the service, which has extended beyond medication and flare advice; and further exploration of text and email platforms.Disclosure L. Knight: None. J. Miller: None. S. Dahiya: None.

Evaluation of patient satisfaction for telehealth (telephone and video) in rheumatology outpatients during COVID-19 pandemic.

Telehealth in rheumatology has been a topic of interest for many years, but the COVID-19 pandemic placed it in the forefront. To evaluate patient perception of rheumatology telehealth and determine predictive factors for future telehealth acceptability. A questionnaire containing 30 questions was sent to public and private rheumatology patients who attended telehealth appointments between April and May 2020. The questionnaire aimed to obtain information on baseline demographics, traditional appointment details, telehealth appointment details and appointment satisfaction using a 5-point Likert scale. Descriptive statistical analysis was conducted. The questionnaire was sent to 1452 patients, of whom 494 (34%) patients responded. More than 70% of responses indicated overall satisfaction in specialist care through telehealth, and 88.7% perceived this suitable during a pandemic. Less than 50% of patients were agreeable for future telehealth either through telephone or video conference after the pandemic is over. Higher odds ratio for future telehealth acceptability was associated with visual impairment, perceived cost-effectiveness and previous time lost at work for a face-to-face appointment. During the unprecedented time of the pandemic, telehealth appointments (telephone/video) assisted in providing ongoing patient care remotely, with high level of satisfaction seen in this study. The patient's experience and perception of telehealth was strongly influenced by financial incentives, and certain subgroups of patients were more accepting for future telehealth appointments. Nevertheless, low level of future telehealth acceptability also highlighted the potential dissatisfaction among patients in telehealth compared with the traditional appointments.

HIV-ASSOCIATED ARTHRITIS. Review and clinical cases

Relevance. HIV infection is characterized by a wide spectrum of clinical manifestations, including musculoskeletal symptoms, which can occur at any stage of the disease.
 Objective: to analyze own clinical cases with rheumatologic manifestations of HIV infection in context of literature data on the spectrum of musculoskeletal manifestations of HIV infection, approaches to diagnosis and treatment.
 Methods. Presentation of own clinical cases and review of scientific publications in the international electronic scientometric database PubMed using keywords «HIV infection», «arthritis», «musculoskeletal manifestations» over the period 2000-2021 years.
 Results. The prevalence of musculoskeletal symptoms in HIV-infected individuals ranges from 10 to 45%. Articular manifestations of HIV infection can be divided into 3 main groups: 1) related to HIV (arthralgias, painful articular syndrome, HIV-associated arthritis, septic arthritis); 2) inflammatory arthritis (rheumatoid arthritis, reactive arthritis, psoriatic arthritis, undifferentiated spondyloarthritis); 3) associated with antiretroviral therapy (aseptic necrosis, osteoporosis, osteomalacia, immune reconstitution inflammatory syndrome, gout). For treatment of articular manifestations analgesics, nonsteroidal anti-inflammatory drugs (drug of choice - indomethacin), intraarticular or oral glucocorticoids, disease-modifying antirheumatic drugs (drug of choice - hydroxychloroquine) may be used. Conditions for initiation of therapy with disease-modifying antirheumatic drugs: a controlled steady course of HIV with antiretroviral therapy performed, the number of CD4+ cells >200/ml, undetectable viral load. Our clinical cases confirm that indications for HIV testing in rheumatologic patients are reactive arthritis of unknown etiology, atypical lupus, persistent leukopenia, unreasonable weight loss, lack of an adequate response to traditional therapy of rheumatological diseases.
 Conclusions. Articular syndrome in HIV-infected individuals may be a separate manifestation of HIV infection and result of antiretroviral therapy. Treatment of articular manifestations in HIV-infected individuals primarily involves the treatment of HIV infection, and it depends on its clinical stage, use of antiretroviral therapy, the severity of articular syndrome and involvement of other organs. Our clinical observations demonstrate the possibility of articular manifestations at various stages of HIV infection: before diagnosis, during prolonged stable antiretroviral therapy, as well as after a change in antiretroviral therapy.

Evaluation of Humoral and Cellular Responses in SARS-CoV-2 mRNA Vaccinated Immunocompromised Patients.

BackgroundImmunocompromised patients are at increased risk of severe COVID-19 and impaired vaccine response. In this observational prospective study, we evaluated immunogenicity of the BNT162b2 mRNA vaccine in cohorts of primary or secondary immunocompromised patients.MethodsFive clinical groups of immunocompromised patients [primary immunodeficiency (PID) (n=57), people living with HIV (PLWH) (n=27), secondary immunocompromised patients with a broad variety of underlying rheumatologic (n=23) and homogeneous (multiple sclerosis) neurologic (n=53) conditions and chronic kidney disease (CKD) (n=39)] as well as a healthy control group (n=54) were included. Systemic humoral and cellular immune responses were evaluated by determination of anti-SARS-CoV-2 Spike antibodies using a TrimericS IgG assay (Diasorin) and through quantification of interferon gamma release in response to SARS-CoV-2 antigen with QuantiFERON SARS-CoV-2 assay (Qiagen), respectively. Responses were measured at pre-defined time-points after complete vaccination.ResultsAll healthy controls, PLWH and CKD-patients had detectable antibodies 10 to 14 days (T2) and 3 months (T3) after administration of the second vaccination. In contrast, only 94.5% of the PID, 50.0% of the rheumatologic and 48.0% of neurologic patients developed antibodies at T2 and only 89.1% of the PID, 52.4% of the rheumatologic and 50.0% of neurologic patients developed antibodies at T3. At T3 no significant differences in cellular response between the healthy control group and the PLWH and CKD groups were found, while proportions of reactive subjects were lower in PID and rheumatologic patients and higher in neurologic patients. Humoral and cellular immune responses significantly correlated in the healthy control, PID, PLWH groups for all 3 antigens.ConclusionPatients with acquired or inherited immune disorders may show variable immune responses to vaccination with the BNT162b2 mRNA vaccine against SARS-CoV-2. Whether humoral, cellular or both immune responses are delayed depends on the patient group, therapy and individual risk factors. These data may guide the counselling of patients with immune disorders regarding vaccination of SARS-CoV-2.

Clinical and Neurophysiological Characteristics of Patients with Carpal Tunnel Syndrome Presenting at the Tertiary Rheumatology Out-Patient Clinic

Background: Carpal tunnel syndrome (CTS) is the most commonly-encountered entrapment neuropathy. The classic symptoms of CTS are numbness and paraesthesia in the first three fingers of the hand, which is commonly exacerbated at night. The diagnostic signs include sensory loss along the lateral aspect of the hand, motor weakness and wasting of abductor pollicis brevis muscle. Tinel’s and Phalen’s signs are elicited at the wrist. Methods: This is a prospective analysis of clinical and electrophyisologic study performed on patients that attended the rheumatology outpatient clinic of a tertiary institution. The primary patients of the unit and those that were referred to the rheumatology clinic on account of clinical features of CTS were included in the study. Excluded from the study were pregnant women and those with previous history of CTS surgery. Nerve conduction study was carried out on all patients with features of nerve compression at the wrist. Results: Sixty nine (69) patients out of 82 that presented with clinical features of CTS were diagnosed of CTS. Females constituted 84.1% (58) and males were 15 .9% (11). The most affected age group was (31-40) years. Diabetes patients had the highest presentation of CTS (42%). The classic history of CTS was reported in 33.3%, Paraethesia was observed in 46.4%, numbness in 44.9% while paraethesia and numbness together were reported in 40.6% of patients. Day pain and nocturnal pain was seen in 60.9% and only nocturnal pain was reported by 42.0%. Abductor policis brevis (APB) muscle weakness was found in 24.6% of patients while 11.65% had wasting of the muscle. Conclusion: CTS was fairly common among the rheumatology patients and diabetes patients were predominantly affected.

Medical cannabis use by rheumatology patients in routine clinical care: results from The Ontario Best Practices Research Initiative.

Medical cannabis is often used to alleviate common symptoms in patients with chronic conditions. With cannabis legalisation in Canada and easier access, it is important that rheumatologists understand its potential impact on their practice. Among patients attending rheumatology clinics in Ontario we assessed: the prevalence of medical cannabis use; symptoms treated; rheumatologists' perceptions. Eight rheumatology clinics recruited consecutive adult patients in a 3-part medical cannabis survey: the first completed by rheumatologists; the second by all patients; the third by medical cannabis users. Student's t-test and Chi-square test were used to compare medical cannabis users to never users. 799 patients participated, 163 (20.4%) currently using medical cannabis or within <2 years and 636 never users; most had rheumatoid arthritis (37.8%) or osteoarthritis (34.0%). Compared to never users, current/past-users were younger; more likely to be taking opioids/anti-depressants, have psychiatric/gastrointestinal disorders, and have used recreational cannabis (p<0.05); had higher physician (2.9 vs. 2.1) and patient (6.0 vs. 4.2) global scores, and pain (6.2 vs. 4.7) (p<0.0001). Pain (95.5%), sleeping (82.3%) and anxiety (58.9%) were the most commonly treated symptoms; 78.2% of current/past-users reported medical cannabis was at least somewhat effective. Most rheumatologists reported being uncomfortable to authorise medical cannabis, primarily due to lack of evidence, knowledge, and product standardisation. Medical cannabis use among rheumatology patients in Ontario was two-fold higher than that reported for the general population of similar age. Use was associated with more severe disease, pain, and prior recreational use. Reported lack of research, knowledge, and product standardisation were barriers for rheumatologist use authorisation.

The Patient-Centered Approach in Rheumatologic Painful Diseases: A Narrative Review.

A patient-centric approach to pain control represents a paradigm shift in analgesia and one that is both easy to endorse but challenging to execute. As pain mechanisms become increasingly elucidated, the understanding of pain has changed to encompass its complexities. Multiple types and mechanisms of pain have been described, and pain must be seen through the subjective experience of the patient. Earlier descriptions of pain based on intensity are one-dimensional and do not fully encompass the experience of pain. Thus, treating rheumatology patients or any patient in pain requires an understanding of the primary or secondary nature of the pain, underlying conditions, and patient factors such as anxiety, depression, fearfulness, and catastrophizing, all of which can shape and change the nature of the pain. Further, it is important to manage patient expectations concerning chronic pain as complete pain relief may not be possible, but a Patient Acceptable Symptomatic State (PASS) may serve. Functional goals are often more meaningful to patients than pain scores. Pharmacologic therapy for pain must consider side effects as well as analgesia. Patient-centered pain control requires a focus on wellness and disease prevention, personalized care plans, education, support for self-care, and may involve coordination across disciplines to help the patient meet personally meaningful objectives. While patient-centric care has become a buzzword in modern medicine, it is extremely relevant and may be very beneficial to pain patients.

Non-English Language Preference Associated With Decreased Rheumatology Telehealth Use During the COVID-19 Pandemic.

ObjectiveThe study objective was to assess sociodemographic disparities in telehealth use among patients in an urban adult rheumatology clinic during the coronavirus disease 2019 (COVID‐19) pandemic.MethodsIn this retrospective cohort study, patient‐level sociodemographic data associated with all rheumatology visits in the following two periods were reviewed: pre‐COVID‐19 (March 1, 2019 to February 28, 2020) and COVID‐19 (April 1, 2020 to March 31, 2021). Data were extracted from the electronic health record. Multivariable logistic regression analyses were performed to determine sociodemographic factors associated with video visits during the COVID‐19 period.ResultsIn the pre‐COVID‐19 period, 1503 patients completed 3837 visits (100% in person). In the COVID‐19 period, 1442 patients completed 3406 visits: 41% in person, 30% video, and 29% telephone only. Several factors were associated with decreased video use: preference for Spanish language (adjusted odds ratio [aOR] 0.27, 95% confidence interval [CI] 0.15‐0.47) or other non‐English languages (aOR 0.34, 95% CI 0.21‐0.55), Black or African American race/ethnicity (aOR 0.50, 95% CI 0.35‐0.73), Medicaid payer, and increasing age.ConclusionDecreased video visit use among rheumatology patients was associated with non‐English language preference, minority race/ethnicity, increasing age, and indicators of low income. Rapid deployment and expansion of telehealth during the COVID‐19 pandemic likely has improved access for some but widened preexisting disparities for others. As medical care evolves toward ongoing digital care delivery, clarifying and addressing causes of telehealth disparities is essential for delivering equitable health care.

Ефективність та доцільність застосування напроксену при різних клінічних ситуаціях

В оглядовій статті подано докази клінічної ефективності напроксену в лікуванні пацієнтів ревматологічного профілю. Сучасна концепція раціонального й безпечного застосування нестероїдних протизапальних препаратів (НПЗП) передбачає досягнення максимальної ефективності разом з максимальним зниженням ризику ускладнень, насамперед із боку серцево-судинної та гастроінтестинальної систем. За даними клінічних досліджень, серед усіх НПЗП найменший ризик кардіоваскулярних ускладнень відзначений у напроксену. Напроксен належить до групи неселективних НПЗП, активно використовується в клінічний практиці вже понад 40 років та завоював довіру лікарів як надійний анальгетик та протизапальний засіб. Терапевтичний потенціал напроксену доведений при різних клінічних ситуаціях — від гострих епізодів болю та запалення і до хронічного больового синдрому в ревматологічній практиці. У статті наведені та проаналізовані рандомізовані клінічні випробування, що підкреслюють клінічну ефективність та безпеку при застосуванні напроксену при гострому подагричному артриті, гострих травмах, остеоартриті, ревматоїдному артриті та спондилоартритах.

P115 Implementation of a vaccination tool in the electronic patient health record significantly increases vaccination coverage

BackgroundPatients with immune-mediated inflammatory diseases (IMID) are at higher risk for infectious diseases. Despite this increased risk and the available guidelines1, we reported a sub-optimal vaccination rate of 27.4% of IMID patients in 2018. In the meantime, a vaccination module was introduced in the electronic patient health record of our hospital to accurately document and monitor vaccination status of patients. The impact of this new module on vaccination coverage was re-evaluated in the same IMID patients in 2021.MethodsBetween Aug and Oct 2021, the vaccination status of 1448 (out of the original 1488) IMID patients (44.8% male, median age 53.6 years) was collected (798 patients with IBD, 612 with rheumatological, and 38 with dermatological inflammatory conditions) and compared to that of 2018. The vaccination status was obtained mainly through the patients’ electronic medical records. Missing data were added after contacting patients or their general practitioner.ResultsFrom 2018 to 2021, the overall vaccination coverage of all IMID patients significantly increased from 27.4% to 51.9% (p<0.001, Figure 1).The vaccination coverage in IBD patients increased significantly from 75.9% to 86.3% for influenza (p<0.001), from 72.9% to 88.7% for pneumococci (p<0.001), from 66.0% to 80.2% for hepatitis B (p<0.001), from 79.9% to 85.7% for tetanus (p=0.041) and from 42.2% to 60.4% overall (p<0.001) (Figure 1 and Table 1).Similarly, the vaccination coverage significantly increased for rheumatology patients, namely from 69.3% to 78.3% for influenza (p<0.001), from 34.5% to 85.0% for pneumococci (p<0.001), from 32.8% to 36.5% for hepatitis B (p<0.001) and from 7.8% to 32.6% overall (p<0.001) (Figure 1 and Table 1).For patients with dermatological inflammatory conditions, vaccination coverage significantly increased from 60.5% to 81.6% for pneumococci (p=0.031) and from 47.1% to 55.3% for hepatitis B (p=0.002) (Table 1). ConclusionThe suboptimal vaccination rate measured in 2018 and the COVID-19 pandemic stressed the importance of vaccination recommendations to patients and healthcare professionals. We here show that the implementation of a vaccination tool integrated in the electronic medical record of patients is correlated with a significant increase in specific vaccination rates and also in the total amount of IMID patients that were fully vaccinated according to guidelines.Reference1. Rahier JF, Magro F, Abreu C, et al. Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis. 2014;8:443–468.

Influenza Vaccine Hesitancy and Its Determinants Among Rheumatology Patients.

ObjectivePatients with rheumatic disease (RD) have an increased risk of influenza and its complications. Despite inactivated influenza vaccine (IIV) recommendations, IIV uptake in patients with RD is suboptimal, a problem of increasing importance in the COVID‐19 era. We estimated the frequency of IIV hesitancy and associated factors among Canadian patients with RD.MethodsA cross‐sectional vaccine hesitancy survey was completed by rheumatology clinic patients (November 2019 to January 2020). Patients rated their likelihood of receiving the influenza vaccine (scale of 0‐10). We categorized these as follows: likely to refuse (scale of 0‐2), uncertain (scale of 3‐7), or likely to accept (scale of 8‐10). Multivariate logistical regression was used to evaluate factors associated with vaccine hesitancy.ResultsA total of 282 patients (63.5% of those approached) completed the survey, with 165 (58.5%) being likely to accept, 67 (23.8%) being likely to refuse, and 50 (17.7%) uncertain. Uncertain patients were younger and more likely to be employed than those in the other two groups. No previous influenza vaccination (odds ratio [OR] 36.6, 95% confidence interval [CI] 5.3‐252.9), belief that vaccination should not be mandatory (OR 0.1, 95% CI 0.0‐0.7), unwillingness to take time off work to be vaccinated (OR 6.8, 95% CI 1.5‐30.6), and distrust in pharmaceutical companies (OR 41.0, 95% CI 5.6‐301.5) predicted likeliness to refuse. Reluctance to pay for vaccination (OR 2.8, 95% CI 1.1‐7.5) and no previous influenza vaccination (OR 18.9, 95% CI 3.3‐109.7) predicted uncertainty.ConclusionMore than 40% of rheumatology patients are either likely to refuse or uncertain about receiving IIV. This contributes to suboptimal vaccine coverage in this population. Interventions addressing these concerns are needed, particularly in the COVID‐19 era.

The spectrum of hemophagocytic lymphohistiocytosis: a retrospective study comparing adult macrophage activation syndrome to malignancy-associated hemophagocytic lymphohistiocytosis.

Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening inflammatory syndrome that can be triggered by autoimmune diseases, malignancy, or infection. In rheumatologic patients, sHLH is referred to as macrophage activation syndrome (MAS). Differentiating between triggers is important for prompt treatment and prognosis. Data comparing subsets of sHLH are limited due to the rarity of this disease. We aim to explore differences in clinical features that may differentiate MAS from malignancy-associated HLH (mHLH) patients. We conducted a single-center retrospective study assessing clinical characteristics, laboratory parameters, treatment regimens and outcomes in 34 patients with sHLH over a 16 year period. We compared patients with MAS to those with mHLH. Hepatomegaly was not present in the MAS group but was present in the mHLH group (0 vs. 25%, p = 0.024). MAS patients had on average nearly double the concentration of platelets at 50.0 (IQR: 31.0–78.0 Kµ/L) vs. 29.0 Kµ/L (IQR: 14.0–37.5 Kµ/L), p = 0.003. Soluble IL-2R concentrations were four times lower in the MAS group with a median soluble IL-2R concentration of 6814.5 kU/L (IQR: 2101–2610 kU/L) vs. 27972.0 kU/L (IQR: 12,820–151,650 kU/L), p = 0.010. The MAS group fared better overall than the mHLH group but was not statistically significant (mortality 22 vs. 44%, p = 0.18). MAS and mHLH patients exhibited different laboratory parameters and clinical features, most notably differences in platelet counts, soluble IL-2R concentration and hepatomegaly, which may help differentiate these conditions early in their course.

Effect of COVID-19 Pandemic on Anxiety in Rheumatology Patients Taking Immunosuppressive Drugs

Effect of COVID-19 Pandemic on Anxiety in Rheumatology Patients Taking Immunosuppressive Drugs

Complementary and Alternative Medicines Used by Individuals With Rheumatological Diseases to Cope With Sleeplessness.

This study aims to determine complementary and alternative medicine methods used by rheumatology patients to cope with insomnia and to evaluate their attitudes toward complementary and alternative medicine methods. This descriptive study was completed with 167 patients followed up by the rheumatology unit of a university hospital. Data were collected with the patient identification form and the Holistic Complementary and Alternative Medicine Questionnaire. The mean age of the participants was 44.76 ± 8.96 years and the mean disease duration was 52.90 ± 35.51 months. Most of the participants (69.5%) were women, with 64.1% primary school graduates. Majority of the participants (96.4%) knew complementary and alternative medicine methods, and the main source of information (51.5%) was the internet and social media. The most frequently applied method was phytotherapy (58.7%), the most frequently used plant (30.5%) was stinging nettle and the mean Holistic Complementary and Alternative Medicine Questionnaire score of the patients was 26.68 ± 3.51. Rheumatology patients frequently use complementary and alternative medicine methods to cope with insomnia symptoms and the most commonly used complementary and alternative medicine method used by patients is phytotherapy.

Prospective study of patients with inflammatory back pain, clinical characteristics and treatment response in ankylosing spondylitis in two centers of rheumatology in South India

Introduction: Ankylosing spondylitis is inflammatory arthritis affecting the spine and peripheral joints more commonly in men of 15 years to 40 years of age and is a part of the spectrum of diseases called spondyloarthropathy. Psoriasis, uveitis, ulcerative colitis, and inflammatory bowel disease form part of the systemic manifestations. There exists a long delay between the onset of inflammatory back pain and being diagnosed with ankylosing spondylitis.Methodology: We set out to study the clinical profile, diagnosis, and management of patients with spondyloarthritis (SpA) prospectively and follow-up over 2 years period. All patients who had inflammatory back pain and diagnosed to have SpA were included in this prospective study in two different centers of Rheumatology. Clinical characteristics, magnetic resonance imaging (MRI)-spine and sacroiliac joints, disease activity using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), and early treatment response were assessed. Other investigations including bloods, X-rays, and screening for biologics were done as and when indicated. We used both synthetic Disease-Modifying AntiRheumatic Drugs (DMARDS) and biosimilars as per the British Society of Rheumatology guidelines and patient choice. Patients were reviewed every 3 months for 1–2 years. The response to treatment was assessed and compared with other studies.Results: Forty -two patients were studied in this 2 years period (15 patients out of 57 lost to follow up). All patients had the diagnosis of ankylosing spondylitis as per Assessment of Spondylo Arthritis international Society (ASAS Score) criteria and MRI evidence of sacroiliitis and 22 patients had peripheral synovitis. HLA-B27 was positive in 11/19 patients. Eleven patients had been on anti-Tumor Necrosis Factor (TNF) drugs and 26 patients were on DMARDs. At the end of 24 weeks, disease activity indices including BASDAI and BASFI were low in remission and statistically significant. At the end of 2 years, most of them were in remission and 81% were continuing to work and maintain productivity. Patients who underwent treatment with biosimilar TNFs showed a significant reduction in disease activity and achieved remission earlier, as evidenced by BASDAI and BASFI scores, compared to others who were on DMARDS and supportive therapy. The usage of DMARDS was more than biosimilar drugs as they are expensive.Conclusion: This study shows the real-world data on the diagnosis and management of patients with ankylosing spondylitis, achieving remission, and maintaining the work-life balance. Early diagnosis with MRI and appropriate intervention with DMARDS are the important factors in this study.

Telemedicine for Rheumatology Patients in Covid-19 Pandemic: Perspectives of Patients.

Telemedicine use for patients with autoimmune rheumatic conditions during the pandemic mandates better characterization. We conducted a telephonic survey on patients who consulted rheumatologists remotely to determine their attitudes toward telemedicine. The study was conducted at Aga Khan University Hospital, a tertiary care hospital in Pakistan which is a lower-middle-income country. Descriptive analyses were performed. Fifty patients visited tele-rheumatology clinic, 35 (70.0%) were female with a mean (SD) age of 47.6 (18.1) years. Majority (27, 54.0%) learned about telemedicine from hospital website and outpatient clinic desk or helpline. Lack of examination was the biggest concern with teleconsultation (18, 22.2%). Most patients (38, 76.0%) agreed to continue teleconsultation beyond the pandemic. Telemedicine is preferable for providing rheumatology outpatient service during and after the pandemic.

Knowledge, attitude and practices study regarding current COVID-19 pandemic in patients presenting to rheumatology clinic of a Tertiary Care Hospital

Introduction: The most important step in controlling the spread of any communicable disease is to stick to preventive measures and COVID-19 pandemic is no exception. Keeping this in mind, a KAP study was performed in the rheumatology unit of a tertiary care hospital of Islamabad. The main idea was to know the level of understanding of rheumatologic patients with respect to COVID-19 pandemic and its preventive measures.&#x0D; Objective: The objective of the study was to understand the knowledge, attitude and practices of rheumatologic patients towards COVID-19 pandemic.&#x0D; Methodology: A descriptive cross-sectional study in which consecutive, non-probability sampling technique was used.&#x0D; Results: There were 37 males and 73 females in the study group, with mean age of 38.75±13.9 years.&#x0D; The total knowledge score was 17 points. It was found that 12 (10.9%) participants had poor knowledge regarding COVID-19, whereas 27 (24.5%) and 71 (64.5%) had good and excellent knowledge respectively. The total attitude score of study participants 7 points. It was found that 11 (10.0%) participants had poor attitude, whereas 72 (65.5%) and 27 (24.5%) had good and excellent attitude. The total practice score was 11 points. It was calculated that 30 (27.3%) study participants had poor practices regarding COVID-19 prevention, whereas 78 (70.9%) had good practices and only 2 (1.8%) had excellent practices.&#x0D; Conclusion: Overall, it was noted that KAP of our rheumatologic patients towards COVID-19 infection was reasonable, however, there is always room for improvement.

Anti-inflammatory drugs and immunogenicity of vaccines in patients with rheumatic diseases

The problem of comorbid infections in rheumatology seems to be very relevant in connection with the active introduction into clinical practice of innovative disease-modifying anti-rheumatic drugs (DMARDs), the so-called targeted DMARDs (tDMARDs), as well as genetically engineered biological drugs (biologics), the action of which is directed at specific links in the pathogenesis of immuno-inflammatory rheumatic diseases. With the accumulation of global clinical experience, the association of the use of these drugs with an increasing risk of developing comorbid infections of various nature and localization has become clearly traced. The real way out of this situation seems to be the creation, improvement and introduction into clinical practice of various vaccines. At the same time, a number of anti-rheumatic drugs may have a certain negative effect on the immunogenicity of some vaccines, which may lead to a decrease in the preventive effectiveness of the latter. This review presents the latest data on the effect of various anti-rheumatic drugs on the immunogenicity of vaccines against influenza, pneumococcal and herpes virus infections, viral hepatitis B, yellow fever and COVID-19 used in rheumatological patients. It has been shown that the anti-B-cell drug ritux imab has a significant negative effect on the immunogenicity of vaccines, which increases with a shortening of the time between immunization and the use of the drug. Methotrexate also negatively affects the immunogenicity of most vaccines, but to a lesser extent. Abatacept probably reduces the immunogenicity of vaccines, although studies were performed in the absence of adequate control groups. Tumor necrosis factor inhibitors-α and tDMARDs (janus kinase inhibitors) reduce the absolute values of antibody concentrations for many vaccines, but apparently do not have a significant effect on the frequency of patients who have achieved seroprotection. Inhibitors of interleukin (IL) -6, IL-12 / IL-23 and IL-17 practically do not affect the immunogenicity of vaccines. The accumulated data on the effect of the above drugs on the immunogenicity of the vaccine against SARS-CoV-2, apparently, are similar to those obtained in studies on vaccination against other infections in patients with immuno-inflammatory rheu matic diseases. Further clinical studies are needed to assess the effect of immunosuppressive therapy on the vaccine response and to develop methods for its optimization.

Polymyalgia rheumatica in 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography : Improvement in diagnostic accuracy and differentiation from rheumatoid arthritis

The diagnosis of patients with polymyalgia rheumatica (PMR) has relied upon the clinical examination of symptoms and laboratory parameters of inflammation until now. Currently, the use of different imaging modalities is being explored, including ultrasound, MRI and PET. The aim was to evaluate the diagnostic value of 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography (18F-FDG-PET/CT) for PMR, in order to improve the sensitivity and specificity of diagnosing PMR and to improve the differential diagnosis of rheumatoid arthritis (RA). Examinations using 18F-FDG-PET/CT of 284 rheumatological patients, including 97 patients with PMR, were retrospectively evaluated over a44-month period. Furthermore, 13regions changed by inflammation were analysed via athree-dimensional region of interest (ROI) measurement with determination of maximum standardized uptake values (SUVmax), followed by statistical analyses. Patients with PMR presented significantly elevated uptake in all regions examined (p < 0.001), compared with acontrol group treated for rheumatological diseases. The method with the highest diagnostic relevance was represented by the combination of four SUVmax values of both anterolateral hip capsules and both ischial tuberosities, reaching asensitivity of 91.3% and aspecificity of 97.6% with acut-off of 11.0 SUV at the initial diagnosis of PMR patients who had not yet received any immunosuppressive therapy. Patients with RA could be significantly distinguished from those with PMR at initial diagnosis in the same anatomical regions (p < 0.001).