COVID-19 and rheumatic musculoskeletal disease patients: infection rates, attitudes and medication adherence in an Irish population

Objectives

To establish, amongst Irish rheumatic musculoskeletal disease (RMD) patients, rates of COVID-19 symptoms and positive tests, DMARD adherence and attitudes to virtual clinics.

Methods

An online survey assessing COVID-19 status, RMD diagnoses, adherence and information sources was disseminated via the Arthritis Ireland website and social media channels.

Results

There were 1381 respondents with 74.8% on immunosuppressive medication. Symptoms of COVID-19 were reported by 3.7% of respondents of which 0.46% tested positive, consistent with the general Irish population. The frequency of COVID-19 symptoms was higher for respondents with spondyloarthropathy [odds ratio (OR) 2.06, 95% CI: 1.14, 3.70] and lower in those on immunosuppressive medication (OR 0.48, 95% CI: 0.27, 0.88), and those compliant with health authority (HSE) guidance (OR 0.47, 95% CI: 0.25, 0.89). Adherence to RMD medications was reported in 84.1%, with 57.1% using health authority guidelines for information on medication use. Importantly, adherence rates were higher amongst those who cited guidelines (89.3% vs 79.9%, P <0.001), and conversely lower in those with COVID-19 symptoms (64.0% vs 85.1%, P =0.009). Finally, the use of virtual clinics was supported by 70.4% of respondents.

Conclusion

The rate of COVID-19 positivity in RMD patients was similar to the general population. COVID-19 symptoms were lower amongst respondents on immunosuppressive medication and those adherent to medication guidelines. Respondents were supportive of HSE advice and virtual clinics.

P207 A quality improvement intervention to increase pneumococcal and influenza vaccination rates in immunosuppressed inflammatory arthritis patients

Background

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

Methods

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

Results

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

Conclusion

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

Disclosures

K. Murray: None. C. Low: None. F. Young: None. A. O'Rourke: None. I. Callanan: None. E. Feeney: None. D. Veale: None.

P126 An analysis of the quality and readability of online information for osteoarthritis

Background

Osteoarthritis is the most common cause of disability in people over 65 years old. The readability of of online osteoarthritis information has never been assessed. A 2003 study found the quality of online osteoarthritis information to be poor. This study reviews the quality of online information regarding osteoarthritis in 2018 using three validated scoring systems. Readability is reviewed for the first time, again using three validated tools.

Methods

The term osteoarthritis was searched across the three most popular English language search engines. The first 25 pages from each search engine were analysed. Duplicate pages, websites featuring paid advertisements, inaccessible pages (behind a pay wall, not available for geographical reasons) and non-text pages were excluded. Readability was measured using Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL) and Gunning-Fog Index (GFI). Website quality was scored using the the Journal of the American Medical Association (JAMA) benchmark criteria and DISCERN criteria. Presence or absence of HONcode certification, age of content, content producer and author characteristics were noted.

Results

37 unique websites were suitable for analysis. Readability varied by assessment tool from 8th to 12th grade level. This compares with the recommended 7- 8th grade level. One (2.7%) website met all four JAMA Criteria. Mean DISCERN quality of information for OA websites was “fair”, comparing favourably with the “poor” grading of a 2003 study. HONCode endorsed websites (43.2%) were of a statistically significantly higher quality.

Conclusion

Quality of online health information for OA is “fair”. 2.7% of websites met JAMA benchmark criteria for quality. Readability was equal to or more difficult than recommendations. HONcode certification was indicative of higher quality, but not readability.

Disclosures

K. Murray None. T. Murray None. C. Low None. A. O'Rourke None. D.J. Veale None.

A quality improvement intervention failed to significantly increase pneumococcal and influenza vaccination rates in immunosuppressed inflammatory arthritis patients

OBJECTIVES

Pneumococcal and influenza vaccination rates have been suboptimal in studies of immunosuppressed patients. We aimed to assess barriers to and increase rates of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and influenza vaccination in this group. The primary endpoint was a statistically significant increase in adequate PPSV23 and influenza vaccination.

METHODS

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

RESULTS

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

CONCLUSIONS

PPSV23 and influenza vaccination rates were suboptimal. The intervention did not cause a statistically significant change in vaccination rates. Point-of-care vaccination may be more effective.Key Points• Low vaccination rates amongst immunosuppressed inflammatory arthritis outpatients• Less than 5% of vaccinations occurred in hospital• There was no statistically significant difference in the rates of adequate PPSV23 (41.0 to 47.2%) or influenza (61.8 to 62.1%) vaccination following our intervention.

Seroepidemiology of hepatitis A, hepatitis B and varicella virus in people living with HIV in Ireland

Epidemiological studies investigating seroprevalence of vaccine preventable infections at both individual and population level are important in guiding screening and vaccination practices. Data on seroprevalence of common vaccine preventable infections in HIV-infected individuals is lacking. We carried out a retrospective cohort study to investigate serological immunity and factors associated with immunity to hepatitis A virus (HAV), hepatitis B virus (HBV) and varicalla virus (VZV) in a cohort of HIV-infected individuals attending a large ambulatory HIV specialist centre in Ireland. Basic demographic data including risk of acquisition of HIV and region of origin was recorded. Between-group prevalence was compared using the Chi2 test and Wilkoxin signed rank test. Univariate variables with p<0.2 were entered into a multivariate logistic regression model. Of 1287 HIV-infected individuals included in this study (median [SD] age 39 [10] years, 68% male, 46% Irish), 75% were hepatitis A IgG positive, 94% were VZV IgG positive, 3% were HBV surface antigen (sAg) positive while 29% were HBV core antibody (cAb) positive. This study identifies a significant proportion of HIV infected who were susceptible to common vaccine preventable infections. These results highlight the importance of proactive screening and immunization of HIV-infected individuals to ensure optimal protect ionagainst vaccine preventable diseases in this at risk patient group.

Factors associated with non-retention in HIV care in an era of widespread antiretroviral therapy

In an era of antiretroviral therapy (ART) for all HIV-1-infected patients, our primary aim was to describe prevalence and characteristics of patients disengaged from care at an urban ambulatory HIV clinic. We conducted a nested case-control study. All patients who disengaged from care (defined as being lost to follow-up for at least one year) from 2007 to 2014 inclusive were identified. Cases were matched to controls in a 1:4 ratio. A total of 1250 cases were included; 250/2289 (10.9%) of patients attending our HIV clinic disengaged from 2007 to 2014. One hundred and twenty-six (50.4%) were heterosexual, 81 (32.4%) were men who have sex with men and 40 (16%) were intravenous drug users. On univariate analysis only, patients with heterosexual risk were more likely to disengage from care (50.4% vs. 33.7%, p: <0.001). Those who disengaged were younger, mean age of 39 (p: <0.001). A higher proportion of patients who disengaged from care was not receiving ART and did not have a suppressed HIV-1 viral load (p: <0.001). On multivariable analysis, Irish patients were less likely to disengage from HIV care (odds ratio: 0.567, p: 0.002). Factors associated with non-retention in HIV care have been identified. A semi-structured interview of those patients who re-engaged will take place to further examine reasons for disengagement from care.

Coefficients of fat and nitrogen absorption in healthy subjects and individuals with cystic fibrosis

BACKGROUND

We sought to compare the differences of coefficient of fat absorption (CFA) and coefficient of nitrogen absorption (CNA) in healthy individuals and those with cystic fibrosis (CF) and to study the precision of CFA and CNA.

METHODS

Sixteen healthy and 23 subjects with CF and pancreatic insufficiency ate a high-fat, high-protein diet for 72 hours; stool was collected between blue food dye markers to determine CFA and CNA. Subjects with CF withheld pancreatic enzymes. Tests were repeated on 5 of the CF and 10 of the healthy subjects.

RESULTS

In healthy subjects, mean CFA was 93.5% ± 2.7%; mean CNA was 88.1% ± 5%. Median test-retest in 10 healthy subjects was +0.7% CFA (range, -8.1% to + 5.9%) and +0.9% CNA (range, -14.6% to +6.8%). For subjects with CF, mean CFA was 38.5% ± 14.7% and mean CNA was 52.2% ± 11.4%. Median test-retest change in 5 subjects with CF was -6.9% CFA (range, -19.7% to +42.8%) and +14.7% CNA (range, -6.4% to +42.8%).

CONCLUSIONS

CFA and CNA have inconsistent precision in CF. The limitations of CFA as a measure of steatorrhea correction in CF should be recognized in studies of pancreatic enzyme supplements.

Improving patient care--the first year in a dedicated surgical assessment unit

A surgical assessment unit (SAU) was established in October 2009 at the Mid-Western Regional Hospital. We assessed this servic in its initial year and compared it to Emergency Department (ED) services. We audited SAU and ED databases and theatre logbooks from November 2009 to October 2010. 1949 patients were referred to the SAU and 857 patients were admitted (44%). Only 44 SAU patients (6%) waited more than 6 hours for a bed compared to 828 patients (68%) admitted through the ED. SAU patients who required emergency surgery had a shorter waiting time before theatre (37 (18.6%) vs 9(6%) waited less than 6 hours, p < 0.05). To summarise, we found that almost 2,000 patients who would otherwise have presented to the ED were referred to the SAU. Waiting times for admission and theatre were significantly shorter. Further resource allocation could expand the service and improve it further, by diverting more patients from the ED.

The role of pre-operative assessment and ringfencing of services in the control of methicillin resistant Staphlococcus aureus infection in orthopaedic patients

BACKGROUND

MRSA is a major economic and health issue internationally and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial.

MATERIALS AND METHODS

This study was a review of a prospectively maintained database from our unit over three time points from 2005 to 2007. At each time point a new infection control measure was implemented in an effort to reduce MRSA infections. Total rates of MRSA infection and colonisation in all orthopaedic patients were recorded, before and after separation of trauma and elective services, and after the introduction of a screening pre assessment clinic.

RESULTS

12259 orthopaedic patients were reviewed over the three years. The mean age of MRSA infected patients was 71. A higher proportion of female patients were infected than male patients. The mean length of stay for infected patients was 23.4 days. The rate of infection dropped from 0.49% in 2005 to 0.24%in 2007. After the introduction of these measures there was a substantial reduction in organ space and deep tissue infections.

CONCLUSION

The separation of emergency and elective orthopaedic services coupled with effective pre-operative screening has resulted in a significant reduction in MRSA infection despite an ever increasing prevalance.

Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: a five-year analysis

This prospective five-year study analyses the impact of methicillin-resistant Staphylococcus aureus (MRSA) on an Irish orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41,971). A total of 240 (76%) cases were colonised with MRSA, while 120 (37.7%) were infected. Patients were admitted from home (218; 68.6%), nursing homes (72; 22.6%) and other hospitals (28; 8.8%). A total of 115 cases (36.6%) were colonised or infected on admission. Many patients were both colonised and infected at some stage. The length of hospital stay was almost trebled because of the presence of MRSA infection. Encouragingly, overall infection rates have not risen significantly over the five years of the study despite increased prevalence of MRSA. However, the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.

Safety and preliminary clinical activity of a novel pancreatic enzyme preparation in pancreatic insufficient cystic fibrosis patients

OBJECTIVES

Currently available pancreatic enzyme products are crude porcine products with few data available regarding their efficacy, safety, and manufacture. We conducted a phase 1 study of a novel pancreatic enzyme product, TheraCLEC-Total (TCT), a proprietary formulation of microbial-derived lipase, protease, and amylase, to determine its safety and preliminary efficacy in cystic fibrosis.

METHODS

We conducted an open-label, dose-ranging study in 23 subjects diagnosed with pancreatic insufficiency with cystic fibrosis. The subjects received TCT containing lipase dose of 100, 500, 1000, 2500, or 5000 USP U/kg per meal with each meal or snack for 3 days. The clinical and laboratory parameters and adverse events (AEs) were monitored.

RESULTS

There were no serious AEs. Most AEs were mild, although gastrointestinal complaints were common. TCT increased the coefficient of fat and nitrogen absorption in all groups except in the low-dose group. At the other dosing levels, the mean coefficient of fat and nitrogen absorption increases were 19.1% +/- 24.9% and 17.8% +/- 13.6%, respectively, whereas the mean stool weight decreased by 517 +/- 362 g.

CONCLUSIONS

TCT was well tolerated in this short-term exposure study. The preliminary efficacy data demonstrate lipase and protease activity with little difference seen with lipase doses greater than 500 USP U/kg per meal. These data support a larger randomized phase 2 trial.

Change management in primary care: design and evaluation of an internet-delivered course

OBJECTIVES

To deliver and evaluate an internet course in change management for primary care professionals.

DESIGN

A 12-week course delivered over the internet. Respondents were allocated into two groups: one had access to the course tutor individually, while the other could also communicate with the rest of the learner group. Learning outcomes were assessed by means of pre- and post-intervention questionnaires and by interviews with some participants.

SUBJECTS

111 primary care professionals.

RESULTS

Subjects showed significant improvements on all learning outcomes. The group with access to the course tutor alone completed more units and had greater improvements in their learning outcomes. More of this group completed the course and completed a portfolio. Respondents who could communicate with other members of the group did not find this a positive experience.

CONCLUSION

The internet can be used to deliver learning in change management to primary care professionals. Access to a discussion forum did not improve, and possibly impaired learning. More work is needed on the mentoring of internet learning.

Dealing with prejudice

Few of us are free of all prejudices, however subtle and subconscious, and they may affect both patient care and teaching. Here I use reflection about a patient with HIV infection, from the points of view of two doctors caring for him and the patient himself, to explore prejudice against lifestyles that are considered "dangerous". The paper then goes on to discuss research about physicians' attitudes to such cases, the teaching of ethics in a clinical environment and the need to support junior medical staff.

Tissue- and epitope-specific mechanisms account for the diverse effects of anti-CD44 antibodies on the maintenance of primitive hematopoietic progenitors in vitro

The identification of rare stromal cells that support high levels of stem cells has opened avenues to identify molecules that contribute to the maintenance of these cells. We show that the maintenance of long-term culture initiating cells (LTC-IC) in stromal cell-supported cultures can be modulated via mAbs specific for CD44. mAb IM7.8.1 suppressed while mAb RAMBM44 enhanced LTC-IC levels in culture. Genetic polymorphisms in CD44 were used to show that the stromal cell compartment is targeted by mAb RAMBM44 and the hematopoietic compartment by mAb IM7.8. Neither of the CD44-specific mAbs inhibited adhesion of LTC-IC to the stroma, suggesting alternative mechanisms of action. In support of this interpretation, we show that mAb RAMBM44 directly induces signal transduction in the stromal cell line S17 but not in hematopoietic cells. Conversely, mAb IM7.8 elicited the appearance of phosphorylated bands in hematopoietic cells, but not in stromal cells. Collectively, the data indicate that the opposing effects of CD44-mediated regulation can be explained by different cellular programs that are elicited in distinct cell compartments. The binding of the enhancing mAb RAMBM44 to CD44 is specifically inhibited by collagen IV, while binding of the suppressive mAb IM7.8.1 is inhibited by a substance contained in the supernatant of the stromal cell line AC3.U. Thus, the CD44 epitopes defined by the mAbs bind distinct ligands and the ligands provide a potential physiological counterpart for the regulatory actions of the mAbs.

Measurement of serum antigen concentration by ultrasound-enhanced immunoassay and correlation with clinical outcome in meningococcal disease

The distribution of Neisseria meningitidis serogroup B and C polysaccharide antigen in blood and the prognostic significance of antigen concentration was examined by ultrasound-enhanced immunoagglutination of coated microparticles. Specimens (169 sera/plasma from 145 patients with confirmed meningococcal disease) were tested retrospectively. The ultrasonic immunoassay detected serum antigen in 136 samples from 112 patients. Titration of antigen-positive specimens allowed estimation of blood antigen concentration. The modal blood antigen titre was 1/16, corresponding to an estimated polysaccharide concentration of 0.85 microg/ml. The lowest mean blood antigen concentration found ultrasonically was 0.05 microg/ml; compared to the 1.98 microg/ml found by conventional latex agglutination, this represents an approximately 30-fold improvement in sensitivity. Three grades of outcome were correlated with the presenting antigen titre in 83 patients: (i) <2 weeks hospitalisation, (ii) > or =2 weeks hospitalisation and (iii) mortality. High polysaccharide concentrations correlated with mortality. Nine of 15 patients with a serum antigen titre of 1/64 or greater (> or =3.4 microg/ml polysaccharide) died, whereas no patient with titres equal to or less than 1/4 (< or = 0.21 microg/ml) died, including those patients in whom antigen was undetectable by ultrasonic immunoassay. Increasing antigen concentration significantly correlated with severity of outcome (P<0.001). Ultrasound-enhanced agglutination provides a rapid prognostic indicator by sensitive measurement of serum antigen level.

The Wisdom Project: virtual education in primary care

This article examines the development of the Wisdom Project, a pilot for the teaching of informatics to primary health care professionals, using an original educational model based on e-mail and Web pages. The article begins by placing the development of the Wisdom Project in the context of changes in medical education and training. The aims and objectives of Wisdom are outlined, and the methodologies for setting up and evaluating the project are described. The article then presents the results of the evaluation, including the identification of significant improvements in knowledge of CD ROMs (P = 0.01), e-mail (P = 0.03), Medline (P = 0.02), operating systems (P = 0.02), Web browsers (P = 0.003) and word processing (P = 0.03). Improvements in evidence-based practice (EBP) did not reach significance. Finally, a number of conclusions are presented, considering the lessons learnt for the future development of such projects.

The effects of physical exercise training and cardiac education on levels of anxiety and depression in the rehabilitation of coronary artery bypass graft patients

OBJECTIVE

to evaluate whether an exercise and education-based rehabilitation programme is sufficient treatment for individuals with clinically significant levels of anxiety or depression following coronary artery bypass graft (CABG) surgery.

DESIGN

follow-up and repeated assessment after surgery.

SETTING

outpatient cardiac rehabilitation programme.

PATIENTS

all 88 attenders after CABG surgery.

ASSESSMENTS

structured interview and Hospital Anxiety and Depression (HAD) scale (using 8 as the cut-off) administered by rehabilitation nurses at start of course and HAD repeated at 12 weeks and 6 and 12 months (by post after discharge).

RESULTS

return rates of 76 and 80% at 6- and 12-month assessments, respectively; statistically significant reductions in levels of anxiety and depression found between first and all subsequent assessments; subdividing into groups revealed significant reduction in anxiety and depression in the anxious and depressed groups at 12 weeks and 6 months, respectively, but at 12 months there was no significant reduction.

CONCLUSIONS

there is a need to address the problems of anxiety and depression directly by screening and treatment, and to provide more psychologically-orientated cardiac rehabilitation programmes.

A phase I trial of continuous infusion cisplatin

Treatment with continuous infusions of cisplatin results in increased filterable drug exposures as measured by the area under the curve (AUC) of nonprotein-bound plasma platinum levels. To determine the dose-limiting toxicity and optimal method of administration, 24 patients were treated with continuous infusions of cisplatin at a dose rate of 25 mg/M2/day in a limited Phase I trial. A total of 47 courses were given. Nine patients received 13 courses of 4 days duration, 19 received 29 courses of 5 days duration, and five received courses of 6 or 7 days duration. Dose-limiting toxicity was found to be leukopenia: 42% of patients receiving the 5-day treatment developed a nadir count of less than 3000 cells/mm3. Nausea and vomiting were easily controlled. Minimal nephrotoxicity occurred in five patients and was associated with daily volume expansion with 2 l of 0.9% NaCl solution in four patients. All other patients were given 3 l of daily volume expansion during treatment. Responses were seen in 6 of 22 evaluable patients (27%). It is concluded that continuous infusion cisplatin at a dose rate of 25 mg/M2/day can be given safely for 5 days as a single agent if concomitant volume expansion with at least 3 l of 0.9% NaCl solution is given daily. Phase III comparative trials with a conventional bolus and newer high-dose regimens for response and toxicity are indicated.