The impact of the COVID-19 pandemic and stringent social distancing measures on health-related quality of life and COVID-19 infection rates in patients with rheumatic disease: a longitudinal analysis through the pandemic

Objective

The aim was to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic and stringent social isolation measures on patients with rheumatic disease (RD) from the beginning of the pandemic (April 2020).

Methods

In this UK-based single-centre, prospective, observational cohort study, all RD follow-up patients at our centre were invited by SMS text message in April 2020 to participate in the study. Participants completed questionnaires at four time points between April 2020 and December 2021. We collected demographics, clinically extremely vulnerable (CEV) status, short form 12 mental (MCS) and physical health component scores (PCS) for health-related quality of life, vaccination status, COVID-19 infection rates and incidence of long COVID.

Results

We enrolled 1605 patients (female, 69.0%; CEV, 46.5%); 906 of 1605 (56.4%) completed linked responses to our final questionnaire. MCS improved (+0.6, P < 0.05), whereas PCS scores deteriorated (-1.4, P < 0.001) between April 2020 and December 2021. CEV patients had worse mental and physical health scores than non-CEV patients at entry (PCS, 36.7 and 39.3, respectively, P < 0.001; MCS, 40.9 and 43.0, respectively, P < 0.001) and at each time point throughout the study; both mental and physical health outcomes were worse in CEV compared with non-CEV patients (P < 0.001 and P = 0.004, respectively). At study close, 148 of 906 (16.3%) reported COVID infection, with no difference in infection, vaccination or long COVID rates between CEV and non-CEV patients.

Conclusions

Mental and physical health in RD patients has changed throughout the pandemic; outcomes for both metrics of health were worse in CEV patients, although there were no differences in infection rates between the groups. These data might assist the understanding and planning of future health-care policy and social restrictions in RD patients.

Trial registration

ClinicalTrials.gov, www.clinicaltrials.gov, NCT04542031.

Can a Giant Cell Arteritis (GCA) Risk Stratification Score Be Helpful in Clinical Practice?

INTRODUCTION

Giant cell arteritis (GCA) is the most common type of large vessel vasculitis. The diagnosis of GCA is often challenging and there is a difficult balance of over- and underinvestigation. There have been several proposed scoring systems to help clinicians risk stratify patients who may present with suspected GCA.

METHODS

A retrospective cohort study was performed using electronic medical records of patients referred for a temporal artery biopsy (TAB) and temporal artery ultrasound scan (USS) for suspected GCA. All TABs performed at the Royal Wolverhampton NHS Trust between June 2014 and June 2018 and all USS procedures performed between January 2015 and January 2019 were analysed. Patients who undergo a USS for suspected GCA at our centre routinely have scanned bilateral temporal and axillary arteries. Patients were excluded if they already had a previous diagnosis of GCA (and the clinical question was suspected flare), or if there was insufficient information available.

RESULTS

The total number of patients who underwent a confirmatory diagnostic test (either TAB or USS) for suspected GCA was 187. Thirteen of these patients met the exclusion criteria, the remaining 174 patients were included for analysis. A total of 126 of 174 patients underwent a TAB and 63 of 174 had a USS performed; 15 of 174 who had both these were included in the USS cohort because for all these patients, the ultrasound was the first diagnostic test performed. Our results appear to closely mirror the original multi-centre results with regard to the prediction of biopsy-positive GCA, with the centiles closely following those in the inception cohort. Also, 0% of the 'low' risk probability biopsy cohort were misclassified; none had a positive biopsy. However, 8% of the low-risk-probability ultrasound cohort were misclassified, as two had a positive ultrasound.

CONCLUSION

 Our study highlights that a probability score for GCA derived from a large multi-centre cohort of patients who were biopsy positive predicts ultrasound positivity with similar accuracy. Our work reveals that scoring systems are not infallible but can be helpful in guiding clinical decision making.

Understanding the impact of systemic lupus erythematosus on work amongst South Asian people in the UK: An explorative qualitative study

SLE has a range of fluctuating symptoms affecting individuals and their ability to work. Although South Asian (SA) patients are at increased risk of developing SLE there is limited knowledge of the impact on employment for these patients in the UK. Understanding ethnicity and disease-specific issues are important to ensure patients are adequately supported at work. Semi-structured interviews were conducted with patients of SA origin to explore how SLE impacted on their employment. Thematic analysis was used to analyse the data which are reported following COREQ guidelines. Ten patients (8 female; 2 male) were recruited from three rheumatology centres in the UK and interviewed between November 2019 and March 2020. Patients were from Indian (n = 8) or Pakistani (n = 2) origin and worked in a range of employment sectors. Four themes emerged from the data: (1) Disease related factors; (2) Employment related factors; (3) Cultural and interpersonal factors impacting on work ability; (4) Recommendations for improvement. Patients’ ability to work was affected by variable work-related support from their hospital clinicians, low awareness of SLE and variable support from their employers, and cultural barriers in their communities that could affect levels of family support received. These findings highlight the need for additional support for SA patients with SLE in the workplace.

P159 Factors associated between SLE and work amongst South Asian people: an explorative qualitative study

Background/Aims 

Systemic lupus erythematosus (SLE) affect patients from minority ethnic backgrounds, with many patients experiencing symptoms that affect their daily lives despite receiving long-term controller medication. Work is a large part of most people’s lives, yet little has been explored into how people from minority ethnic backgrounds cope at work whilst living with SLE. We conducted a study to understand the impact of SLE on working lives of South Asian patients. The aim was to identify and develop support mechanisms that could assist them with remaining at work.

Methods 

Semi-structured interviews were conducted with ten patients of South Asian origin with SLE to explore their work experiences. Patients were recruited from three rheumatology centres in the West Midlands, UK and were interviewed between November 2019 and March 2020. Interviews were audio-recorded and typed by an independent transcribing company. Returned transcripts were analysed using thematic analysis and QSR NVivo 12 software was used to organise and manage the data.

Results 

The majority (n = 8) of patients were female. Eight patients were from an Indian background, and two were from a Pakistani background. Half of all patients were educated to degree level. The age range of patients was 23 - 58 years old (S.D = 10.79), and disease duration varied between 3 months-33 years (S.D = 9.52). All patients had permanent jobs; six were in full-time employment, and four were in part-time employment. Four main themes emerged from the data: 1) Disease related factors; impacting work ability; 2) Employment related factors; impacting work ability; 3) Personal and cultural related factors; impacting work ability; 4) Recommendations for improvement were made by patients.

Conclusion 

In this novel study we highlight patients’ experiences of being at work. This study reports low awareness of SLE and mixed support in the workplace. Patients discussed work to varying degrees with their clinicians and needed further information for employers that was not available nor provided by their clinicians. The study reports cultural barriers in understanding SLE that could lead to lack of family support to remain in employment. Moreover, recommendations made in this study require further investigation and could be used by clinicians and Lupus UK to support patients of South Asian origin at work.

Disclosure 

M. Ubhi: None. S. Dubey: None. J. Reynolds: None. C. Gordon: None. T. Adizie: None. T. Sheeran: None. K. Allen: None. R. Jordan: None. S. Sadhra: None. J. Adams: None. R. Daji: None. K. Kumar: None.

P015 Improving the diagnostic performance of ANCA testing: evaluating the use of a gating strategy for ANCA test requests

Background/Aims 

Anti-neutrophil cytoplasmic antibody (ANCAs) associated vasculitis (AAV) encompasses: Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The 1999 international consensus for ANCA testing recommended the use of indirect immunofluorescence (IIF) to screen for ANCAs, with immunoassays for proteinase-3 (PR3)-ANCAs and myeloperoxidase (MPO)-ANCAs in positive samples. In 2017 this consensus was revised, recommending the implementation of a strict gating strategy for ANCA requests, followed by high-quality immunoassays as the primary screening method, to reduce the volume of tests requested, reducing the false-positive rates, thereby improving the diagnostic performance of ANCA testing. Testing at the Royal Wolverhampton Trust is based on the 1999 consensus. Tests perform poorly when not carried out in the correct setting due to low pre-test probability; we aimed to implement a gating strategy to filter inappropriate ANCA test requests to improve the diagnostic performance of ANCA testing at our centre. We assessed the use of IIF and antigen specific assays in the diagnosis of AAV.

Methods 

We reviewed the records of patients that had ANCA tests requested in June 2019. A gating strategy in the form of an indication selection ‘pop-up box’ directing clinicians to select an appropriate clinical indication for the request was implemented. We re-audited ANCA requests made post-intervention Feburary 2020. ANCA requests were assessed against clinical indications in the 1999 consensus for appropriateness; we assessed the diagnostic performance by the proportion of ANCA tests correctly identifying AAV and calculating the sensitivity and specificity of IIF and immunoassays for MPO/PR3-ANCAs in detecting AAV.

Results 

Post-intervention, 105 fewer ANCA requests were made (298v403). Due to insufficient information, 345 patients pre-gating and 252 patients post-gating-strategy were used for analysis. The proportion of appropriate requests made was greater post-intervention, 215/252 (85.3%) vs 119/345(34.5%). Pre-intervention AAV was identified in 13 (3.8%) patients; AAV was identified in 21 (8.3%) patients following the gating-strategy introduction. IIF was found to have sensitivity of 91.7% pre and 76.2% post-intervention; specificity was 53.0% pre and 58.9% post-intervention. MPO/PR3 immunoassay testing was found to have a sensitivity of 91.7% pre and 57.1% post-intervention; specificity was 97.4% pre and 97.9% post-intervention.

Conclusion 

The introduction of a gating-strategy for ANCA testing at our centre effectively reduced the overall number of ANCA requests by 26.1% over a 1-month period and significantly increased requests with an appropriate recorded indication. The proportion of tests correctly identifying AAV diagnosis increased following the introduction of the gating strategy indicating an improvement in diagnostic performance of ANCA testing. These results indicate antigen specific testing is more specific for a diagnosis of AAV and sensitivity of IIF was reduced following introduction of the gating strategy suggesting IIF is of no additional benefit when an effective gating strategy is employed.

Disclosure 

N. Cleaton: None. N. Barkham: None. T. Adizie: None.

The impact of COVID-19 on rheumatology patients in a large UK centre using an innovative data collection technique: prevalence and effect of social shielding

OBJECTIVES

We sought to gain insight into the prevalence of COVID-19 and the impact stringent social distancing (shielding) has had on a large cohort of rheumatology (RD) follow-up patients from a single large UK centre.

METHODS

We linked COVID-19-related deaths, screening and infection rates to our RD population (1.2.20-1.5.20) and audited active rheumatology follow-up patients through survey data communicated via a linked mobile phone SMS message. We assessed epidemiology, effect of stringent social distancing (shielding) and quality of life (HRQoL) by Short Form 12 (SF12).

RESULTS

There were 10,387 active follow-up patients, 7911 had linked mobile numbers. 12/10,387 RD patients died from COVID-19 (0.12%); local population 4131/7,415,149 (0.12%). For patients with mobile phones, 1693/7911 (21%) responded and of these, 1605 completed the SF12. Inflammatory arthritis predominated 1174/1693 (69%); 792/1693 (47%) were shielding. Advice on shielding/distancing was followed by 1372/1693(81%). 61/1693 (4%) reported COVID-19 (24/61 shielding); medication distribution was similar in COVID and non-COVID patients. Mental SF12 (MCS) but not physical (PCS) component scores were lower in COVID (60) vs. non-COVID (1545), mean differences: MCS, - 3.3; 95% CI - 5.2 to - 1.4, P < 0.001; PCS, - 0.4; 95% CI, - 2.1 to 1.3). In 1545 COVID-negative patients, those shielding had lower MCS (- 2.1; 95% CI - 2.8 to - 1.4) and PCS (- 3.1, 95% CI - 3.7 to - 2.5), both P < 0.001.

CONCLUSIONS

Our full RD cohort had no excess of COVID deaths compared to the general local population. Our survey data suggest that shielding adversely affects both mental and physical health in RD. These data broaden our understanding of shielding, indicating need for further study.

AB0488 CAN A GCA RISK STRATIFICATION SCORE BE HELPFUL IN CLINICAL PRACTICE?

Background:

Giant cell arteritis (GCA) is the most common type of large vessel vasculitis. Typically it presents in patients over the age of 50 with a combination of temporal headaches, scalp tenderness, jaw claudication, raised inflammatory markers and visual disturbance. The diagnosis of GCA is often challenging and there is a difficult balance of over and under investigation. There have been several proposed scoring systems to help clinicians risk stratify patients who may present with suspected GCA. One such scoring system, published in 2017, showed clinical utility in a large international multi-centre study. Following analysis by logistic regression on data from 530 biopsies, Ing et al. developed a parsimonious prediction model comprising 5 candidate criteria: age, jaw claudication, ischemia-related loss of visual acuity, platelet count and logCRP (Figure 1).[1]

Objectives:

Increasingly, ultrasound doppler imaging is recognised and accepted as satisfactory means of confirming the diagnosis of GCA, with the presence of the halo sign characteristic for GCA. The aim of our study was to determine whether this GCA prediction model accurately predicts positive temporal artery biopsies in a large, real world UK cohort. In addition, we assessed whether this model accurately predicts positive temporal artery ultrasounds.

Methods:

A retrospective cohort study was performed using electronic medical records of patients referred for temporal artery biopsy (TAB) and temporal artery ultrasound (USTA) for suspected GCA. All TAB performed at the Royal Wolverhampton NHS Trust between June 2014 - June 2018 and all USTA performed between January 2015 - January 2019 were analysed. Patients who undergo USTA for suspected GCA at our centre routinely have bilateral temporal and axillary arteries scanned. Patients were excluded if they already had a previous diagnosis of GCA (and the clinical question was suspected flare), or if there was insufficient information available.

Results:

The total number of patients who underwent a confirmatory diagnostic test (either TAB or USTA) for suspected GCA was 187. Thirteen of these patients met the exclusion criteria, the remaining 174 patients were included for analysis. 126/174 patients underwent a TAB, 63/174 had an USTA. 15/174 had both these were included in the USS cohort because for all these patients the ultrasound was the first diagnostic test performed (Table 1). Our results appear to closely mirror the original multi-centre results with regards to prediction of biopsy positive GCA, with the centiles closely following those in the inception cohort. 0% of the ‘low’ risk probability biopsy cohort were misclassified - none had a positive biopsy. However, 8% of the ‘low’ risk probability ultrasound cohort were misclassified - 2 had a positive ultrasound.

Table 1.

Investigation outcome summary

Total number of patients who underwent TAB +/or USS TA for?GCA187 - 13 patients rejectedN = 174TAB = 111USS = 63Of these 15 patients hadbothUSS & TABPositive TAB =31 (28%)Negative TAB =80 (72%)Positive USS =24 (38%)Negative USS =39 (62%)

Conclusion:

Our study, highlights that a probability score for GCA derived from a large multi-centre cohort of patients who were biopsy positive, predicts ultrasound positivity with similar accuracy. Our work reveals that scoring systems are not infallible but can be helpful in guiding clinical decision making

References:

[1]Ing EB, Lahaie Luna G, Toren A, et al. Multivariable prediction model for suspected giant cell arteritis: development and validation.Clin Ophthalmol. 2017;11:2031–2042. Published 2017 Nov 22.

Acknowledgments:

Many thanks to the Rheumatology, Opthalmology & Ultrasound teams at Royal Wolverhampton NHS Trust

Disclosure of Interests:

None declared

P181 Detection of anti-neutrophil cytoplasmic antibodies: a single-centre evaluation of the value of indirect immunofluorescence versus antigen-specific immunoassays

Background

Anti-neutrophil cytoplasmic antibodies (ANCAs) are valuable laboratory markers used for the diagnosis of medium and small-vessel vasculitis, including granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). According to the 1999 international consensus, indirect immunofluorescence (IIF) should be used to screen for ANCAs; samples containing ANCAs should then be tested by immunoassays for proteinase 3 (PR3)-ANCAs and myeloperoxidase (MPO)-ANCAs. As dependable immunoassays for PR3ANCAs and MPO-ANCAs have become broadly available, there is increasing agreement that high-quality immunoassays are the preferred screening method for the diagnosis of ANCA-associated vasculitis (AAV). This single centre study was performed to evaluate the accuracy of MPO and PR3 immunoassays in comparison to IIF in the diagnosis of AAV.

Methods

We retrospectively reviewed the clinical information of patients that underwent ANCA testing between 1/6/19-30/6/19, via our electronic web portal. Data collected included patients’ demographics, ANCA /MPO/PR3 result, and diagnosis as established by their treating physician. A total of 403 ANCA requests were submitted to the Immunology Department at the Royal Wolverhampton NHS Trust. We excluded 55 patients with insufficient information. Due to multiple ANCA tests in a single patient we included only the first test request. Therefore, the study population includes 345 patients. IIF at our centre is performed for all ANCA requests using a commercially available ASP1200 automated dilutor to process the IIF slides with Werfen (Inova) ANCA slides. For the detection of antibodies against MPO and PR3 a commercially available immuno-assay Phadia-250 ImmunoCAP analyser is used in patients with positive IIF. Diagnostic performance was assessed using sensitivity and specificity.

Results

The proportion of ANCA negative patients by IIF (177 patients,51.3%) was almost identical to that of the ANCA positive group (168 patients,48.7%). Only 13 patients (3.8%) received a diagnosis of AAV. Of the ANCA positive patients 12 (7.1%) had an AAV. 6 of the 13 patients with vasculitis had a supportive tissue biopsy. One ANCA negative patient and one ANCA positive MPO/PR3 negative patient had a diagnosis of vasculitis, previously diagnosed and now on steroid treatment; both were ANCA and MPO positive at diagnosis. 15 patients were MPO or PR3 positive, 11/15 had a diagnosis of vasculitis (73%). Our data found IIF has a sensitivity of 91.67%, specificity 53.01% for detection of AAV. In comparison immunoassay was found to have a sensitivity of 91.67% and specificity of 97.44%.

Conclusion

ANCAs are helpful in the diagnosis of AAV, but their use as a diagnostic biomarker should be undertaken in the appropriate clinical context. Immunoassay has a superior diagnostic performance at our centre. Our data suggests screening for ANCA with IIF is not of added value when using high-quality antigen-specific immunoassays.

Disclosures

N. Cleaton None. T. Adizie None. N. Barkham None.

Knowledge of features of inflammatory back pain in primary care in the West Midlands: a cross-sectional survey in the United Kingdom

KEY MESSAGES

There is a relative lack of confidence among GPs in the assessment and management of IBP vs. mechanical back pain. A simple screening tool for SpA, applicable in primary care urgently needs to be developed. It is reasonable for patients with symptoms suggestive of inflammatory back pain to be referred to secondary care without further investigations. The objective of this study was to assess current practice of our local general practitioners (GPs) in using clinical features, as well as radiological and laboratory investigations to assess patients with IBP. An online, observational questionnaire-based survey was done in 10 West Midlands CCGs including disparate geographical and socioeconomic areas. The survey consisted of 23 questions based on Calin, Berlin and ESSG Criteria for spondyloarthropathies. GPs were asked to rate the importance of a range of symptoms as indications of IBP IBP (10 point scale, range 1-10), and what their views were on which were the most important treatments for patients with suspected inflammatory back pain(4 point scale, range 1-4). The 4 most important symptoms for predicting inflammatory back pain according to our local cohort of GPs were 'morning stiffness' 'sleep disturbances caused by back pain' 'insidious onset' and 'age of onset' < 45. Among the treatment options, NSAIDs were ranked as the most important treatment option for IBP. DMARDS were rated as the next most important treatment option, ahead of physiotherapy and anti-TNF therapy. This study has highlighted relative lack of confidence among GPs in the assessment of IBP. Whether this reflects a need for education or poor performance of these questions in primary care populations requires further study.

Inflammatory arthritis in HIV positive patients: A practical guide

Background

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) have been described since the outset of the global HIV epidemic. Articular syndromes that have been described in association with HIV include HIV-associated arthropathy, seronegative spondyloarthropathies (SPA) (reactive arthritis, psoriatic arthritis (PsA) and undifferentiated SPA), rheumatoid arthritis (RA) and painful articular syndrome.

Methods

We carried out a computer-assisted search of PubMed for the medical literature from January 1981 to January 2015 using the keywords HIV, acquired immune-deficiency syndrome, rheumatic manifestations, arthritis, spondyloarthropathy, anti-TNF and disease modifying antirheumatic drugs. Only English language literature was included and only studies involving adult human subjects were assessed.

Results

There are challenges in the management of inflammatory arthritis in patients who are HIV-positive, including difficulties in the assessment of disease activity and limited information on the safety of immunosuppressive drugs in these individuals.

Conclusions

This review focuses on the clinical characteristics of the inflammatory articular syndromes that have been described in association with HIV infection and discusses the therapeutic options for these patients.

Travel- and immigration-related problems in rheumatology

Health problems are self-reported by up to 64% of travellers to the developing world. Traditionally, rheumatic symptoms are accorded little significance, but many travellers do return home with musculoskeletal complaints. The assessment of these patients is often hindered by the Western clinician's lack of familiarity with the types of infections that the patient may have encountered while travelling. Standard serological tests for autoimmune diseases can be unreliable in the setting of concomitant tropical infection, and these infections themselves can have musculoskeletal manifestations. Even in the absence of tropical infection, laboratory investigation of musculoskeletal symptoms in individuals of different ethnicities is challenging due to genetic and physiological variation. This review focusses on addressing the impact global migration has had on rheumatological clinical practice.

Efficacy and tolerability of leflunomide in difficult-to-treat polymyalgia rheumatica and giant cell arteritis: a case series

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are related inflammatory rheumatic conditions affecting adults over the age of 50 years. Both conditions respond to initial glucocorticoid (GC) therapy. However, most patients require 12-36 months of a tapering steroid regime. Adverse events at 2 years are seen in up to 65% of patients with PMR and 86% of patients with GCA with over 50% developing serious events. There is also a high incidence of relapse in both diseases -40% within 2 years for GCA and 50% of patients with PMR at some point having a relapse. Effective steroid-sparing adjuvant therapies are urgently required especially in incomplete, poorly sustained or non-responders to glucocorticoids. In this case series, we found that Leflunomide is efficacious, with 22 out of our 23 patients exhibiting a complete or partial response. It was also steroid sparing and well tolerated. It may be a useful adjunctive agent in difficult-to-treat GCA and PMR. Prospective randomised controlled trials of Leflunomide in both GCA and PMR are now required.

Efficacy and tolerability of leflunomide in difficult-to-treat polymyalgia rheumatica and giant cell arteritis: a case series

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are related inflammatory rheumatic conditions affecting adults over the age of 50 years. Both conditions respond to initial glucocorticoid (GC) therapy. However, most patients require 12-36 months of a tapering steroid regime. Adverse events at 2 years are seen in up to 65% of patients with PMR and 86% of patients with GCA with over 50% developing serious events. There is also a high incidence of relapse in both diseases -40% within 2 years for GCA and 50% of patients with PMR at some point having a relapse. Effective steroid-sparing adjuvant therapies are urgently required especially in incomplete, poorly sustained or non-responders to glucocorticoids. In this case series, we found that Leflunomide is efficacious, with 22 out of our 23 patients exhibiting a complete or partial response. It was also steroid sparing and well tolerated. It may be a useful adjunctive agent in difficult-to-treat GCA and PMR. Prospective randomised controlled trials of Leflunomide in both GCA and PMR are now required.