Prevalence and identification of neuropsychiatric symptoms in systemic autoimmune rheumatic diseases: an international mixed methods study

OBJECTIVE

A limited range of neuropsychiatric symptoms have been reported in systemic autoimmune rheumatic diseases (SARDs), with varied symptom prevalence. This study aimed to investigate a wider range of potential symptoms than previous studies, compare patient self-reports with clinician estimates, and explore barriers to symptom identification.

METHODS

Mixed methods were used. Data from SARDs patients (n = 1853) were compared with controls (n = 463) and clinicians (n = 289). In-depth interviews (n = 113) were analysed thematically. Statistical tests compared means of survey items between patients and controls, 8 different SARD groups, and clinician specialities.

RESULTS

Self-reported lifetime prevalences of all 30 neuropsychiatric symptoms investigated (including cognitive, sensorimotor and psychiatric) were significantly higher in SARDs than controls. Validated instruments assessed 55% of SARDs patients as currently having depression and 57% anxiety. Barriers to identifying neuropsychiatric symptoms included: (i) limits to knowledge, guidelines, objective tests and inter-speciality cooperation; (ii) subjectivity, invisibility and believability of symptoms; and (iii) under-eliciting, under-reporting and under-documenting. A lower proportion of clinicians (4%) reported never/rarely asking patients about mental health symptoms than the 74% of patients who reported never/rarely being asked in clinic (P < 0.001). Over 50% of SARDs patients had never/rarely reported their mental health symptoms to clinicians, a proportion underestimated at <10% by clinicians (P < 0.001).

CONCLUSION

Neuropsychiatric symptom self-reported prevalences are significantly higher in SARDs than controls, and are greatly underestimated by most clinicians. Research relying on medical records and current guidelines is unlikely to accurately reflect patients' experiences of neuropsychiatric symptoms. Improved inter-speciality communication and greater patient involvement is needed in SARD care and research.

Neuropsychiatric symptoms in Systemic Lupus Erythematosus: mixed methods analysis of patient-derived attributional evidence in the international INSPIRE project

OBJECTIVE

Attribution of neuropsychiatric symptoms in systemic lupus erythematosus (SLE) relies heavily on clinician assessment. Limited clinic time, variable knowledge, and symptom under-reporting contributes to discordance between clinician assessments and patient symptoms. We obtained attributional data directly from patients and clinicians in order to estimate and compare potential levels of direct attribution to SLE of multiple neuropsychiatric symptoms using different patient-derived measures.

METHODS

Quantitative and qualitative data analysed included: prevalence and frequency of neuropsychiatric symptoms, response to corticosteroids, and concurrence of neuropsychiatric symptoms with non-neuropsychiatric SLE disease activity. SLE patients were also compared with controls and inflammatory arthritis (IA) patients to explore attributability of neuropsychiatric symptoms to the direct disease effects on the brain/nervous system.

RESULTS

We recruited 2,817 participants, including 400 clinicians. SLE patients (n = 609) reported significantly higher prevalences of neuropsychiatric symptoms than controls (n = 463) and IA patients (n = 489). SLE and IA patients' quantitative data demonstrated multiple neuropsychiatric symptoms relapsing/remitting with other disease symptoms such as joint pain. Over 45% of SLE patients reported resolution/improvement of fatigue, positive sensory symptoms, severe headache, and cognitive dysfunction with corticosteroids. Evidence of direct attributability in SLE was highest for hallucinations and severe headache. SLE patients had greater reported improvement from corticosteroids (p= 0.008), and greater relapsing-remitting with disease activity (p< 0.001) in the comparisons with IA patients for severe headache. Clinician and patients reported insufficient time to discuss patient-reported attributional evidence. Symptoms viewed as indirectly related/non-attributable were often less prioritised for discussion and treatment.

CONCLUSION

We found evidence indicating varying levels of direct attributability of both common and previously unexplored neuropsychiatric symptoms in SLE patients, with hallucinations and severe headache assessed as the most directly attributable. There may also be-currently under-estimated-direct effects on the nervous system in IA and other systemic rheumatological diseases.

Attribution of neuropsychiatric symptoms and prioritisation of evidence in the diagnosis of neuropsychiatric lupus: mixed methods analysis of patient and clinician perspectives from the international INSPIRE study

OBJECTIVE

Neuropsychiatric lupus (NPSLE) is challenging to diagnose. Many neuropsychiatric symptoms, such as headache and hallucinations, cannot be verified by tests or clinician assessment. We investigated prioritisations of methods for diagnosing NPSLE and attributional views.

METHODS

Thematic and comparative analyses were used to investigate how clinicians prioritise sources of evidence from a 13-item list, and explore discordances in clinician and patient perspectives on attribution.

RESULTS

We identified high levels of variability and uncertainty in clinicians' assessments of neuropsychiatric symptoms in SLE patients. In attributional decisions, clinicians (surveys n = 400, interviews n = 50) ranked clinicians' assessments above diagnostic tests (many of which they reported were often unenlightening in NPSLE). Clinicians ranked patient opinion of disease activity last, and 46% of patients reported never/rarely having been asked if their SLE was flaring, despite experienced patients often having "attributional insight". SLE Patients (surveys n = 676, interviews n = 27) estimated higher attributability of neuropsychiatric symptoms to the direct effects of SLE on the nervous system than clinicians (p < 0.001 for all symptoms excluding mania), and 24% reported that their self-assessment of disease activity was never/rarely concordant with their clinicians. Reports of misattributions were common, particularly of non-verifiable diffuse symptoms. Terminology differed between clinicians and influenced attribution estimates.

CONCLUSION

NPSLE diagnostic tests and clinician assessments have numerous limitations, particularly in detecting diffuse neuropsychiatric symptoms that can be directly attributable and benefit from immunosuppression. Our findings suggest that incorporating patient attributional insights-although also subject to limitations-may improve attribution decision-making. Consensus regarding terminology and interpretations of "direct attributability" is required.

Will 'the feeling of abandonment' remain? Persisting impacts of the Covid-19 pandemic on rheumatology patients and clinicians

OBJECTIVE

To better understand rheumatology patient and clinician pandemic-related experiences, medical relationships and behaviours in order to help identify the persisting impacts of the Covid-19 pandemic, and inform efforts to ameliorate the negative impacts and build-upon the positive ones.

METHODS

Rheumatology patients and clinicians completed surveys (Patients N = 1,543, Clinicians N = 111) and interviews (Patients N = 41, Clinicians N = 32) between April 2021 and August 2021. A cohort (N = 139) of systemic autoimmune rheumatic disease patients was also followed-up from March 2020 to April 2021. Analyses used sequential mixed methods. Pre-specified outcome measures included the Warwick-Edinburgh Mental wellbeing score (WEMWBS), satisfaction with care, and healthcare-behaviours.

RESULTS

We identified multiple ongoing pandemic-induced/increased barriers to receiving care. The percentage of patients agreeing they were medically supported reduced from 74.4% pre-pandemic to 39.7% during-pandemic. Ratings for medical support, medical-security and trust were significantly (p< 0.001) positively correlated with patient WEMWBS and healthcare-behaviours, and decreased during the pandemic. Healthcare-seeking was reduced, potentially long-term, including from patients feeling 'abandoned' by clinicians, and a 'burden' from Government messaging to protect the NHS. Blame and distrust were frequent, particularly between primary and secondary care, and towards the UK Government, whom <10% of clinicians felt had supported clinicians during the pandemic. Clinicians' efforts were reported to be impeded by inefficient administration systems, and chronic understaffing, suggestive of the pandemic having exposed and exacerbated existing healthcare-system weaknesses.

CONCLUSION

Without concerted action-such as rebuilding trust, improved administrative systems, and more support for clinicians-barriers to care and negative impacts of the pandemic on trust, medical relationships, medical-security and patient help-seeking may persist longer-term.

TRIAL REGISTRATION

This study is part of a pre-registered longitudinal multi-stage trial, the LISTEN study (ISRCTN-14966097), with later Covid-related additions registered in March 2021, including a pre-registered statistical analysis plan.

P120 Self-reported disease activity was the main determinant of the perceived impact of COVID-19 pandemic on adolescent and young patients with juvenile dermatomyositis (JDM) and juvenile onset systemic lupus erythematosus (JSLE)

Background/Aims 

The impact of the COVID-19 pandemic on adolescent and young patients with chronic diseases is likely to be multi-factorial, and influenced by various aspects, such as age, sex, education, ethnicity, as well as disease control or personal coping strategies. Adolescents and young adults are at a time in their live when disruption in their education and social life, as well as uncertainty related to professional prospects and long-term disease outcomes are all associated with significant personal concerns. The aim of this survey was to assess the main determinants of COVID-19 associated concern in adolescent and young adults with JSLE and JDM as well as their well-being and resilience.

Methods 

Questionnaires comprising of questions related to patient and disease characteristics, wellbeing, resilience and concern about the COVID-19 pandemic were disseminated through hospital contacts and patient charities social media platforms. Participation was voluntary and implied consent. The preliminary results of this ongoing survey have been analysed using descriptive statistics and linear regression (R).

Results 

The main patient and disease characteristics, self-reported well-being, resilience and perceived concern about the COVID-19 pandemic are presented in comparison in male vs. female patients. Linear regression showed that the strongest determinant of COVID-19 concern was self-reported disease activity (p < 0.0003). The self-reported disease activity was associated with the COVID-19 concern level in both female (P = 0.003) and male patients (p = 0.004) and also with disease duration in males (P = 0.018). The COVID concern was not affected by any other factors such as, employment, education, well-being or resilience.

Conclusion 

The preliminary analysis of our survey showed that patient-reported COVID-19 concern during the pandemic was strongly determined by the self-reported disease activity irrespective of patients’ sex, despite significantly increased concern in the female compared to male patients, and association with disease duration in male patients only. We propose that further strategies for better patient support during the pandemic should focus on their optimal disease control as well as take into consideration the sex-biased patient concerns. P120 Table 1:

	Female	Male	p-value
Number	38	9
Current age mean (IQR)	22.21 (18.25- 25.75)	18.89 (14.00-26.00)
Age at diagnosis years mean (IQR)	13.01 (9.00-15.00)	9.333 (7.00-11.00)
Disease duration Mean (IQR)	9.197 (4.000-13.000)	9.556 (2.000-13.000)	0.4841
Ethnicity; White Non-white	25 (65.8%) 13 (34.2%)	7 (77.8%) 2 (22.2%)	0.4841
Location; England (%) Other (%)	35 (92.1%) 3 (7.9%)	9 (100%) 0 (0%)	0.2578091
Well-being (VAS -2 to + 2) mean (IQR)	-0.6765 (-2.0000 – 0.0000)	-0.4286 (-1.0000 – 0.0000)	0.5667
Resilience (VAS 1-7) mean (IQR)	4.906 (4.000 - 6.000)	5.0 (4.5 - 5.5)	0.8718
Self-reported disease activity (VAS 1-100) mean (IQR)	35.32 (15.00- 53.00)	18.67 (3.00-25.00)	0.06429
Self-reported COVID concern (VAS 1-100) mean (IQR)	62.92 (50.00-80.00)	32.33 (15.00- 40.00)	0.01052
Still in education No Yes Not recorded	16 (42.1%) 18 (47.4%) 4 (10.5%)	3 (33.3%) 4 (44.4%) 2 (22.2%)
Currently working No Yes Not recorded	24 (63.2%) 10 (26.3%) 4 (10.5%)	5 (55.6%) 2 (22.2%) 2 (22.2%)

Funding statement: This work was supported by Versus Arthritis (21593)

Disclosure 

A. Khatun: None. W. Wu: None. J. Peng: None. L. Hennelly: None. M. Sloan: None. M. Bosley: None. P. Howard: None. L. Jury: None. C. Ciurtin: None.

The impact of the COVID-19 pandemic on the medical care and health-care behaviour of patients with lupus and other systemic autoimmune diseases: a mixed methods longitudinal study

OBJECTIVE

The aim was to explore the self-reported impact of the COVID-19 pandemic on changes to care and behaviour in UK patients with systemic autoimmune rheumatic diseases, to help ensure that patient experiences are considered in future pandemic planning.

METHODS

This was a longitudinal mixed methods study, with a cohort completing baseline surveys in March 2020 and follow-up surveys in June 2020 (n = 111), combined with thematic analysis of the LUPUS UK forum and participant interviews (n = 28).

RESULTS

Cancellations of routine care and difficulties in accessing medical support contributed to some participants deteriorating physically, including reports of hospitalizations. The majority of participants reported that fear of COVID-19 and disruptions to their medical care had also adversely impacted their mental health. Feeling medically supported during the pandemic was correlated with multiple measures of mental health and perceptions of care, including the Warwick-Edinburgh mental well-being score (r = 0.44, P = 0.01). Five themes were identified: detrimental reduction in care; disparities in contact and communication (medical security vs abandonment sub-theme); perceived and actual endangerment; the perfect storm of reduced clinician ability to help and increased patient reticence to seek help; and identifying the patients most vulnerable to reduced medical care.

CONCLUSION

The diversion of resources away from chronic disease care was perceived by many participants to have caused adverse outcomes. Fear about increased vulnerability to COVID-19 was high, contributing to health-care-avoidant behaviours. This study also highlights the influence of clinician accessibility and patients feeling medically supported on multiple measures of physical and mental health.

'But you don't look sick': a qualitative analysis of the LUPUS UK online forum

Lupus is a multi-system autoimmune rheumatic disease with increased morbidity and mortality. Some manifestations are life-threatening with many aspects of living with the disease, difficulties in diagnosis and accessing appropriate medical care, having an impact on quality of life. The disease itself, and these patients’ perspectives, are currently poorly understood and under-researched. The LUPUS UK forum of conversations between over 25,000 members provides a rich environment to explore the views of these patients. Conversations on the LUPUS UK online forum were qualitatively explored using virtual ethnography and thematic analysis. The forum itself and positive medical relationships were widely considered to provide a means of support, understanding and validation. Forum members expressed difficulties in diagnosis, disease management, and the psychological and physical impact of living with an unpredictable, poorly understood disease, often with life-changing symptoms. Invalidating personal, social and medical environments were perceived as exacerbating these difficulties. Delays in diagnosis and misdiagnoses were frequently discussed as causing significant damage, especially when symptoms were disbelieved or dismissed. Invalidation was the key theme with further themes of: Uncertainty, Medical (mis)communications and misunderstandings, Navigating health systems and Resilience and support. Although effective care and support was reported by some members, the negative impact of living with an incurable, life-changing disease was often exacerbated by perceived invalidation, uncertainty, and difficulties in multiple areas of members’ lives. Improved knowledge of the disease and greater support at all stages of the diagnostic journey could improve outcomes and quality of life for these patients.

End-hole Versus Microvalve Infusion Catheters in Patients Undergoing Drug-Eluting Microspheres-TACE for Solitary Hepatocellular Carcinoma Tumors: A Retrospective Analysis

INTRODUCTION

Pre-transplant locoregional therapy for hepatocellular carcinoma (HCC) during bridge-to-transplant impacts recurrence and survival rates following liver transplantation. Optimizing the effectiveness of transarterial chemoembolization (TACE) in this population is imperative, and microvalve infusion catheters offer a means of such improvement.

METHODS

All treatment-naive patients with solitary HCC tumors < 6.5 cm who underwent drug-eluting microspheres (DEM) TACE between 04/2015 and 08/2017 were retrospectively reviewed. Eighty-eight included patients underwent DEM-TACE with either standard end-hole catheters (EH) or microvalve infusion catheters (MVI). The EH (n = 70) and MVI (n = 18) cohorts had similar baseline tumor size, laboratory values, and tumor etiologies.

RESULTS

Initial objective response rates were significantly higher in MVI vs. EH (100% vs. 76.5%, p = 0.019). There was no difference in adverse events between groups (p = 0.265). MVI patients exhibited lower AST (p = 0.003) and ALT (p = 0.044) at 6 months. Blinded pathological analysis of explanted livers showed greater concentrations of microspheres within the tumor relative to the surrounding tissue in MVI explants (88.7 ± 10.6%) versus the EH explants (55.3 ± 32.7%) (p = 0.002). There was significantly higher percentage tumor necrosis in the MVI group (89.0 ± 2.2%) compared with the EH group (56.1 ± 44.5%) (p = 0.006).

CONCLUSION

In this retrospective study of a single-center cohort, DEM-TACE procedures with MVI were associated with improved tumor response, increased deposition of microspheres within tumor tissue, and higher percentage tumor necrosis at explant relative to those performed using EH catheters.

Massive hepatic adenoma response to bland embolization: A case study

Hepatic adenomas are rare, benign liver masses of rising incidence in the United States. We present a report of a 22-year-old asymptomatic female with a massive (14.2 × 11.4 cm), centrally located hepatic adenoma. The unique presentation of the adenoma in close proximity to the hepatic vasculature meant the patient was not a candidate for surgical resection. An arterial embolization was used as an alternative approach to initial treatment. Arterial branches supplying the adenoma were identified via computed tomography and embolized with embospheres and coils. The treatment resulted in a large reduction in size and density of the adenoma identified at a 1-month follow-up. The case supports further use of arterial embolization as an initial treatment for large adenomas to improve the outcome of subsequent surgical approaches.

Multivariate analysis of prognostic factors for survival following doxorubicin-eluting bead transarterial chemoembolization for hepatocellular carcinoma

PURPOSE

To identify prognostic factors for survival in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization with doxorubicin-eluting beads (DEBs).

MATERIALS AND METHODS

In a retrospective, single-center analysis, tumor- and patient-related factors were recorded for univariate and multivariate analyses via Kaplan-Meier and Cox regression. Infiltrative HCC phenotype and portal vein invasion (PVI) were correlated, and patients with either or both were classified as having radiographically advanced (RAdv) HCC. The primary endpoint was overall survival, which was calculated from the time of first DEB chemoembolization procedure.

RESULTS

A total of 168 patients underwent 248 procedures, of which 215 (86.7%) were outpatient procedures. Mean length of stay was 0.33 days, and 25 patients (10.1%) were readmitted within 30 days. A total of 33 patients underwent liver transplantation and were excluded from survival analyses. A total of 130 had cirrhosis; 62, 50, and 18 had Child class A, B, and C disease, respectively. Forty-one patients had infiltrative HCC phenotype, 28 of whom also had PVI. Multivariate analysis of survival in all patients showed α-fetoprotein (AFP), performance status (PS), RAdv HCC, Child classification, albumin level, and ascites to predict survival. In patients without RAdv HCC, AFP, PS, Child classification, albumin level, and International Normalized Ratio were independent predictors. Increased bilirubin level was not an independent risk factor for death.

CONCLUSIONS

Independent prognostic factors in patients with HCC undergoing DEB chemoembolization have been identified. Increased bilirubin level was not an independent risk factor. These data can be used in HCC patient selection and counseling for DEB chemoembolization.