2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVES

Fatigue is prevalent in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and recognised as one of the most challenging symptoms to manage. The existence of multiple factors associated with driving and maintaining fatigue, and the evidence about what improves fatigue has led to a multifaceted approach to its management. However, there are no recommendations for fatigue management in people with I-RMDs. This lack of guidance is challenging for those living with fatigue and health professionals delivering clinical care. Therefore, our aim was to develop EULAR recommendations for the management of fatigue in people with I-RMDs.

METHODS

A multidisciplinary taskforce comprising 26 members from 14 European countries was convened, and two systematic reviews were conducted. The taskforce developed the recommendations based on the systematic review of evidence supplemented with taskforce members' experience of fatigue in I-RMDs.

RESULTS

Four overarching principles (OAPs) and four recommendations were developed. OAPs include health professionals' awareness that fatigue encompasses multiple biological, psychological and social factors which should inform clinical care. Fatigue should be monitored and assessed, and people with I-RMDs should be offered management options. Recommendations include offering tailored physical activity and/or tailored psychoeducational interventions and/or, if clinically indicated, immunomodulatory treatment initiation or change. Patient-centred fatigue management should consider the individual's needs and preferences, their clinical disease activity, comorbidities and other psychosocial and contextual factors through shared decision-making.

CONCLUSIONS

These 2023 EULAR recommendations provide consensus and up-to-date guidance on fatigue management in people with I-RMDs.

Lifestyle Modifications and Nonpharmacologic Interventions to Improve Outcomes in Psoriatic Arthritis: A Systematic Review

PURPOSE

Psoriatic arthritis (PsA) is a multisystem inflammatory disorder associated with significant mortality and morbidity, including functional impairment and psychological disability. Although evidence-based treatment recommendations are available for the use of drug treatments in PsA, there is little guidance for health professionals on nonpharmacologic and psychological interventions that may be useful in PsA. The objective of this systematic review (SR) was to identify how lifestyle modifications and the use of nonpharmacologic and psychological interventions may improve the outcomes of patients with PsA.

METHODS

Studies were included if they evaluated adults diagnosed with PsA and included exposure to nonpharmacologic interventions, psychological interventions, and lifestyle modifications. The outcomes used needed to have been validated in PsA. A systematic literature search was run on May 28, 2021, in the Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), EMBASE, Global Health, MEDLINE, and PsycINFO databases to identify articles related to lifestyle modifications and nonpharmacologic or psychological interventions for adults with PsA published between 2010 and 2021. Two review authors independently screened and selected full-text studies for inclusion in the SR. Risk of bias was assessed with either the Risk of Bias 2 (ie, RoB 2) tool or Critical Appraisal Skills Program checklist depending on the study type.

FINDINGS

The search strategy identified 26,132 references. Eight studies examining lifestyle modifications and the effect on PsA were eligible to be included in the SR. Three of the 8 studies were randomized controlled trials, and 5 were nonrandomized studies. Three studies assessed physical activity, 3 assessed diet, 1 study assessed smoking, and another study assessed mud bath therapy. There was large heterogeneity between studies, and the measures of disease activity, and psychological and functional outcomes varied widely between studies.

IMPLICATIONS

Although this SR identified 8 relevant studies, these studies did not provide high-quality evidence to guide patients for non-drug treatments of PsA. The effectiveness of these interventions has therefore not been established. We found that physical activity seems to have a positive impact on disease activity and psychological well-being. Further well-designed research studies are needed to develop treatment recommendations. PROSPERO identifier: CRD42021257404.

The role of physical activity in obesity: let's actively manage obesity

Obesity, physical inactivity and sedentary behaviour are major public health concerns. A complex interaction of many factors leads to obesity, which requires an individualised multicomponent management strategy. As new interventions become available to help individuals manage obesity, it is essential that physical activity remains a core part of the approach. Here, we summarise current evidence regarding the benefits of physical activity as part of a management strategy of obesity. Additionally, we discuss current methods for increasing physical activity levels in individuals with obesity and outline the role of sport and exercise medicine physicians as part of the multidisciplinary team.

Antibodies to FXa and thrombin in patients with SLE differentially regulate C3 and C5 cleavage

OBJECTIVES

The significance of antibodies directed against activated factor X (FXa) and thrombin (Thr) in patients with SLE and/or antiphospholipid syndrome (APS) is unknown. FXa and Thr are coregulated by antithrombin (AT) and activate complement. Therefore, we studied the ability of anti activated factor X (aFXa) and/or anti-(a)Thr IgG from patients with SLE±APS to modulate complement activation.

METHODS

Patients with SLE±APS were selected on the basis of known aThr and/or aFXa IgG positivity, and the effects of affinity-purified aFXa/aThr IgG on FXa and Thr-mediated C3 and C5 activation were measured ±AT. Structural analyses of FXa and Thr and AT-FXa and AT-Thr complexes were analysed in conjunction with the in vitro ability of AT to regulate aFXa-FXa and aThr-Thr-mediated C3/C5 activation.

RESULTS

Using affinity-purified IgG from n=14 patients, we found that aThr IgG increased Thr-mediated activation of C3 and C5, while aFXa IgG did not increase C3 or C5 activation. Structural analysis identified potential epitopes and predicted a higher likelihood of steric hindrance of AT on FXa by aFXa IgG compared with the AT-Thr-aThr IgG complex that was confirmed by in vitro studies. Longitudinal analysis of 58 patients with SLE (±APS) did not find a significant association between positivity for aFXa or aTHr IgG and C3 levels or disease activity, although there was a trend for patients positive for aFXa IgG alone or both aFXa and aThr IgG to have lower levels of C3 compared with aThr IgG alone during clinical visits.

CONCLUSIONS

We propose a novel method of complement regulation in patients with SLE±APS whereby aFXa and aThr IgG may have differential effects on complement activation.

122 Neurological manifestations of haemophagocytic lymphohistiocytosis

rachel

brown@ucl.ac.uk|ABN Bursary

86

Patient characteristics in tardive COVID-19 pseudoperniosis: a case series of 16 patients

Background

Acute pseudoperniosis (PP) has a recognized association with COVID‐19 and tends to occur without cold precipitation in young, healthy patients, often without a clear history of COVID‐19. These lesions usually resolve within 2 weeks and without long‐term sequelae. In the early months of 2021, patients with delayed and protracted PP began to emerge. We have called this presentation ‘tardive COVID‐19 PP (TCPP)’.

Aim

To consolidate and expand knowledge on TCPP, we describe the clinical characteristics, treatments and outcomes of 16 patients with TCPP who were reviewed by our outpatient dermatology service.

Results

The initial clinical manifestations were erythema, swelling and PP of the fingers in 56.2%, and of the toes in 31.2%, desquamation in 56.2% and acrocyanosis in 12.5%. Ten patients had eventual involvement of all acral sites. The median duration of symptoms was 191 days. Six patients reported close contact with a confirmed or suspected case of COVID‐19, but only two had positive COVID‐19 tests. Four patients experienced complete or almost complete resolution of symptoms, while the rest remain under active treatment.

Conclusion

Unlike acute PP, TCPP has a protracted and delayed presentation that is typically associated with profound acrocyanosis. Patients with TCPP represent a new phenomenon that is part of the post‐COVID‐19 syndrome, with risk factors and pathophysiology that are not yet fully understood. Our data indicate that likely predisposing factors for developing TCPP include young age, a preceding history of cold intolerance and an arachnodactyloid phenotype. Anorexia, connective tissue disorders or sickle cell trait may also predispose to TCPP. In addition, low titre antinuclear antibody positivity, the presence of cryoglobulins, or low complement levels may represent further risk factors. Finally, prolonged low temperatures are also likely to be contributing to the symptoms.

A validation study of the identification of haemophagocytic lymphohistiocytosis in England using population-based health data

We assessed the validity of coded healthcare data to identify cases of haemophagocytic lymphohistiocytosis (HLH). Hospital Episode Statistics (HES) identified 127 cases within five hospital Trusts 2013-2018 using ICD-10 codes D76.1, D76.2 and D76.3. Hospital records were reviewed to validate diagnoses. Out of 74 patients, 73 were coded D76.1 or D76.2 (positive predictive value 89·0% [95% Confidence Interval {CI} 80·2-94·9%]) with confirmed/probable HLH. For cases considered not HLH, 44/53 were coded D76.3 (negative predictive value 97·8% [95% CI 88·2-99·9%]). D76.1 or D76.2 had 68% sensitivity in detecting HLH compared to an established active case-finding HLH register in Sheffield. Office for National Statistics (ONS) mortality data (2003-2018) identified 698 patients coded D76.1, D76.2 and D76.3 on death certificates. Five hundred and forty-one were coded D76.1 or D76.2 of whom 524 (96·9%) had HLH in the free-text cause of death. Of 157 coded D76.3, 66 (42·0%) had HLH in free text. D76.1 and D76.2 codes reliably identify HLH cases, and provide a lower bound on incidence. Non-concordance between D76.3 and HLH excludes D76.3 as an ascertainment source from HES. Our results suggest electronic healthcare data in England can enable population-wide registration and analysis of HLH for future research.

POS0440 REDUCTION IN MONOCYTE COUNT PREDICTS SUSTAINED REMISSION IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH ANTI-TNF THERAPY

Background:

Sustained remission is the ultimate goal in the management of rheumatoid arthritis (RA) but is infrequently achieved. After conventional therapy, TNFi (tumour necrosis factor inhibitor) has a strong track record for achieving remission. Existing studies suggest variable effect of RA and TNFi on various cellular components of the full blood count (FBC), but their relationship with loss of remission (LOR) is unclear.

Objectives:

To investigate whether cellular changes in the FBC can predict LOR (remission defined as DAS28-ESR≤2.6) in patients with RA receiving TNFi, adjusted using key clinical factors.

Methods:

Real-world clinical and routine laboratory data were analysed from two independent cohorts of adult RA patients, who were started on their first TNFi (from 2009 to December 2019), and went into remission. Data was extracted in October 2020. A linear mixed model was used to investigate longitudinal changes of different components of FBC and CRP, stratified by LOR, and grouped by years of follow-up. Pairwise post-hoc comparisons were performed by Bonferroni correction. Area Under the Receiver Operating Characteristics (AUROC) of cellular changes in FBC components to predict LOR at different time points were calculated. Latent class mixed models were used to investigate trajectories of change in cellular components of the FBC from baseline to one year. Further survival analysis to predict LOR of TNFi was done by using the latent class model and adjusted by clinical parameters, demographics and concomitant treatment.

Results:

92 and 43 biologic-naïve RA patients who attained remission were included from cohorts 1 and 2 respectively. 73 (54%) were treated with adalimumab and 62 (46%) with etanercept. 87 (64%) of patients lost remission over a 10-year period with median time to LOR of 3.3 years (95% CI 2.6-3.7).

Among the cellular components of FBC, monocyte count changes in the first year after initiation of TNFi fell significantly in those who maintained remission over the five years of follow-up, compared to those who lost remission [p<0.001 for all years evaluated] (Figure 1). AUROC of monocyte count change at 6 months and 12 months, to predict LOR from year 1 to year 5 (after TNFi initiation) and after 5 years, ranged between 0.70-0.90. Three latent classes were identified based on monocyte count changes over time: 1-decrease (N=41), 2-increase (N=7) and 3- no change (N=87). Among these latent classes, patients in class 1, sustained remission for longer (unadjusted log-rank p=0.001) compared to the other 2 classes. Monocyte latent classes as a predictor of LOR was further tested by cox-regression, where variables (anti-citrullinated protein antibody/ACPA, concomitant methotrexate, baseline DAS28-ESR) were selected by elastic net regularisation and further adjusted by use of steroid, age and gender. Class 2 and Class 3 monocyte latent classes showed a hazard ratio (HR) of 3.15 (95% CI 1.02-9.74, p = 0.046, n. of event = 6/7) and 5.48 (95% CI 2.6-11.57, p <0.001, n. of event = 73/87) respectively compared to Class 1. ACPA positivity also increased the risk of LOR with HR of 2.13 and 95% CI 1.04-4.37, p = 0.04 (n. of event = 78/117) compared to seronegative patients (n. of event = 9/18).

Conclusion:

In seropositive RA patients treated with TNFi, a reduction of total monocyte count in the first year was associated with maintenance of remission in subsequent years. Further studies are required to determine whether these effects are specific to TNFi or reflect sustained remission in RA irrespective of therapy.

Figure 1

(A-F). Mean change (with 95% confidence interval) in absolute count of monocyte after initiation of tumour necrosis factor inhibitor grouped by years of follow-up and stratified by loss of remission. N = number indicate cumulative number of patients who lost remission by the end of each year.

Acknowledgements:

Muhammad Shipa is funded by Versus Arthritis. Su-Ann Yeoh is funded by the Royal College of Physicians, Rosetrees Trust, NIHR University College London Hospitals Biomedical Research Centre, UCLH Charities, and Versus Arthritis. Michael Ehrenstein is supported (in part) by the University College London Hospital Biomedical Research Centre. None of the funding bodies have been involved in preparation of this manuscript.

Disclosure of Interests:

None declared

O22 Evaluating the impact of COVID-19 on patient access to rheumatology services, medication and future care: a nationwide study of more than 2,000 patients

Background/Aims 

COVID-19 has had significant impacts upon the delivery of rheumatology care in the UK. To date, there is little data specifically addressing how care has been disrupted and the impact upon patient attitudes and beliefs. Herein, we describe the results of a national study investigating how COVID-19 has; (1) reduced access to services; (2) altered treatment and drug monitoring; (3) impacted on clinic follow-up; (4) changed patient beliefs regarding ongoing/future care.

Methods 

We conducted an online survey of patients attending rheumatology clinics in the UK. Questions were developed by clinicians with input from patient charities and four expert patients. The survey was hosted online between 8 September and 8 October 2020.

Results 

In total, 2,054 patients completed the survey and the average number of rheumatic conditions each patient reported was 1.98±1.38 with the most common being; rheumatoid arthritis (48%), lupus (20%), Sjogren’s syndrome (19%), fibromyalgia (15%) and vasculitis (8%). More than half (57%) were told to shield, whilst 10% decided to shield of their own accord. Compared with before the pandemic, 57% felt it was difficult/very difficult to contact their rheumatologist. Regarding treatment, 15% reported difficulty obtaining their usual medication. Less than half (45%) of patients continued medication as previously and had no problem accessing it, although 21% said their usual drug monitoring had been discontinued. Overall, 3% stopped their treatment of their own accord. In all, 26% said their appointments in rheumatology clinics had been cancelled and they did not know when they would be seen again (4% reported no change in their outpatient follow-up). Prior to the pandemic, 13% of patients had received a telephone consultation, however, since the pandemic 60% had received one. Just 19% felt it was easy to be honest with their clinician via telephone. Only 33% were satisfied with the current level of care, 43% reported their rheumatology care was worse than pre-pandemic and 38% of patients felt they needed to see their rheumatologist but could not get an appointment. Over half (57%) of patients expressed worries about their future care. If offered an appointment in the next few months 66% said they would prefer it be face-to-face.

Conclusion 

To our knowledge, this study is the largest survey of patient experiences of the COVID-19 pandemic under rheumatological care anywhere in the world. We found more than half of patients were told to shield and one-in-ten decided to shield without being directly told to do so. Less than half of patients maintained relatively good access to their usual medication without necessary monitoring in many cases. In particular, patients express high levels of concern about their future care. These high levels of disruption indicate the importance of maintaining routine rheumatology services during the ongoing pandemic.

Disclosure 

C. Wincup: Grants/research support; CW has received research funding from Versus Arthritis, LUPUS UK and the British Society for Rheumatology. R. Amarnani: None. I. Giles: None.

P062 How do our patients feel about face-to-face review in rheumatology clinics since COVID-19? A single tertiary care centre experience

Background/Aims 

The COVID-19 pandemic has had a significant impact on the management of outpatients. During the first wave of the pandemic, and in common with other departments, almost all our patient consultations happened over the phone. As the rate of infection fell, we felt it was crucial that the patient voice was heard as we re-organised clinical areas and re-opened services. In view of this, we conducted an online survey to better understand patient concerns around visiting our hospital for appointments and how we can adapt the way we work to ensure patient safety and satisfaction.

Methods 

Using our electronic patient record, we identified patients from the clinic lists of 2 adult rheumatology consultants over a 6-week period between June and August 2020. This timeframe was selected as it was towards the end of the UK nationwide shielding period and our department was returning to deliver an increasing proportion of outpatient care face-to-face. Included patients had to have been treated with an immunosuppressive drug and only those on monotherapy hydroxychloroquine, sulfasalazine or prednisolone under 5mg were excluded. We consented each patient via telephone before sending them an email link to an online anonymised survey. This included a combination of 9 multiple choice and white space questions.

Results 

65 patients were identified of which 16 were excluded as we were unable to contact them or they declined consent. 49 patients were sent the survey of which 31 responses were received. 21/31 (67%) of patients had been shielding. The survey revealed six themes of concern. These include: lack of social distancing in common hospital areas, lack of personal protective equipment compliance amongst staff, prolonged time spent in waiting rooms, lack of knowledge on new hospital policies, logistics of using public transport to come to the hospital, and the importance of retaining virtual consultations going forward. 55% of patients stated they would feel safe in returning to the hospital for face-to-face appointments over the next few months.

Conclusion 

Important themes have emerged from this project that we have presented to our rheumatology multi-disciplinary team, Director of Innovation and Head of Patient Experience. This has reinforced adaptations in our hospital environment such as installing safe distance seating in waiting rooms and scheduled phlebotomy slots. Further, where possible we call patients before face-to-face appointments to inform them of our safety measures and try to schedule these patients for outside peak travel hours. We acknowledge that using an online survey may limit responses from older individuals or those with English as a second language. Despite this, our project has shown the importance of recognising the unique concerns of rheumatology patients and the value in using their opinions to create a “new normal” for our outpatient environment.

Disclosure 

R. Amarnani: None. B. Goulden: None. J. Manson: None. V. Morris: None.

P069 Results of an online survey exploring the effects of shielding during the COVID-19 pandemic on patients with spondyloarthritis (SpA)

Background/Aims 

The COVID-19 pandemic has created many challenges for patients with chronic rheumatological diseases. SpA - which includes ankylosing spondylitis (AS), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), and enteropathic arthritis - often affects young people who are otherwise fit and able. Many SpA patients take immunosuppressive medications and therefore were advised to shield. In view of this, we conducted a survey to better understand how shielding has affected the physical activity and symptoms of SpA patients during the pandemic.

Methods 

An online anonymised survey was created and advertised via social media from 4th June to 4th July 2020. Patients with SpA were invited to complete the survey which included 18 questions exploring the impact of the pandemic on their symptoms, physical activity levels and medication use.

Results 

There were 136 survey respondents, of whom 74.3% were female, with an age range from under 25 to over 75 years. The underlying diagnoses were PsA (60.5%), AS (28.4%), axSpA (10.5%) and enteropathic arthritis (0.8%). The majority (66.7%) of respondents were shielding; 44.1% were on disease modifying anti-rheumatic drugs (csDMARDs) and 56.6% were on biologics (bDMARDs). Most (94.1%) had continued their DMARDs throughout the shielding period. Non-steroidal anti-inflammatory drug (NSAID) use was reported to be increased in 18.6% of respondents, and unchanged in 69.0%. Compared to before the pandemic, 54.8% reported worsening joint stiffness and 45.6% reported worsening joint pain.

Most respondents (67.6%) reported reduced levels of physical activity, the commonest reasons being: shielding (54.6%); increased fatigue (45.8%); concerns around social distancing (45.4%); poor sleep quality (38.6%); working from home (28.6%) and low mood (28.6%). Only 14.7% had attended a virtual exercise class.

Conclusion 

Approximately 2 in 3 patients with SpA reported they were shielding during the first wave of the pandemic. Similar numbers of patients reported reduced physical activity levels and increased joint stiffness over this time. It is important to acknowledge that given the nature of the anonymised survey, we cannot be certain if the same patients who were shielding were the same as those who had reduced levels of physical activity or worsening symptoms. We have, however, shown that over half of the surveyed patients attributed their reduced physical activity levels to shielding. Taking into account that social restrictions (either self-imposed or government advised) are likely to be ongoing, we believe that a focus should be placed on supporting patients to maintain their activity levels, through initiatives such as specialist virtual exercise classes.

Disclosure 

M. Naja: None. R. Amarnani: None. M. Castelino: None.

P014 An audit of bone health assessment in patients admitted to hospital with a fracture following a fall

Background/Aims 

Over three million people in the UK have osteoporosis; and are at a substantially increased risk of fragility fractures. There are approximately 536,000 new fragility fractures each year in the UK, with substantial associated morbidity and health service burden. Preventing fragility fractures is thus clinically and economically important and will result in substantial savings for health and social care. The aim of this audit was to assess and improve falls and bone health assessments in a high-risk patient group at a central London hospital.

Methods 

Data was collected over a 2-month period (02/05/2019-28/06/2019) of consecutive patients over the age of 50 admitted to hospital following a fall and fracture. We used the 2017 National Osteoporosis Guidelines Group, NICE clinical guideline on falls in older people (CG161) and the local hospital osteoporosis screening policy as the audit standards. Patient notes were reviewed to assess for evidence of bone health assessment and key falls assessment domains having taken place.

Results 

43 patients were included; 8 of which had a neck of femur fracture (NOF). Table 1 demonstrates the different components that we included in the falls assessment. Only 5 (12%) of all of the patients had a full falls assessment recorded. In all domains, patients with a NOF were more likely to have a more complete falls assessment than patients with other fractures, especially fundamental components such as osteoporosis risk assessment. P014 Table 1:Number of patients who had each aspect of the falls and bone health assessment completedNOF (N = 8, mean age=80.3)Non-NOF (N = 35, mean age=75.3)YesNoPartialYesNoPartialFalls Assessment3 (37.5%)0 (0%)5 (62.5%)2 (5.7%)15 (42.9%)18 (51.4%)Medical diagnosis of aetiology7 (87.5%)1 (12.5%)18 (51.4%)17 (48.6%)Lying/standing BP3 (37.5%)5 (62.5%)5 (14.3%)30 (85.7%)Therapies assessment?8 (100%)0 (0%)24 (68.6%)11 (31.4%)Medication review?6 (75%)2 (25%)10 (28.6%)25 (71.4%)Osteoporosis assessment?8 (100%)0 (0%)9 (25.7%)26 (74.3%)FRAX completed3 (37.5%)5 (62.5%)3(8.6%)32 (91.4%)Referred to falls clinic1 (12.5%)7 (87.5%)1 (2.9%)34 (97.1%)Referred to post discharge falls prevention5 (62.5%)3 (37.5%)3 (8.6%)32 (91.4%)Referred to bone health clinic1 (12.5%)7 (87.5%)0 (0%)35 (100%)Patients divided into groups of neck of femur (NOF) and non-NOF fractures

Conclusion 

Key aspects of falls and bone health assessment are simple and quick to do, yet often not done in patients admitted with a fracture following a fall. These measures are highly valuable in the long term to mitigate future fragility fracture risk. Our results show that post fall assessment, including bone health, are performed more often in patients with NOF than non-NOF fractures. There is large scope for improvement in practice for this at-risk cohort of patients. Therefore, going forward, our next steps are to create an education programme and embed a standardised, simple proforma into electronic healthcare records to guide post fall bone health assessment.

Disclosure 

J. Kimpton: None. B. Wong: None. R. Amarnani: None. M. Loader: None. C. Fong: None. I. Mannan: None.

P065 The road to recovery: developing a new service for urgent face-to-face rheumatology outpatient appointments during the COVID-19 pandemic: a single centre experience

Background/Aims 

COVID-19 poses many challenges to the way in which rheumatology services are delivered. In particular, the sudden change from face-to-face (F2F) appointments to telephone consultations (TC) has adversely impacted upon the assessment and management of disease activity. Therefore, we established a dedicated urgent F2F rheumatology clinic to rapidly assess new or follow-up patients with symptoms that could not be managed remotely during the pandemic. Herein we present patient outcomes to inform future service planning in the context of the ongoing pandemic and continuing need for rationing of F2F services.

Methods 

Patients requiring urgent F2F assessment between 22^nd April and 28^th July 2020 were evaluated. Referrals came from rheumatologists, rheumatology trainees, nurse specialists, general practitioners, and other medical teams. Prior to attendance, patients were screened for symptoms of COVID-19 by a clinician. Temperature monitoring was performed on the day of attendance. A retrospective review of electronic medical records was conducted in which we identified outcomes of all patients reviewed.

Results 

A total of 201 patients were scheduled an appointment (10 did not attend). Mean age was 45.4±16.6 years of which 14% were ‘shielding’. In all, 85% of patients were referred following a previous TC in which assessment and/or treatment could not be done remotely. New referrals consisted primarily of possible new inflammatory arthritis (55%), new autoimmune rheumatic disease (6%) or polymyalgia rheumatica (4%) with 23% currently undergoing investigation to confirm diagnosis. All patients required physical examination and alteration in investigation and/or management. Of those who attended, blood tests (66%), radiographs (32%), MRI (14%), and ultrasound (8%) were the most common investigations requested. In total 14% were referred to another secondary care specialty, 14% to physiotherapy, and 13% for specialist nurse review. Regarding treatment, 25% required intra-articular joint injection (37 patients received a total of 45 joint injections on the day of the clinic with a further 10 patients referred for ultrasound-guided injection); 13% of patients received intramuscular steroids; and 16% were prescribed oral steroids. New disease-modifying anti-rheumatic drug therapy was initiated in 17% of cases with an additional 11% starting a new biologic agent. No patients had their treatment reduced or discontinued. We are not aware of any new cases of COVID-19 following attendance at this clinic.

Conclusion 

This urgent clinical service was formed because virtual remote consultations alone were insufficient to address the clinical needs of our patients. We found this service to be safe and effective for assessment of patients, with escalation of treatment according to clinical need, in spite of the adverse impact of COVID-19 upon our services. However, for future service planning during the ongoing COVID-19 pandemic this F2F service requires the availability and support of nursing, allied healthcare professionals, pharmacy and diagnostic services.

Disclosure 

C. Wincup: Grants/research support; CW has received funding for research from LUPUS UK, Versus Arthritis, British Society for Rheumatology. R. Amarnani: None. S. Rana: None. J. Tan: None. F. Farinha: Grants/research support; FF has received funding for research from LUPUS UK and the Portuguese Foundation for Science and Technology. S. Yeoh: Grants/research support; SAY has received research funding from (UCLH NIHR BRC), UCLH Charities, Royal College of Physicians, Rosetrees Trust. C. Raine: Grants/research support; CR has received funding for research from UCB. I. Giles: None.

P074 Insights into creating a virtual patient and public involvement initiative

Background/Aims 

Patient and public involvement (PPI) initiatives are important to ensure patient-centered research. However, traditional focus groups can present challenges including the recruitment and retention of patient partners. Additional challenges to patient involvement have also arisen due to the coronavirus pandemic (COVID-19). The University College London (UCL) Patient Partners in Rheumatology Research initiative has been developed to explore novel ways to boost patient involvement and foster an active collaboration between basic researchers and patient partners.

Methods 

Two online surveys were designed to obtain information with regards to the expectations and practicalities of this initiative. One survey was sent to patients who had registered an interest in being patient partners and the other survey to rheumatology researchers at UCL and University College London Hospital (UCLH).

Results 

We received responses from 25 researchers and 21 patients. The majority of patients who responded (71%) had not previously been involved in PPI. Most of the researchers (84%) had previously utilised PPI, however 20% of those had some difficulty accessing it.

Most patients (86%) were interested in becoming a patient partner. Amongst those with reservations, one stated that “I don't think I have the qualifications to be involved with scientists and researchers”. Over half of patients (52%) were happy to participate in PPI more than five times a year and most researchers (84%) expressed that five times a year was acceptable. Patients favoured (52%) conducting PPI meetings after office hours (5-8pm) during the working week. Due to social restrictions because of COVID-19, we asked both patients and researchers their preferred mode of meeting. Both groups favoured a mixed (virtual and face to face) meeting arrangement (81% for patients and 68% for researchers). A third of patients (38%) expressed that they would need technical assistance accessing a virtual meeting. Almost all patients (95%) were happy to contribute to lay summary reviews remotely via email.

Conclusion 

Based on the insights gained from the survey results, our PPI initiative meetings will be hosted in a hybrid virtual/face to face format. These will be held at a time and frequency that is convenient for the patient partners to increase participation across wider demographics. This survey has highlighted that we have to be mindful of certain patient perceptions of PPI which creates a barrier to patient involvement and that some individuals may require further support in accessing virtual meetings. By designing a PPI initiative that creatively addressed the needs of both the researchers and patient partners we hope to create a platform for productive dialogue and collaboration to ensure patient-centred research, despite the changes brought about by the COVID-19 pandemic.

Disclosure 

E. Hawkins: Other; funded by National Institute of Health Research, Clinical Research Network. T. Hyndman: None. R. Amarnani: None. J. Kimpton: None. S. Yeoh: Other; University College London Hospital National Institute of Health Research Biomedical Research Centre, UCLH Charities, Royal College of Physicians and Rosetrees Trust. M. Castelino: Other; University College London Hospitals National Institute for Health Research Biomedical Research Centre.

P126 The effectiveness of pharmacological interventions and cognitive behavioural therapy in improving sleep in fibromyalgia: a systematic review

Background/Aims 

Fibromyalgia (FM) is a common yet complex musculoskeletal condition. Sleep disturbance frequently coexists with FM yet optimal management of this important association is unclear. Current standard treatment for FM in general often includes a combination of pharmacological and psychological treatments - most commonly cognitive behavioural therapy (CBT). This systematic review aims to critically appraise the evidence regarding the effectiveness of these treatments at improving sleep in FM.

Methods 

Pre-defined search terms were entered into PubMed, Cochrane CENTRAL, Embase, Medline and CINAHL. Randomised controlled trials (RCTs) studying the effectiveness of any pharmacological intervention or CBT (including electronic CBT) in managing FM-associated sleep disturbances in adults were included.

Results 

Of 682 RCTs identified, 56 (n = 17,005; aged 18-84) met the inclusion criteria: 45 pharmacological studies assessing 24 medications and 11 CBT-based studies. Sleep assessment methods varied between studies, the most common being the visual analogue scale. The most common pharmacological interventions were pregabalin (n = 8) and milnacipran (n = 8), followed by sodium oxybate (n = 4), amitriptyline (n = 4) and fluoxetine (n = 3). Although outcome measures differed across the pregabalin studies, they all showed varying degrees of sleep improvement. Conversely, only 2/8 studies of milnacipran showed improved sleep scores. All 4 studies investigating sodium oxybate showed significant improvements in the Jenkins Sleep Scale. Only 1/4 study analysing amitriptyline and 1/3 assessing fluoxetine showed statistically significant improvement in sleep scores compared to placebo. The remaining 18 pharmacological studies included multiple antidepressants and analgesic agents, with a wide range of efficacy at improving sleep scores. The 11 CBT-based studies typically compared CBT to sleep hygiene or standard pharmacological therapies. Traditional, online and combined CBT methodologies (all n = 4), CBT for insomnia (CBT-I) (n = 7) and/or pain (CBT-P) (n = 4) were all evaluated. Studies conducting CBT-I and CBT-P showed significant improvements in the Pittsburgh Sleep Quality Index and self-reported sleep diaries. Long-term traditional CBT improved sleep in both included studies. One study using multicomponent CBT also showed significant sleep improvements. Only one study assessed online CBT, showing no significant results, though there was a trend towards improved sleep.

Conclusion 

The optimal management of sleep disorders in FM is complex and needs to be tailored to the individual patient. We have shown that there are varying degrees of efficacy throughout a range of commonly used drugs in FM. Unfortunately, lack of consistency in outcome measures between studies makes it difficult to draw definitive conclusions pertaining to superiority between these agents. Conversely, CBT interventions appear to show consistent sleep improvement in FM. It is not clear whether this translates to online variations of CBT. We believe that a longitudinal appraisal of sleep as a primary variable, with robust consistent outcome measures, using pharmacological interventions with CBT would benefit future research.

Disclosure 

A. Pathak: None. I. Brennan: None. R. Amarnani: None. A. Soni: Grants/research support; UCB Prize Fellowship.

106 A Whole Hospital Delirium Audit with 20 Week Follow-Up

Introduction

Delirium is a common manifestation of acute illness, characterised by fluctuating changes in mental state. Its aetiologies and presentations are diverse. This can lead to underdiagnosis. We screened all adult inpatients at Barnet Hospital for delirium. 20 weeks follow-up data was collected, including mortality and admission to institutional care.

Methods

The 4AT and Clinical Frailty Score (CFS) were recorded for every adult inpatient (n = 220) in Barnet Hospital on 13/03/2019. Hospital notes were reviewed to establish whether delirium assessments were performed during admission. Electronic records were used to establish length of stay, discharge destination, mortality and readmission rate over 20 weeks.

Results

30% (n = 65) of inpatients had possible delirium (4AT score ≥ 4). Delirium was more common in older, frailer patients (Table 1). Most patients with delirium were under the care of geriatric (40%) or acute medicine (26%). Only gastroenterology and gynaecology had no patients with delirium. Patients with delirium were 3 times more likely to die during their admission and were twice as likely to be discharged to institutional care (Table 1). 20 week mortality of patients with delirium was 26%.

Conclusion

Delirium is common in hospital inpatients. Delirium has a high morbidity and mortality. Better diagnosis of delirium in hospital may improve outcomes. Table 1: Mean(SD) unless stated. *p &lt; 0.05 Delirium (n = 65) No Delirium (n = 155) Male: % 46 46 Age* 81(11) 71(20) Clinical Frailty Score* 5.6(1.7) 3.8(1.8) Dementia (%)* 53 10 Assisted living: n(%) o Pre-admission * 18.5 3.2 o Post Admission * 44.6 22.6 Length of stay 33 (25) 30.6 (28) Mortality (%) o Hospital * 10.7 3.9 o 20 Weeks * 26.2 14.2 Readmission rate (%) 30.8 31.

Lupus and the Lungs: The Assessment and Management of Pulmonary Manifestations of Systemic Lupus Erythematosus

Pulmonary manifestations of systemic lupus erythematosus (SLE) are wide-ranging and debilitating in nature. Previous studies suggest that anywhere between 20 and 90% of patients with SLE will be troubled by some form of respiratory involvement throughout the course of their disease. This can include disorders of the lung parenchyma (such as interstitial lung disease and acute pneumonitis), pleura (resulting in pleurisy and pleural effusion), and pulmonary vasculature [including pulmonary arterial hypertension (PAH), pulmonary embolic disease, and pulmonary vasculitis], whilst shrinking lung syndrome is a rare complication of the disease. Furthermore, the risks of respiratory infection (which often mimic acute pulmonary manifestations of SLE) are increased by the immunosuppressive treatment that is routinely used in the management of lupus. Although these conditions commonly present with a combination of dyspnea, cough and chest pain, it is important to consider that some patients may be asymptomatic with the only suggestion of the respiratory disorder being found incidentally on thoracic imaging or pulmonary function tests. Treatment decisions are often based upon evidence from case reports or small cases series given the paucity of clinical trial data specifically focused on pulmonary manifestations of SLE. Many therapeutic options are often initiated based on studies in severe manifestations of SLE affecting other organ systems or from experience drawn from the use of these therapeutics in the pulmonary manifestations of other systemic autoimmune rheumatic diseases. In this review, we describe the key features of the pulmonary manifestations of SLE and approaches to investigation and management in clinical practice.

P260 The efficacy of biologic treatment in improving fatigue in ankylosing spondylitis: a literature review and implications for clinical practice

Background

Ankylosing spondylitis (AS) is a chronic, inflammatory condition that predominantly manifests as arthritis in the axial skeleton. AS related fatigue remains under-researched despite evidence that it is an important contributor to the quality of life in these patients. The impact of biologic therapy on fatigue in patients with AS is not fully understood. Furthermore, it is not clear whether any of the licensed biologic drugs are more effective in treating fatigue in AS than others. The aim of this review is to critically appraise the evidence regarding the effectiveness of biologic agents in treating AS associated fatigue to help guide clinical practice.

Methods

Pre-defined search terms were entered into PubMed and Embase to identify papers studying the effectiveness of etanercept, adalimumab, infliximab, golimumab, certolizumab pegol and secukinumab in AS associated fatigue. Results were restricted to those published in English from 1990 onwards. 64 papers were initially identified and screened using predefined exclusion criteria; of these, 13 were selected for final inclusion.

Results

No head-to-head studies analysing fatigue were identified and all studies included analysed fatigue as a secondary outcome measure. Most studies utilised a single question fatigue measurement such as the BASDAI fatigue score. Variation in methodology precluded a meta-analysis. There is evidence that all six biologics improve fatigue in AS to varying degrees. For etanercept, three out of four studies found significant improvement compared to placebo at week 12 and week 54. However, one study that utilised a more robust form of fatigue assessment found no significant differences between etanercept and placebo at week 12. For Adalimumab, two studies were identified, both of which were robust and suggested strong efficacy in treating AS associated fatigue at week 12. For infliximab, two out of three studies were open label trials which showed significant improvement in fatigue at week 6. The third study was a post-hoc analysis of a randomised placebo-controlled trial and showed improvement in fatigue scores at week 24. Two studies were identified for Golimumab, both of which showed significant improvement in fatigue scores at week 24 and week 104 respectively. One placebo-controlled trial of certolizumab pegol showed significant improvement in fatigue at week 24. For secukinumab, one study was identified: a post-hoc analysis of a randomised, placebo-controlled trial. This showed a significant improvement in fatigue at week 16; however, this improvement was not sustained at week 104.

Conclusion

Although none of the studies analysed fatigue as a primary outcome measure, it appears that biologic treatment overall is successful to varying degrees in the treatment of AS associated fatigue. Future studies would benefit from utilising robust fatigue assessments, comparing biologics, and evaluating long-term effectiveness. In addition, vigilance in recognising fatigue and subsequent considered holistic management is paramount.

Disclosures

R. Amarnani None. A. Soni Grants/research support; Oxford-UCB Prize Fellowship.

Aneurysmal benign fibrous histiocytoma of the anal canal: a rare differential diagnosis

BACKGROUND

To our knowledge, we report the first case of an aneurysmal benign fibrous histiocytoma occurring in the anal canal.

METHODS

Clinical, histological, radiological and surgical data pertaining to this patient were analysed. Additionally, a literature review on aneurysmal benign fibrous histiocytoma was conducted.

RESULTS

We describe a 48-year-old Caucasian male presenting with a 2-week history of a painful anus, fresh rectal bleeding and tenesmus. Digital rectal examination identified a tender firm mass in the anal verge. Magnetic resonance imaging revealed high signal in the anal canal. Flexible sigmoidoscopy revealed an ulcerated 3-cm indurated lesion at the four o'clock position. Biopsies taken of the mass confirmed the diagnosis of an aneurysmal benign fibrous histiocytoma (BFH). Following a discussion in the colorectal multi-disciplinary team, the patient was counselled for an excision of the lesion. Diathermy dissection was performed to completely excise the tumour with a margin involving the fibres of the anal sphincter. The patient made a full recovery and had no residual symptoms. Histology of the excised specimen confirmed clear margins of the BFH.

CONCLUSIONS

This paper aims to highlight a rare differential diagnosis for an anal mass. An aneurysmal BFH most often presents as a painless mass within the dermis and subcutaneous tissue. As such, this case presents a diagnostic challenge to both colorectal surgeon and histopathologist due to its low incidence and unusual location. We further present the clinical and radiographic evidence to confirm the diagnosis. Additionally, we discuss the literature pertaining to this condition and its optimal management.