A. Moorthy

Differences and similarities in rheumatology specialty training programmes across European countries

Objectives To analyse the similarities and discrepancies between the official rheumatology specialty training programmes across Europe. Methods A steering committee defined the main aspects of training to be assessed. In 2013, the rheumatology official training programmes were reviewed for each of the European League Against Rheumatism (EULAR) countries and two local physicians independently extracted data on the structure of training, included competencies and assessments performed. Analyses were descriptive. Results 41 of the 45 EULAR countries currently provide specialist training in rheumatology; in the remaining four rheumatologists are trained abroad. 36 (88%) had a single national curriculum, one country had two national curricula and four had only local or university-specific curricula. The mean length of training programmes in rheumatology was 45 (SD 19) months, ranging between 3 and 72 months. General internal medicine training was mandatory in 40 (98%) countries, and was performed prior to and/or during the rheumatology training programme (mean length: 33 (19) months). 33 (80%) countries had a formal final examination. Conclusions Most European countries provide training in rheumatology, but the length, structure, contents and assessments of these training programmes are quite heterogeneous. In order to promote excellence in standards of care and to support physicians’ mobility, a certain degree of harmonisation should be encouraged.

FRI0607 Rheumatology Training in India – A Reflection and Comparison with United Kingdom

Background Indian subcontinent is one of the largest growing economy in the world.The burden of rheumatic musculoskeletal disease among Indian population is overwhelmimg.Clearly,there is a demand for specialist rheumatology work force in India.In this era of biologics and biosimilars,rheumatology is an attractive speciality among aspirant doctors.Our previous observational studies have explored and identified the strength and weakness in the rheumatology training programme in UK,Canada1 and South Asian countries2. We aim to explore the perception of rheumatology training among specialist and current trainees in India,and compare with UK training. Objectives 1.To explore the perception of rheumatology training in India. 2.To identify the strength and weakness and the areas of improvement in training programme in India. Methods This is an observational questionnaire based study. A pilot study was conducted with 32 questions during APLAR conference 2015 in India. The re-designed questionnaire was circulated electronically to rheumatology trainees across India through their training leads. Our survey was directed towards exploration of rheumatology curriculum including content, training and research opportunities and job prospect. The results were analysed through smart survey. Results Total respondents were n=77, 16% (40/240)from UK and 49% (37/75) from India. There were female predominance (55%) in UK and male predominance (71%) in India. Noted a wide variation in application process, structure and duration of training. In India, training duration is 6 years (3 yrs in GIM and 3 yrs in rheumatology), whereas it is 5 years for combined and 4 years for pure rheumatology in UK.The national rheumatology curriculum was designed by JRCPTB in UK, but multiple regional syllabus were followed in India with lack of adherence to national curriculum. Trainees from both countries received weekly institutional teaching. UK trainees received structured supervision for joint injections, whereas Indian trainees received more training for crystal identification and immunological studies. Fewer cross speciality clinics were practised in India. Less exposure to MSK ultrasound skills was noted among the trainees, however the concept of MSK Ultrasound was clearly evolving in India. Postgraduate research programmes and opportunities were available in UK, whereas Indian trainees need to complete a formal supervised dissertation project as a part of postgraduate qualification. Mandatory training for generic skills were lacking in India. Training records were maintained electronically in UK and by paper log book in India. Although speciality exit exam was mandatory in both countries, the format was different including MCQ based in UK and theoretical and practical based in UK. Conclusions 1. This is the first study comparing rheumatology training between UK and India. 2. Lack of structured Curriculum and homogenous rheumatology training exist in India. 3. Harmonisation of rheumatology training in India is essential, matched with developed nations. References Das P, Moorthy A, Maksymowych W, Pope J. A comparative study of rheumatology specialist training across UK and Canada. Ann Rheum Dis 2014;73(Suppl2): 802 Das P, Moorthy A, Chapman P, Suresh E, Sakthiswary R. Comparative survey of rheumatology training including UK, Singapore, Malaysia and New Zealand. Ann Rheum Dis 2013;72(Suppl3):1037 Disclosure of Interest None declared

OP0145 An Evaluation of Inflammatory Back Pain in The Community – A Novel Way of Using Social Media (Facebook)

Background In the management of Spondyloarthropathy, early diagnosis is the key. Previous UK studies show an average delay in diagnosis of IBP of up to 8 years. This is partly due to a failure of individuals with IBP symptoms to present to their GP and partly to a failure of GPs to recognize the IBP patient subgroup. IBP classification criteria have recently been developed and used in clinical practice. We applied a novel recruitment method using Facebook to identify IBP sufferers in the community. This may help to raise awareness toreduce the delay in diagnosis of Spondyloarthropathy. Objectives Evaluate a novel way of recruiting potential patients with IBP, using social media. Determine which of the two criteria sets for IBP, ie. ASAS or Calin, is fulfilled by more patients. Methods A novel recruitment method using Facebook was applied in a cross-sectional survey carried out in the UK over 5 months to identify adults (≥18 years) with symptoms suggestive of IBP. Other methods, principally newspaper advertising, were used to generate a second group of participants for comparison. Online questionnaire-based surveys were completed to assess each group for IBP using the ASAS and Calin criteria. Data about previous diagnoses, GP, hospital consultations and back pain-related investigations, were also collected. Results Of the 585 participants, 455 (77.8%) were recruited through Facebook and 130 (22.2%) by a Non-Facebook method. Of the Non-Facebook group, 90 (15.4%) were recruited by a newspaper advert and 40 (6.8%) by another method. The mean age of the Facebook group was typical of IBP at 41.5 years, and the mean age of the Non-Facebook group was higher at 59.4 years. Most participants were female: 447 (76%). Proportions of those previously diagnosed with Ankylosing Spondylitis, told that their back pain was associated with “inflammation”, and were IBP positive on the questionnaire respectively, are shown in Table 1. In total 122 survey participants (21%) met the ASAS, and 292 (50%) met the Calin criteria for IBP at the time of the survey. The majority of patients from each group reported consulting their GP, however few patients from either group had seen a rheumatologist (Table 1). The reason for non-referral to secondary care is unclear. Regarding further investigations, 45% (204) of the Facebook group reported having an MRI scan and 45% (205) an X-ray, whereas 50% (65) of the Non-Facebook group reported having an MRI scan and 59% (77) said they had been for an X-ray. Conclusions – Facebook advertising recruited a younger group of respondents of whom more fulfilled the criteria for IBP, suggesting this may be a cost-effective way of identifying patients earlier.– Most patients with chronic back pain had consulted their GP, but few who met the criteria for IBP had been referred to a rheumatologist indicating the need for additional GP education.– In our study group the ASAS IBP criteria were fulfilled by fewer patients than the Calin criteria. Acknowledgement This study was sponsored by AbbVie and financial support for the study was provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract. The authors wish to thank Bobby Brown, who supported this work as a medical writer and Patients Direct, who designed and conducted the study. Disclosure of Interest None declared

FRI0408 A Twelve Month Follow-Up Study of Patients Recruited through Social Media Who Fulfilled ASAS/Calin Criteria for Inflammatory Back Pain

Background Epidemiology data on inflammatory back pain (IBP) prevalence within the UK is still lacking. Previous studies from the UK show delay in diagnosis of IBP for up to 8 years. This is partly due to lack of awareness among Public and Primary care practitioners. New criteria have been developed to identify conditions at an early stage with a view to reducing times to referral. Our previous work, using social media, helped identify patients with IBP. New IBP classification criteria were applied to the identified patients in the present analysis. Objectives To follow up IBP positive patients over a twelve month period to see how their back pain had changed, whether treatment was actively sought and what treatment(s) were provided. Methods A cross-sectional survey was carried out between December 2013 and May 2014 to identify adults (≥18 years) who had IBP. Recruitment was targeted in a novel way to enlist UK participants using social media (Facebook) and national newspaper (Daily Mail) advertisements. Online questionnaire-based surveys supplemented by telephone response were completed. Those participants who fulfilled either the ASAS or Calin criteria at the initial assessment were offered an information leaflet on IBP. The participants were also asked to complete follow-up questionnaires at 6 and 12 months. Results A total of 586 participants completed the initial survey; of these, 304 (51.87%) satisfied either the ASAS or Calin criteria for IBP. Many patients at both 6 and 12 months follow-up reported that their back pain was unchanged, with more reporting a decline (37% of responses) than an improvement (31% of responses). Evaluation of changes in quality of life using mean EQ5D scores also suggested a small deterioration. Of the 91 patients who completed a follow-up questionnaire at 6 months 57 (63%) had seen a GP, 6 (7%) had seen a rheumatologist, 16 (18%) had physiotherapy and 8 (9%) were finally diagnosed with a spondyloarthropathy (eg. Ankylosing Spondylitis). Of the 67 patients who completed a follow-up questionnaire at 12 months 41 (61%) had seen a GP, 5 (7%) had seen a rheumatologist, 13 (19%) had physiotherapy and 9 (13%) were finally diagnosed with a spondyloarthropathy. Only 1 patient (1.5%) at 12 month follow-up (none at 6 month follow-up) had received biologic treatment with anti-TNF. Of the 91 patients who completed the 6 month follow-up questionnaire only 28 downloaded the IBP information leaflet and no new IBP diagnoses resulted. Conclusions Patients who were IBP positive (ASAS or Calin) in an online survey, many recruited using social media, deteriorated slightly over a 12 month follow-up period. Providing these IBP positive participants with a link to an information leaflet did not result in any new IBP diagnoses. Although most patients had seen a GP, only 7% had seen a rheumatologist despite fulfilling the IBP criteria. Primary care education on IBP is key in the early diagnosis of Spondyloarthropathy. Acknowledgement This study was sponsored by AbbVie and financial support for the study was provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract. The authors wish to thank Bobby Brown, who supported this work as a medical writer and Patients Direct, who designed and conducted the study. Disclosure of Interest None declared

AB1207 Audit on the Management of Rheumatology Patients Who Developed Malignancy While on Anti TNF Treatment

Background Anti TNF therapy has revolutionised the management of Rheumatic diseases. However, this effective therapy is contraindicated in patients with past or current malignancy. Currently, there are a lack of clear guidelines, other than in RA, where rituximab is used. Current practice is to discontinue anti-TNF therapy and alternative non TNF biologics are usually considered. Current evidence does not suggest this group of patients are at risk of recurrence. Further clarity is needed so that this patient cohort can be better managed. Objectives 1) To assess the time of anti-TNF discontinuation following the diagnosis of malignancy 2) To explore the commonly used non anti-TNF therapy (if any) used after confirming malignancy 3) To explore the management practice of various rheumatic diseases, post malignancy diagnosis Methods This is a retrospective audit of patients who received anti TNF therapy at a busy teaching Hospital. The data was obtained from the departments biologics database. Patients who developed malignancy whilst on anti TNF therapy were identified and cross-referenced with the oncology database. Clinical letters and notes were subsequently reviewed. This data was then collated and analysed. Results A total of 950 patients who are currently on anti-TNF therapy were included in this Audit. 27 (2.8%) were diagnosed with malignancy whilst on anti-TNF therapy - 17 (63%) female and 10 (37%) male. 56% (15) had solid malignancy, 15% (5) had skin cancers. The remainder were leukaemia and lymphoid malignancy. Of the solid malignancies, 26% (4) were lung carcinoma and 20% (3) were breast carcinoma. All patients had the anti-TNF therapy discontinued post malignancy diagnosis. Average time of discontinuation was within a month of diagnosis. 55% (15) were previously on adalimumab, 26% (7) had etanercept and the remainder had infliximab and golimumab. 16 (59%) of the patients diagnosed with malignancy were on anti-TNF therapy for RA. 10 (63%) of these patients went on to have rituximab as an alternative therapy, the remainder did not have further biologic therapy. Of the 27 patients, 15% were on anti-TNF therapy for ankylosing spondylitis and 26% for psoriatic arthritis. A death rate of 19% (5) was recorded for this cohort. The cause of death was widespread metastasis. Conclusions Although the numbers of patients who developed malignancy whilst on anti-TNF are small, deductions can still be made based on these results. The majority of patients (63%) who had anti-TNF therapy discontinued, were not treated with further biological therapy. The reasons were varied from patient choice, ongoing treatment for malignancy and lack of evidence for alternative biologic therapy. The most common solid malignancy from this cohort was lung carcinoma. Interestingly all patients in this group were smokers which may play a role in its occurrence. Adalimumab was used most frequently and this mirrors results obtained from other Biologics registries. None of the patients with ankylosing spondylitis had further treatment due to poor data availability on alternate biologic therapy. Evidence based clear guidelines are required to manage this group of patients. References Furst DE, et al Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2008. Ann Rheum Dis 2008;67(Suppl.3):iii225. British Society for Rheumatology. Guidelines for prescribing TNF-blockers in adults with rheumatoid arthritis. 2010. Disclosure of Interest None declared

THU0222 Anti TNF Therapy in Ankylosing Spondylitis – an Observational Study Assessing the Impact of Smoking in White British and Indian Population

Background Ankylosing spondylitis (AS) have heterogeneous clinical manifestations and diverse responses to antiTNF therapy according to ethnic origin.Previous study has shown that smoking has a detrimental effect on disease activity, functional impairment, inflammatory response and efficacy of treatment.1 There is clear dearth of evidence looking at the effect of smoking among Indian patients with AS.No previous study have explored the influence of smoking and antiTNF response among Indians and White British patients with AS.We have attempted to identify influence of smoking on the disease activity and anti TNF response in these two ethnic groups. Objectives 1. To study the impact of smoking on the disease outcome and Anti TNF treatment responses among Indian (IND) and White British (WB). Methods This is a retrospective observational study. We selected two groups of AS patients on antiTNF therapy, 125 in total, with 100 WB and 25 IND with a ratio of 4:1.Clinical, demographics and blood parameters including CRP and HLA B27,Disease outcome measures eg.BASDAI, BASFI and spinal VAS score prior to, 3 months and 12 months after initiation of antiTNF therapy were collected from biologics therapy database.Smokers from both ethnic groups had variable smoke exposure. Tukeys HSD test was used to compare the change in outcome measure from base line at 12 months for smokers and non-smokers among Indians and White British.Analysis of variance (ANOVA) was used to compare the differences in the groups at baseline and 12 months. Results Total number of cases included in the study; (n=125) with 100 WB and 25 IND patients (ratio 4:1).It showed male predominance (68% in WB; 88% in IND).There was no significant association between HLA status, smoke exposure and anti TNF treatment response.Table 1. Treatment outcome Mean BASDAI Mean BASFI Mean SPINAL VAS Mean CRP Pre antiTNF Post antiTNF (12m) Pre antiTNF Post antiTNF (12m) Pre antiTNF Post antiTNF (12m) Pre antiTNF Post antiTNF (12m) Indian smoker 7.4 5.2 6.9 5.29 7.9 5.2 16.2 9.2 Indian non smoker 6.4 3.9 5.95 4.21 6.9 3.8 13.8 7.9 White British smoker 7.03 4.28 7.1 4.4 7.4 4.5 12.8 6.4 White British non smoker 5.9 2.9 6.3 3.1 7.1 3.1 10.5 5.7 P value p=0.03 p<0.05 P=0.107 p=0.43 Patients from both groups showed significant improvement of BASDAI,BASFI and spinal VAS scores following 12 months of treatment.Our study highlighted the negative impact of smoking on AS. Smokers from both ethnic groups showed poorer treatment response.Indian smokers demonstrated comparatively poorer response to anti TNF therapy BASDAI compared to White British cohort (p=0.03), BASFI (p<0.05) and Spinal VAS (p=0.107) (Table -1). We noticed improvement in the CRP levels following 12 months of antiTNF therapy among both ethnic groups,however there were no significant correlation between smoking and inflammatory response. Conclusions 1. Smoking had a detrimental effect on Anti TNF response and disease outcome in both Ethnic group. 2. Indian smokers showed poor clinical outcome and treatment responses to anti TNF therapy. 3. There were no significant correlation observed between smoking and inflammatory responses within both ethnic groups. References Cigarette smoking has a dose dependent impact on progression of structural damage in the spine inpatients with axial spondyloarthritis: Results from the GErman SPondyloarthritis Inception Cohort (GESPIC)Citation:Annals of the Rheumatic Diseases, August 2013;1468-2060. Disclosure of Interest None declared