Kay Greveson

Interferon γ-release assays for detecting latent tuberculosis infection in patients scheduled for anti-TNFα therapy

Screening for, and treatment of, latent tuberculosis infection (LTBI) before anti- tumour necrosis factor α therapy has been shown to decrease the incidence of active tuberculosis by more than 80% and is recommended before initiation of treatment. In the absence of a ‘gold standard’ test for LTBI, current screening involves taking a clinical history of risk factors, chest radiograph and tuberculin skin test. Alternative cellular immune-based screening tests have been developed to detect Mycobacterium tuberculosis infection. This paper summarises the current position and advances in the use of newer screening strategies for LTBI.

T1272 Screening Patients Initiating Anti-TNF Agents for Mycobacterial Infection Using Interferon-Gamma Release Assays (IGRA): the Experience of a Large Inflammatory Bowel Disease Service

P78 Table 1 Patients screened N T Spot TB (Elispot) result Chest radiography result Nonreactive Reactive Indeterminate Normal/abnormal Anti-TNF naı̈ve 24 22 1 1 On immunosuppression (16) (15) (0) (1) 24/0 No immunosuppression (8) (7) (1) (0) Established on anti-TNF 26 24 1 1 On immunosuppression (24) (22) (1) (1) 26/0 No immunosuppression (2) (2) (0) (0) TNF, tumour necrosis factor. Poster sessions Thorax 2009;64(Suppl IV):A75–A174 A107 latent TB infection (LTBI) (household contacts with a Mantoux skin test response >10 mm and absence of clinical or radiographic evidence of active disease) and 50 healthy non-infected controls. Two drops of whole blood from a finger prick plus three drops of diluent are applied to the well in the test plate. Within 5–15 min a negative result shows just a visible control band while a positive result shows an additional visible test band. Results To date, 44 controls, 4 patients with LTBI and 12 with active TB have been tested. All controls and those with LTBI tested negative. Only 3/12 patients with known active TB tested positive (2 pulmonary, 1 lymph node, all smear positive). All 3 had not received any treatment for TB whereas the other 9 had all started therapy (range 3 days to 2 months), giving a sensitivity to date of 25% and specificity of 100%. Conclusions The results to date indicate that this test is not suitable as a diagnostic aid in patients who have received any amount of TB medication. With further numbers it may prove helpful with diagnosis in untreated smear negative or extrapulmonary disease, although our positive results to date have all been in patients with large numbers of organisms. P80 HOW USEFUL ARE INTERFERON-GAMMA RELEASE ASSAYS IN CASES OF SUSPECTED TUBERCULOSIS? HSR Hosker, J Anderson, A Crabtree, P Godwin. Airedale NHS Trust, Keighley, UK doi:10.1136/thx.2009.127159b Interferon-gamma release assays (IGRAs) have an established role in contact tracing, new entrant and occupational health screening for tuberculosis (TB) (NICE/HPA recommendations). Their role in supporting or ruling out TB diagnosis in suspected cases (when microbiology is unavailable) is less clear. We retrospectively analysed results from 95 patients who had a T-spot test performed as part of their investigation for possible TB. Patients presented with a variety of symptoms and clinical findings; TB microbiology was either unavailable or cultures were ongoing at the time of testing. No patient had HIV infection or other significant immunosuppression. 29 (31%) of 95 suspected cases had a positive T-spot test. 11 (38%) were true positive based on subsequent positive cultures or subsequent response to TB therapy. 11 (38%) other positive results were probably due to latent TB (LTBI) from old TB many years ago or recent TB contact with no current evidence of active TB. Seven cases (24%) were false positives in the context of various other diagnoses (including two cases of atypical mycobacteria). Of the 16 cases subsequently found to have active TB (excluding probable LTBI cases), 5 (31%) had a negative T-spot result (false negative). Four of these had ‘‘systemic’’ extrapulmonary TB (2 miliary, 1 TB meningitis, 1 TB empyema) with likely generalised immune paresis. 11 of 12 (92%) cases of pulmonary or mediastinal TB had a positive T-spot result. Overall specificity was 90% and sensitivity was 81% in cases of suspected TB (table 1). We conclude that, in cases of suspected TB, (a) a negative TB spot is useful in ruling out pulmonary TB but (b) patients with extrapulmonary TB often have a false negative result and (c) a positive T-spot might be due to co-existing LTBI or other pathology in some cases. The results of IGRAs in patients with suspected TB need to be interpreted with caution. P81 COMPARISON BETWEEN INTERFERON-GAMMA RELEASE ASSAYS AND THE TUBERCULIN SKIN TEST IN THE DIAGNOSIS OF TUBERCULOSIS IN PATIENTS WITH RENAL DISEASE DW Connell, R Charif, N Duncan, C McCrudden, E Harden, S Seneviratne, OM Kon. Department of Chest and Allergy, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK; West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Immunology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK doi:10.1136/thx.2009.127159c Introduction and Hypothesis There are few studies on the use of interferon-gamma release assays (IGRAs) in the diagnosis of tuberculosis (TB) in patients with renal disease. We describe the real-life contact tracing of 62 patients from a general renal inpatient ward in which a staff member was found to have pulmonary TB. We hypothesised that IGRAs would diagnose more cases of TB in the cohort, and would be more associated with exposure to the index case than the tuberculin skin test (TST). Methods A healthcare worker was found to have pulmonary TB after a period of work on a renal inpatient ward. Patients were invited for standard screening with a TST, and IGRA testing with the T-SPOT and Quantiferon (QFT) tests. Concordance between the tests was calculated with x testing, as was the effect of length of exposure to the index case on the test results. Results 61 patients were contact traced from the cohort of 62. There was a broad spectrum of ethnicities and modalities of renal replacement therapy (haemodialysis in 45%). 29 patients did not receive a completed TST despite standard follow-up by experienced TB nurses. 12 patients (19.6%) had a positive QFT, 13 patients (21.3%) had a positive T-SPOT and 5 patients (8.1%) had a positive TST. No patients had evidence of active TB disease. 25 patients had all three tests performed. Their results are summarised in fig 1. In this group there was a significant association between T-SPOT and QFT results (p,0.002, Kappa 0.694). There were no significant associations with TST and either IGRA (p.0.05, Kappa ,0.37 for both). Length of exposure to the index case had no effect on test results (Mann-Whitney U test, p.0.1 for all tests). Conclusions This is the first UK description of a real-life comparison between TST with IGRAs in a population with mixed kidney disease. It demonstrates the difficulty of performing the TST in these patients. The results of the IGRA tests were significantly associated with one another, suggesting they may be a more reliable test in this population for the diagnosis of TB. Abstract P80 Table 1P80 Table 1 Suspected (N = 95) Treated as TB or LTBI Not TB T spot +ve 22 7 False +ve 24% Specificity 90% T spot 2ve 5 61 False –ve 7.6% Sensitivity 81% Abstract P81 Figure 1 Twenty-five patients (41%) had all three tests. Of this group, four patients had a positive tuberculin skin test (TST), five had a positive Quantiferon (QFT) and eight had a positive T-SPOT. Poster sessions A108 Thorax 2009;64(Suppl IV):A75–A174

Nurses are critical in aiding patients transitioning to biosimilars in inflammatory bowel disease: education and communication strategies

Abstract The increasing prevalence of inflammatory bowel disease and the high costs associated with biologic therapies suggest that biologics with lower costs, but no compromise on efficacy and safety, should be considered when developing a treatment plan for inflammatory bowel disease. Biosimilars offer a more cost-effective alternative, and although the European Medicines Agency has approved the use of biosimilars for many indications, including inflammatory bowel disease, patients may be concerned about the safety and efficacy of these agents. The updated Nurses–European Crohn’s and Colitis Organisation statements, published in March 2018, recommend that inflammatory bowel disease nurses facilitate patient choice of biologic or biosimilar therapy. Nurses are pivotal in managing the challenges associated with patients transitioning to biosimilars. However, there is limited information available on how inflammatory bowel disease nurses can communicate the concept of biosimilars to patients and also on how best to support them before and during the switch from originators. This review article will focus on patients’ concerns regarding biosimilars and describe considerations for nurses when supporting patients transitioning from originators to biosimilars. Through nurse-led patient education and the use of structured communication strategies, as well as investment in managed switching programmes, patients will become more confident and adherent to their biosimilar therapy, and this may lead to overall reductions in health-care expenditure for inflammatory bowel disease.

Gastrointestinal/IBD Nurse of the Year Runner Up

Kay Greveson, IBD Nurse Specialist, Royal Free Hospital was awarded runner up in the British Journal of Nursing Awards 2016, here she tells us about the work she did to be shortlisted.

Tu1079 ‘IBDpassport’: Evaluating the Quality of an Internet-Based Travel Resource for Inflammatory Bowel Disease

Introduction Travellers’ with Inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity with European guidelines recommending expert consultation prior to travel. 1 Previous research into travel and IBD found travel consultations and patient travel preparation and knowledge to be deficient. 2,3 As a result we developed a dedicated, evidence-based non-profit IBD travel advice website (www.ibdpassport.com) to enhance informed, safe travel. Here we present formal evaluation of this website. Method A link to the website, along with a structured web-based survey was sent to a sample of 15 UK IBD patients, clinical nurse specialists and Gastroenterologists respectively. The survey contained demographic questions and asked respondents to rate the content, functionality and credibility of the website using a series of parameters including a 5-point Global Quality Score and Integrity Score. 4 Readability statistics were graded on a 100 word sample of text from each page on the website using the Flesch Reading Ease and Flesch-Kincaid Grade level scores. Results A total of 33 individuals responded (73% response rate; 11, 33% Patient; 10, 30% Nurse; 12, 36% Gastroenterologist. The mean Global Quality score was 4.5 out of a possible 5 (Range 3–5). The Flesch-Kincaid Grade level score was US school grade 10.9 (range 7.2–17.1) and median Flesch Reading Ease score 50.5 out of a possible 100 (Range 22.4–65.1). The integrity score was 4.0 out of 6. The majority of respondents strongly agreed the website was an accurate source of travel information for IBD (60%), used appropriate citations (67%), and was easy to navigate (70%). 26/33 (79%) felt the website improved their knowledge of travel-related issues in IBD. All respondents would recommend the site to peers. Conclusion IBD Passport is the first internet-based travel resource created for both patients and professionals to provide IBD-specific travel information. Our findings demonstrate that patients and healthcare professionals consider IBD Passport to be an excellent quality, evidence-based resource. The readability statistics are favourable when compared to results from other studies examining website quality. Disclosure of interest None Declared. References Rahier JF, et al . J Crohns Colitis 2014;8:443–468 Soonawala D, et al . Inflamm Bowel Dis. 2012;18(11):2079–85 Greveson, et alet al. A recent flare of disease does not prohibit travel: early results of a single centre study in inflammatory bowel disease and travel digestive diseases week, 2014, abstract ID:Su1095 Bernard A, Langille M, Hughes S, et al . A systematic review of patient inflammatory bowel disease information resources on the world Wide Web. Am J Gastroenterol. 2007;102:2070–2077

Tu1080 A Single-Centre Pilot Study Examining Internet Use for Health-Related Information Among Patients With Inflammatory Bowel Disease

Introduction The internet offers a wealth of information for patients with chronic disease, facilitating education and shared decision making; however, this can often be unregulated and inaccurate. 1 Inflammatory bowel disease (IBD) patients use of the internet has been investigated 2 but no studies have examined whether internet use alters with disease activity or influences patients decisions regarding health. We evaluated patients internet use for health-related information (HRI), including factors influencing website choice and whether this information influences decisions regarding healthcare or changes with disease severity. Methods A prospective, pilot survey of 170 consecutive patients attending the IBD clinic over a one month period in November 2013. The anonymous questionnaire included demographic information on age, gender, education level, diagnosis and disease activity. There were also questions regarding use of the internet for HRI, determinants of website quality and influences of information found on the internet on decisions affecting their health. Results A total of 136 IBD patients completed the questionnaire (80% response rate), 60 [44%] male, age 18–85 years [median age 37 years] 67 [49%] had CD; 84 [62%] reported a flare of symptoms in the preceding 6 months. 126 (93%) use the internet, 110 (81%) of which access HRI information via the internet. 94% of patients were educated to completion of high school or above and level of education did not affect internet use. Using NHS direct (46%), Crohn’s and colitis UK (40%) and IBD forums (29%), patients searched for general health (77; 57%); IBD specific (63; 46%) and medication (47; 35%) information. 45 (33%) stated that information found on the internet would influence their choice of medication, irrespective of a flare within the last 6 months. 71% (96) felt confident that they could obtain factual information on the internet, although when determining website quality, overall appearance and position in search engines and whether the site was non-commercial were ranked least important and IBD-specific sites from a reputable source most important. Conclusion In our study, internet use is shown to be a major source of disease –specific information and can affect patients’ decision making. Internet usage and type of information sought do not alter with disease activity, suggesting that information is equally useful to all patients with IBD. References 1 Fortinsky et al . Innflam Bow. Dis 2012; 18(6):1156–63 2 Cima et al . Inflamm Bowel Dis 2012; 13 (10)1266–1270 Disclosure of Interest None Declared.