Lyn Williamson

Factors influencing work disability in psoriatic arthritis: first results from a large UK multicentre study

OBJECTIVE The aim of this study was to determine the extent to which structural damage, clinical disease activity, demographic and social factors are associated with work disability (WD) in PsA. METHODS Four hundred patients fulfilling CASPAR (Classification Criteria for Psoriatic Arthritis) criteria for PsA were recruited from 23 hospitals across the UK. Demographic, socio-economic, work, clinical and radiographic data were collected. WD was assessed with the Work Productivity and Activity Impairment Specific Health Problem (WPAI-SHP) questionnaire reporting WD as a percentage of absenteeism (work time missed), presenteeism (impairment at work/reduced effectiveness) and work productivity loss (overall work impairment/absenteeism plus presenteeism). Logistic and linear regressions were conducted to investigate associations with WD. RESULTS Two hundred and thirty-six participants of any age were in work. Absenteeism, presenteeism and productivity loss rates were 14% (s.d. 29.0), 39% (s.d. 27.2) and 46% (s.d. 30.4), respectively. Ninety-two (26%) participants of working age were unemployed. Greater age, disease duration of 2-5 years and worse physical function were associated with unemployment. Patients reported that employer awareness and helpfulness exerted a strongly positive influence on remaining in employment. Higher levels of global and joint-specific disease activity and worse physical function were associated with greater levels of presenteeism and productivity loss among those who remained in work. CONCLUSION Reduced effectiveness at work was associated with measures of disease activity, whereas unemployment, considered the endpoint of WD, was associated with employer factors, age and disease duration. A longitudinal study is under way to determine whether treatment to reduce disease activity ameliorates WD in the real-world setting.

Atypical psoriasis following rituximab for rheumatoid arthritis.

To the Editor: Rituximab (RTX) is a chimeric B cell-depleting monoclonal antibody used in the treatment of non-Hodgkin’s lymphoma and rheumatoid arthritis (RA), and with an emerging role in connective tissue disease therapy. Its use has rarely been associated with skin reactions, in particular psoriasiform skin lesions. We report a case of atypical psoriasis reactivation in a patient with RA following RTX, and we review the literature. A 49-year-old woman presented in 1999 with a seronegative polyarthritis affecting the hands, elbows, feet, hips, and knees. At the time she gave no history of psoriasis. Over the next 10 years she received several disease-modifying antirheumatic drugs (DMARD) sequentially and in combination including sulfasalazine, hydroxychloroquine, methotrexate, azathioprine, gold, and leflunomide. Disease activity persisted, although radiographs remained nonerosive. Her 28-joint Disease Activity Score (DAS28) in September 2010 was 6.45 despite triple DMARD therapy, and she was assessed for a biologic. RTX was chosen in preference to anti-tumor necrosis factor (TNF) treatment because of recurrent shingles and a previous positive Heaf test (chest radiograph normal, quantiferon test negative). In November 2010 … Address correspondence to Dr. S.A. Hardcastle, Department of Rheumatology, Osprey Unit, The Great Western Hospital, Marlborough Road, Swindon SN3 6BB, UK. E-mail: Sarah.Hardcastle{at}bristol.ac.uk

Supervised exercise plus acupuncture for moderate to severe knee osteoarthritis: a small randomised controlled trial

Objectives Although total knee replacement (TKR) is cost effective and successful in most cases, patient-reported outcome measures demonstrate 20% of people remain unsatisfied at 1 year after a technically successful procedure. Our group has previously shown that patients with severe knee osteoarthritis (OA) awaiting surgery can achieve a short-term reduction in symptom severity when treated with acupuncture, and that a trend towards improved walking distance, as a measure of function, is achieved with preoperative supervised exercise. The aim of this study was to evaluate the effect of combined acupuncture and physiotherapy on preoperative and postoperative pain and function. Methods A total of 56 patients awaiting TKR surgery were randomised to receive either combined physiotherapy and acupuncture or a standardised exercise and advice leaflet. Pain and function were measured primarily using the Oxford Knee Score (OKS), with assessments at baseline prior to intervention, 6 and 12 weeks after intervention and at 3 months postoperatively. Results Due to the introduction of the 18-week waiting times target during this study, the required sample size was not achieved. There were no significant differences demonstrated between the control and treatment groups for OKS. Seven patients withdrew from surgery because of symptomatic improvement in their knees: six from the treatment group and one from the control group (OR 7.64, 95% CI 0.86 to 68.20). Conclusions This study demonstrated that the use of combined acupuncture and physiotherapy in the treatment of patients with moderate to severe knee OA preoperatively did not improve patient outcome postoperatively. As the study was underpowered, a larger trial is required to examine this result further.

Effect of anti-TNF and conventional synthetic disease-modifying anti-rheumatic drug treatment on work disability and clinical outcome in a multicentre observational cohort study of psoriatic arthritis

Objective. To determine the effect of medical treatment on work disability in patients with active PsA in a real‐world setting. Methods. Four hundred patients with active PsA commencing or switching to anti‐TNF or conventional synthetic DMARD (csDMARD) were recruited to a multicentre UK prospective observational cohort study. Work disability was measured using the work productivity and activity‐specific health problem instrument and peripheral joint activity was measured with the disease activity in PsA composite measure. Results. Four hundred patients were recruited, of whom 229 (57.25%) were working (of any age). Sixty‐two patients of working age (24%) were unemployed. At 6 months there was a 10% improvement in presenteeism (P = 0.007) and a 15% improvement in work productivity (P = 0.001) among working patients commenced on csDMARDs (n = 164) vs a larger and more rapid 30% improvement in presenteeism (P < 0.001) and 40% improvement in work productivity (P < 0.001) among those commenced on anti‐TNF therapy (n = 65). Clinical response was poor among patients commenced on a csDMARD (n = 272), with an 8.4 point improvement in disease activity in PsA (P < 0.001) vs those commenced on anti‐TNF therapy (n = 121), who had a 36.8 point improvement (P < 0.001). Conclusion. We report significant and clinically meaningful improvements in both work disability and clinical outcomes after commencement of anti‐TNF therapy in a real‐world setting. Improvements in all outcomes among those commencing csDMARDs were slower and of a smaller magnitude.

Tropical rheumatology in a UK District General Hospital: a case report of leprosy presenting as acute vasculitis

tocilizumab, serum CRP and SAA levels became normal and morning stiffness and shoulder pain improved. By March 2009, a total of five infusions of tocilizumab had been administered without any exacerbation of symptoms or any elevation of serum CRP or SAA levels. MMP3 reduced from 508-727 to 334 ng/ml. Ga-citrate scintigraphy also showed a marked reduction of uptake in the bilateral shoulders and hands, and in the left ankle joint (Fig. 1B). However, just before the sixth administration, cholecystitis occurred and tocilizumab treatment had to be stopped. At 3 months after the cessation, the disease activity flared up with shoulder pain and morning stiffness, leading to an increase in the methylprednisolone dose from 6 mg/day to 8 mg/day. In this report, we demonstrated the ameliorative effect of tocilizumab on symptoms caused by RS3PE. To the best of our knowledge, this is the first report to evince the efficacy of tocilizumab for RS3PE. A response to low-dose corticosteroids and absence of relapse after 2 years of treatment are characteristics of RS3PE [5] but our patient was refractory to corticosteroids and then the present case was thought to be a rare one. Increased serum concentration of IL-6 has been observed in patients with RS3PE [2, 3], and therefore IL-6 inhibition with tocilizumab might constitute a novel strategy for treatment of RS3PE. Indeed, reported here, tocilizumab treatment resulted in a remarkable suppression of clinical symptoms, accompanied by a reduction in MMP3 levels as well as in Ga-citrate uptake in joints. Although tocilizumab treatment had to be discontinued due to the complication of cholecystitis in the patient, tocilizumab can be considered a viable option for treatment of refractory RS3PE.

Screening for pulmonary hypertension in scleroderma

1. Guillen-del-Castillo A, Callejas-Moraga EL, Fonollosa-Pla V, et al. Application of the DETECT algorithm in a single centre. Abstract presented at the 4th Systemic Sclerosis World Congress, 18-20 February 2016, Lisbon, Portugal. J Scleroderma Relat Disord. 2016;1(1):43-169. Abstract P.101. 2. Olivas O, Joven B, Diaz-Anton B, et al. Performance of the DETECT protocol for pulmonary arterial detection in systemic sclerosis patients in clinical practice. Abstract presented at the 4th Systemic Sclerosis World Congress, 18-20 February 2016, Lisbon, Portugal. J Scleroderma Relat Disord. 2016;1(1): 43-169. Abstract P.110. 3. Pozzi MR, De Stasio D, Frattola A, et al. DETECT algorithm and early diagnosis of pulmonary arterial hypertension in systemic slcerosis: a single centre experience. Abstract presented at the 4th Systemic Sclerosis World Congress, 18-20 February 2016, Lisbon, Portugal. J Scleroderma Relat Disord. 2016;1(1): 43-169. Abstract P.114. 4. Denton C, Hughes M, Gak N, et al. BSR and BHPR guideline for the treatment of systemic sclerosis. Rheumatology 2016; 55(10):1906-1910. 5. Coghlan JG, Denton CP, Grünig E, et al; DETECT Study Group. Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study. Ann Rheum Dis. 2014;73(7):1340-1349. 6. Khanna D, Gladue H, Channick R, et al; Scleroderma Foundation and Pulmonary Hypertension Association. Recommendations for screening and detection of connective tissue disease-associated pulmonary arterial hypertension. Arthritis Rheum. 2013; 65(12):3194-3201.

AB1085-HPR Audit of Nurse-Led DGH Rheumatology Advice Line

Background We introduced a nurse led Rheumatology Advice Line in 2004 to offer telephone advice to patients with inflammatory arthritis (1). Since then there has been a year-on-year increase in the number and complexity of calls, putting unsustainable demand on service and staff. A service review in April 2014 demonstrated one third of calls were inappropriate, including calls about the Home delivery service, appointment times and general practice related problems. We therefore changed the recorded message with the expectation that the helpline be used for telephone consultations concerning: medication side effects and effectiveness; flares of arthritis; possible complications of biologics and DMARDs; results of blood and X-Ray tests to avoid outpatient appointments. We audited the use of the Advice Line. Methods We documented the number of calls to the Advice Line from 2004–2014. The recorded message for the Advice Line was altered in May 2014. We audited the calls in April 2014 and compared with data from calls between May and December 2015. All calls were documented and categorised as: Patient calls leading to clinic appointment; Patient calls with advice give related to medication or inflammatory arthritis; GP or district nurse calls with advice given; Home delivery related; Inappropriate calls (including non rheumatological conditions, appointment time related, in-house calls). We also documented whether letters were generated and made a judgement about whether Consultant or GP consultation had been avoided Results The total annual number of calls increased from 438 in 2004; 2752 in 2006; 3074 in 2008; 2817 in 2010; 3857 in 2012; 3210 in 2014. After the recorded message was changed, the number of inappropriate calls fell from 97/311 (31.2%) in April 2014 to 8/258 (3.1%) from April to December 2015. However the number of appropriate calls rose from 131/311 (42.1%) in April 2014 to 194/258 (75.2%). The complexity and time needed to deal with calls has also increased. Reason for call April 2014 April–December 2015 monthly mean (range) Patient call – Appointments generated 71 53 (37–55) Patient call – Advice given 131 182 (125–209) GP/district nurse call – Advice given 3 8 (3–11) Home delivery related 9 7 (2–12) Inappropriate calls 97 8 (4–12) Total number of calls 311 258 (224–282) Number of letters generated 60 59 (41–77) Consultant/GP appointment saved – 117 (74–116) Conclusions The Rheumatology Nurse Practitioner led Advice Line provides a valuable clinical service as an adjunct to face to face consultation. This audit suggests a saving over 100 face-to-face consultations per month. Changing the Advice Line message led to a fall in the number of inappropriate calls but the number and complexity of calls continues to increase. This will need to be reflected in future service evaluation. References RA Hughes. Telephone Helplines in Rheumatology Rheumatology, Vol 42. 197–199 (2003) Disclosure of Interest None declared

THU0190 A Six-Week Progressive Resistance Training Class Improves Function and Fatigue in RA Patients

Background Rheumatoid arthritis (RA) is associated with adverse changes in body composition and physical function that persist despite pharmaceutical treatment. Randomised control trial evidence has shown that Progressive Resistance Training (PRT) is safe and efficacious in restoring lean mass and function in patients with RA. We set up our own PRT programme for RA patients to explore whether similar results could be achieved in an NHS setting. Methods RA patients were invited to attend a PRT programme of six, weekly class held under the supervision of a Senior Physiotherapist. Newly diagnosed and established RA were included. The exercises used within the circuit are: wall slides, chest press, leg extension, rowing, balance board work, triceps extensions, bicep curls, clam, bridging, standing calf raises and step ups. Classes included up to 10 patients at a time. Data collected at induction and after six weeks included demographics, BMI, percentage body fat, grip strength, 60 second Sit to Stand test, HAQ and FACIT (fatigue) scores. After the six-week PRT programme patients were encouraged to continue at home or referred to their local gym. Results Of 34 RA Patients invited, 27 started and 21 completed the 6 week PRT course. Mean age 54 (range 17–78) years; 71% F; 50% RF positive. 11 (32%) patients were diagnosed within 3 months of starting the class. There was no difference in results between recently diagnosed and established RA patients. After six weeks there was a significant improvement in: HAQ mean (range) 1 (0–2.9) vs 0.8 (0–2.5) p=0.03; Body Fat Composition mean (range) 38.0% (21.5%>51%) vs 36.9% (26.3%>48.2%) p=0.02; Sit to Stand mean (range) 20.0 (8–36) vs 23 (9–42) p=0.02. There was a trend towards improvement mean (range) in: handgrip strength 22.0 (2–54) vs 25.8 (5–54) p=0.21 and FACITF score 29.5 (18–49) vs 35.6 (19–49) p=0.05. BMI Sit to stand Grip strength right Grip strength left FACITF Body fat HAQ (60 secs) (kg) (kg) % Baseline mean 30.9 20.0 22.5 22.0 29.5 38.0 1 6 week mean 30.3 23.0 27.3 25.8 35.6 36.9 0.8 p 0.49 0.02 0.08 0.21 0.05 0.02 0.03 Conclusions We present an effective model for PRT workable in the NHS, which encourages patient to take control of their own exercise regimes. The class setting fosters motivation, confidence and a belief in exercise as part of effective treatment. This brief intervention was associated with significant improvement in various aspects of physical function, Grip strength, HAQ and Fatigue scores. Disclosure of Interest None declared

SAT0220 Retrospective Audit Comparing BSR Standards with Detect Criteria for PAH-Screening in Systemic Sclerosis Patients at A DGH

Background Pulmonary arterial hypertension (PAH) is a complication of Systemic Sclerosis (SSc). It is the lead cause of mortality and can affect up to 20% of SSc patients. The DETECT study developed an evidence-based screening algorithm to aid early detection and diagnosis; as well as guide management of those with SSc-PAH. Many studies, including DETECT have shown earlier detection, higher survival rates and improved outcomes in those enrolled to a screening programme. PAH is often diagnosed late, when symptoms are advanced and prognosis is poor. Therefore, screening is crucial to enhance patient safety and improve outcomes. In light of this; a retrospective audit of 29 SSc patients at a DGH in July 2015 was performed to compare adherence rates to the national BSR standards of annual pulmonary function testing (PFT) echocardiogram and DETECT criteria for PAH-screening. Objectives 1. Evaluation of current practice against the BSR standards. 2. Evaluation of current practice against DETECT criteria Methods Data was retrospectively collated from written medical notes, Medway and CVIS in accordance with a Microsoft Excel proforma of 30 variables, including annual echocardiography and PFT; and eight PAH-predictive variables identified by the DETECT study (FVC %predicted/DCLO %predicted, Telangiectasias, ECG Right Axis Deviation (RAD), Serum Urate, Serum Anti-Centromere Antibody (ACA) and Serum NTproBNP). Results Adherence to the BSR standard was 75.9% over the last 18 months. Stratification showed higher rates of adherence in those with more recent diagnoses; 70%, 83.3% and 100% for 0–4years, 5–8 years and 9–12 years disease duration respectively, compared to 50% and 0% for 17–20 years and 21–24 years respectively. DETECT scores were calculable for 2/29 patients. Serum NTproBNP, serum urate and ECG RAD are not routinely tested for or documented in SSc patients. Furthermore, in this audit, less than 50% of patients had a documented serum ACA in their notes. As a result, DETECT scores were not calculable for most patients. Conclusions Adherence rates in the last 18 months are 75.9%. Adherence is highest in those with more recent diagnoses. Seven patients (24%) did not receive annual screening in the past 18 months. Adherence to BSR standards and patient safety could therefore be improved. As a result of this audit, a centralised patient list was uploaded to CVIS for automatic annual screening appointments. The use of DETECT criteria is not currently applicable. However small, inexpensive changes in routine management of SSc patients would make this possibile. References Coghlan JG, Denton CP, Grunig E, Bonderman D, Distler O, Khanna D, et al. Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study. Ann Rheum Dis. 2014;73(7):1340–9. Humbert M, Yaici A, de Groote P, Montani D, Sitbon O, Launay D, et al. Screening for pulmonary arterial hypertension in patients with systemic sclerosis: clinical characteristics at diagnosis and long-term survival. Arthritis Rheum. 2011;63(11):3522–30. Acknowledgement Dr Lyn Williamson, Miss Colleen Wells, Mr Simon Brader, Mr Paul Charlton Disclosure of Interest None declared

AB0984 Herpes Zoster Vaccination, Should Our Patients with Rheumatological Disorders Be Prioritized?

Background Herpes Zoster infection is a common and painful condition with potential for serious complications. The overall life time risk is one in three but the risk is much higher in immunosuppressed patients and in our patients with rheumatological diseases. For example in patients with rheumatoid arthritis alone the risk is 2 fold higher compared to the age and sex matched controls. The risk also increases with age and more than 50% of Herpes infection occurs in those aged over 60. The Herpes Zoster vaccination has been approved by FDA for people aged 50 years and older and CDC recommends it in those aged 60 and above. In United Kingdom this vaccination has recently been started, last year only people who were 70 and 79 years old were being offered the vaccine and this year those aged 71 and 78 are being vaccinated. Current guidelines do not recommend vaccination on biologic treatment, high dose steroid or other significant immunosuppression. Objectives This is a small study to look into Herpes infection in our rheumatology patients and whether we need a more pro-active approach towards vaccinating our patients particularly those who are about to start biologic therapies. Methods We looked at the self-reported incidence of Herpes Zoster infection in our cohort of rheumatology patients. We sent out a questionnaire to all patients on our biologics database asking if they had ever suffered from shingles and whether they had it before or after their respective rheumatological diagnosis and if they were on a biologic or non-biologic DMARD at the time of shingles. Of 512 sent, 160 replied. Mean Age was (65) and main rheumatological diagnoses were: Rheumatoid Arthritis 96/160 (60%), Psoriatic Arthritis 29/160 (18%), and Ankylosing spondylitis 21/160 (13%), the rest were other conditions treated with biologics. Results 38 of 160 (23.75%) had previous shingles and 6 of these 38 patients (15.7%) had suffered more than one episode. 24 of 38 (63.1%) patients had shingles post rheumatologic diagnosis and out of these 24; 6 (25.0%) had shingles whilst on biologic treatment; 6 (25.0%) had it whilst on combination DMARDs plus biologics; 9 (37.5%) on small molecule DMARDS; 3 patients could not tell their drugs at the time of shingles. The mean age for those who had shingles was 61.8 years. Conclusions Nearly one quarter of patients on our biologic database reported one or more episodes of shingles. Out of them 63% had it post their rheumatological diagnosis, and most patients had it whilst on Biologic or Non-Biologic DMARDs. The mean age of those who had shingles was 61.8 years which is much less than the current cut off for vaccination in UK. This is a small study but serves as a reminder for us to consider a more proactive approach towards shingles vaccination in our rheumatology patients, particularly before starting Biologics, in older patients who do not qualify for routine government funded Vaccination. References Allison L. Smitten, Hyon K. Choi, Marc C. Hochenberg, Samy Suissa, Teresa A. Simon, Marcia A. Testa, K. Arnold Chan. The risk of herpes zoster infection in patients with rheumatoid arthritis in United States and United Kingdom. 29 Nov 2007. DOI: 10. 1002/ART.23112. Craig M. Hales, MD, Rafael Harpaz, MD, Ismael Ortega-Sanches PhD, Stephanie R. Bialek, MD. Update on recommendations for use of Herpes Zoster Vaccine August 22, 2014/63(33);729–731 Disclosure of Interest None declared