Sara Carty - Academia.edu (original) (raw)
Papers by Sara Carty
Rheumatology, Apr 16, 2024
Rheumatology advances in practice, Apr 18, 2024
Rheumatology, 2016
Background: The evidence base to support treatment decisions in managing patients with RA and rel... more Background: The evidence base to support treatment decisions in managing patients with RA and related interstitial lung disease (ILD) is very limited. In particular, guidance on which biologic therapy to use in patients with active articular disease does not exist. Methods: We obtained data from the British Rheumatoid InterstitiaL Lung (BRILL) network on all patients with RA-ILD whose first biologic was rituximab (RTX). We assessed survival and compared this with patients with RA-ILD who had taken an anti-TNF agent as their first i86 Tuesday
Rheumatology
Background/Aims The Giant Cell Arteritis Score (GCAPS) was developed by the specialist team in So... more Background/Aims The Giant Cell Arteritis Score (GCAPS) was developed by the specialist team in Southend, Essex, UK in 2018. It is a clinically focused tool to aid diagnosis of GCA by providing a pre-test probability, with a threshold of greater than 9 denoting higher risk of GCA requiring further diagnostic testing. So far, it has been validated externally in patients in 2 centres. In all cases, scoring was completed by a rheumatology consultant. We are keen to validate it in our setting, a district general hospital without rapid access to vascular ultrasound, to determine whether it was a valid and reliable tool for assessing which patients required temporal artery biopsy and which patients could rapidly taper steroids following a negative result. We also aimed to see whether scoring could be completed by clinicians other than rheumatology consultants. Methods We retrospectively applied the GCAPS score to all patients referred as possible GCA to our service between November 2021 - ...
Rheumatology Advances in Practice
Introduction/Background Polyarteritis nodosa (PAN) was first described in 1866 as a necrotising v... more Introduction/Background Polyarteritis nodosa (PAN) was first described in 1866 as a necrotising vasculitis predominantly involving medium-sized arteries. It is a multiorgan disorder which can cause a range of symptoms from cutaneous ulcers to gastrointestinal haemorrhage. For many patients, the cause remains elusive, however a close relationship has been demonstrated between PAN and hepatitis B infection. We describe a case of a 45-year-old who presented with acute abdomen to the emergency department. She was admitted under the general surgical team and common surgical conditions were ruled out. Imaging later revealed coeliac and splenic pseudoaneurysm. Description/Method A 45-year-old woman presented with acute epigastric pain. It was colicky in nature and radiated to the right upper quadrant with some associated vomiting. On examination she looked unwell with a tachycardia but normal blood pressure and temperature. The abdomen was rigid with positive Murphy’s sign. There were no j...
BMJ Case Reports, 2021
Abdominal pain is a very common presentation in the accident and emergency department. However, v... more Abdominal pain is a very common presentation in the accident and emergency department. However, vasculitis is not the usual first differential diagnosis. This paper discusses a case of polyarteritis nodosa presenting with acute abdominal pain alone. Common surgical conditions were obviously considered, but they were not found to cause the patient’s problems. We describe how investigations led to this diagnosis discussed in detail in this paper. It is important to remember that prompt recognition of unusual life-threatening conditions can lead to timely intervention.
Rheumatology, 2020
The guideline will be developed using the methods and processes outlined in Creating Clinical Gui... more The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol (1). This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence (NICE) accreditation.
Rheumatology Advances in Practice, 2020
Case report - Introduction We present what we believe to be the first reported case of post COVID... more Case report - Introduction We present what we believe to be the first reported case of post COVID-19 reactive arthritis, in a previously medically well 16-year-old with no past or family history of inflammatory arthritis. Case report - Case description Our patient was a previously medically fit 16-year-old of Caucasian origin who tested positive for COVID-19 in late March 2020. She developed with a 4-day illness with fever, cough, and myalgia from which she made a full and uncomplicated recovery. Ten days later she developed a new erythematous itchy rash on her legs, trunk, and face and a progressive polyarthralgia affecting her MCPs, wrists, shoulders, hips, and knees. The rash typically lasted for 2 days at one site and was non-scarring. This was associated with a low-grade fever. There were no associated mouth ulcers, photosensitivity, alopecia, Raynaud’s, GI disturbance or respiratory symptoms. She had no relevant family history of autoimmunity, psoriasis or inflammatory bowel d...
In contrast to systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), where cardiovasc... more In contrast to systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), where cardiovascular problems are frequent, extra-articular disease manifestations of cardiovascular disease are not commonly reported in patients with Sjögren’s syndrome (SS), and SS disease-activity measures do not feature cardiovascular disease. The prevalence appears to be higher than in the general population but lower than in RA and SLE populations, possibly due to the lower prevalence of smoking among the SS population. In contrast, respiratory disease is a well-recognized complication of SS. In this chapter cardiovascular and lung manifestations of SS mechanisms are discussed, together with therapies, as well as long-term complications including lymphoma and amyloidosis.
Introduction: The first few months after symptom onset represents a pathologically distinct phase... more Introduction: The first few months after symptom onset represents a pathologically distinct phase in rheumatoid arthritis (RA). We used relevant experimental models to define the pathological role of interferon-γ (IFN-γ) during early inflammatory arthritis. Methods: We studied IFN-γ's capacity to modulate interleukin-1β (IL-1β) induced degenerative responses using RA fibroblast-like synoviocytes (FLS), a bovine articular cartilage explant (BACE)/RA-FLS co-culture model and an experimental inflammatory arthritis model (murine antigen-induced arthritis (AIA)). Results: IFN-γ modulated IL-1β driven matrix metalloproteinases (MMP) synthesis resulting in the down-regulation of MMP-1 and MMP-3 production in vitro. IFN-γ did not affect IL-1β induced tissue inhibitor of metalloproteinase-1 (TIMP-1) production by RA FLS but skewed the MMP/TIMP-1 balance sufficiently to attenuate glycosaminoglycan-depletion in our BACE model. IFN-γ reduced IL-1β expression in the arthritic joint and preve...
Rheumatology, Apr 1, 2018
Recent years have seen an upsurge in clinical trial activity in primary Sjö gren's syndrome. This... more Recent years have seen an upsurge in clinical trial activity in primary Sjö gren's syndrome. This session will provide an update on ongoing trials, explore the rationale behind the investigational therapies and discuss recent trial data. Disclosures: The author has declared no conflicts of interest.
Annals of the Rheumatic Diseases
Background Smoking has been associated with an increased risk of developing rheumatoid arthritis ... more Background Smoking has been associated with an increased risk of developing rheumatoid arthritis (RA), more severe disease and poor response to disease modifying drugs (DMARD). Motivation is the most important aspect of giving up smoking and also awareness of its ill-effects, self-confidence and support. Objectives We have looked at the immediate effect on patient motivation to stop smoking by creating awareness of its ill-effects. Methods We surveyed Rheumatology outpatients with an anonymous questionnaire including demographics, smoking status, education status, employment status and awareness of the ill-effects of smoking. Motivation to stop smoking was assessed by 10cm Visual analogue scale (VAS) before and after receiving information on adverse effects of smoking on RA. The information provided was about increased risk of RA, severe disease and poor response to DMARD. Results 100 unselected patients completed the questionnaire: 74% female; 46% RA; 22% current smokers; 37% never smokers; 41% ex-smokers. 68% of patients in all categories had attended secondary school. A higher proportion of never smokers had attended University compared with current smokers [20% (8/37) vs. 5% (1/22)]. A higher proportion of current smokers were unemployed as compared with never smokers [32% (7/22) vs. 8% (3/37)]. 50% of patients stated that they had never asked about smoking during consultations. When asked how important smoking is in arthritis, 55% of all patients scored >8/10 on a VAS (0=not bad /10=very bad). There was no significant difference in understanding the importance of smoking on arthritis between current smokers (VAS mean; SD 7.06; 2.35) and never smokers (VAS mean; SD 7.37; 2.15) (p=0.115) and between current smokers and ex-smokers (Mean; SD 7.74; 1.87) (p=0.23). 73% (16/22) of current smokers motivation to give up smoking score increased after they were given information on adverse effects of smoking on RA (mean VAS 4.43 before; 5.79 after) (p=0.03). 27% (6/22) did not change, none decreased. 50% (11/22) of patients felt lack of support and help prevented them stopping smoking. Preferred methods for smoking cessation help were: leaflets 41%; verbal advice 9%; GP review 18%. 54% (22/41) of ex-smokers were happy to speak to the current smokers to provide tips on stopping smoking. Conclusions This small study suggests that brief educational intervention may help motivate patients to give up smoking. Lack of support is a common difficulty patients perceive when they try to give up smoking. As RA outcomes are worsened by smoking, clinicians need to be more proactive about promoting smoking cessation. Outpatient appointments provide a good opportunity for this. Disclosure of Interest None declared
Annals of the Rheumatic Diseases
Background We introduced a nurse led Rheumatology Advice Line in 2004 to offer telephone advice t... more 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
Annals of the Rheumatic Diseases
Background Herpes Zoster infection is a common and painful condition with potential for serious c... more 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
Rheumatology
Background: A high proportion of patients with SS have systemic features at some point in the cou... more Background: A high proportion of patients with SS have systemic features at some point in the course of their condition, with the highest prevalence historically reported in the anti-Ro/La-positive group. We reviewed our own well-characterized cohort of patients with primary SS to determine the frequency of clinically significant systemic features. Methods: We undertook a retrospective case note review to determine the prevalence of significant systemic associations. All patients satisfied the American-European Consensus Group (AECG) criteria and were either Ro antibody positive and/or had a positive minor salivary gland biopsy. Results: The cohort included a total of 245 patients and was comprised of 164 Ro þ (13 males, 151 females) and 81 Ro À but lip biopsy-positive patients (7 males, 74 females). Systemic disease was reported in 91 (55.5%) of the antibody-positive and 44 (54%) of the antibody-negative group. Some patients had more than one systemic complication. The prevalence of thyroid disease, lung involvement, liver disease, renal involvement, coeliac disease and osteoporosis were similar in both patient populations (see Table 1). Subacute cutaneous lupus (SCLE), immune thrombocytopaenia (ITP), myositis, monoclonal gammopathy of uncertain significance (MGUS), lymphoma, corneal melt and renal stones were seen only in the antibody-positive group. However, neurological disease was observed
Rheumatology
Background: Smoking has been associated with increased risk of developing RA, more severe disease... more Background: Smoking has been associated with increased risk of developing RA, more severe disease and poor response to DMARDs. Giving up smoking is difficult and requires awareness of the ill effects of smoking, motivation, self-confidence and support. We looked at the effect on patient motivation for giving up smoking through a process of creating awareness of the ill effects of smoking. Methods: We surveyed rheumatology outpatients with an anonymous questionnaire of demographics, smoking status, education status, employment status and awareness of the ill effects of smoking. Motivation to stop smoking was assessed on a 10 cm visual analogue scale (VAS) before and after receiving information on the adverse effects of smoking on RA. The information provided included the increased risk of RA, the severity of disease and poor response to DMARDs. Results: Eighty-two unselected patients completed the questionnaire; 61 (74%) were female and 42 (51%) had RA. Nineteen (23%) were current smokers, 30 (37%) were never smokers and 33 (40%) were exsmokers. Sixty-five per cent of patients in all categories had attended secondary school. Never smokers had attended university more often compared with current smokers [20% (6/30) vs 5% (1/19), P ¼ 0.07]. More current smokers were unemployed compared with never smokers [37% (7/19) vs 6% (2/30), P ¼ 0.0039]. Fifty-two per cent (43/82) of patients felt that they were never asked about smoking status during consultations. Using a VAS asking how important smoking is in arthritis, 55% (45/82) of patients scored >8/10 (0 ¼ not bad, 10 ¼ very bad). There was no significant difference in understanding the importance of smoking on arthritis between current smokers and never smokers (P ¼ 0.18) and between current smokers and ex-smokers (P ¼ 0.58) (Table 1). Seventy-four per cent (14/19) of current smokers showed an improvement in motivation to give up smoking after they were given information on the adverse effects of smoking on RA (mean VAS 4.17 before vs 6.17 after, P < 0.01), while 26% (5/19) showed no improvement. No patient had decreased motivation. Fifty-three per cent (10/19) of patients felt a lack of support and help prevented them from stopping smoking. Thirty-seven per cent of patients wanted smoking cessation advice via leaflets, 10% preferred verbal advice and 16% wanted to see a general practitioner. Fifty-five per cent (18/33) of ex-smokers were happy to speak to current smokers to provide tips on stopping smoking.
Rheumatology
Background: There remains very limited evidence on which to base therapy for the treatment of pat... more Background: There remains very limited evidence on which to base therapy for the treatment of patients with RA-related interstitial lung
Rheumatology
Background: Anti-TNF therapy increases the risk of reactivation of tuberculosis (TB). Pre-treatme... more Background: Anti-TNF therapy increases the risk of reactivation of tuberculosis (TB). Pre-treatment screening should include a clinical examination, history of any prior TB, a chest radiograph and, if appropriate, a tuberculin skin test (TST). For patients on immunosuppressive therapy, a TST is not helpful due to false negatives. Therefore for immunosuppressed patients British Thoracic Society (BTS) guidelines recommend an individual risk assessment is made; if the annual risk of TB is greater than the risk of drug-induced hepatitis, then i114 Wednesday
Rheumatology
Background: Plasma exchange offers the quickest short-term answer by removing harmful autoantibod... more Background: Plasma exchange offers the quickest short-term answer by removing harmful autoantibodies and immune complexes in Behç et's disease. Methods: A 67 year old woman who initially presented generally unwell with multiple purpuric vasculitic areas involving hard palate, nose, face, flanks and limbs. The lesions became necrotic and large areas of tissue were lost. She also developed swelling of the left orbit with proptosis. She was treated with broad spectrum antibiotics for presumed infection within the left eye. Her initial ophthalmology review suggested uveitis complicating vasculitis and she was treated with i.v. methylprednisolone pulses. She was then treated with three cycles of plasma exchange and i.v. CYC pulses. A diagnosis of probable Behç et's was made on the basis of pathergy, vasculitis, uveitis and oral ulceration. She had plastic surgical input for wound management and skin grafting. She also had left orbital extraction as her eye could not be saved. Then she developed deep vein thrombosis in right leg and treated with warfarin. She was discharged home after a period of rehabilitation and remained reasonably well on prednisolone and AZA. Nine months after this episode, she had a relapse of her vasculitis in her foot with ulceration and i.v. CYC was restarted within 2 days of the
Rheumatology, Apr 16, 2024
Rheumatology advances in practice, Apr 18, 2024
Rheumatology, 2016
Background: The evidence base to support treatment decisions in managing patients with RA and rel... more Background: The evidence base to support treatment decisions in managing patients with RA and related interstitial lung disease (ILD) is very limited. In particular, guidance on which biologic therapy to use in patients with active articular disease does not exist. Methods: We obtained data from the British Rheumatoid InterstitiaL Lung (BRILL) network on all patients with RA-ILD whose first biologic was rituximab (RTX). We assessed survival and compared this with patients with RA-ILD who had taken an anti-TNF agent as their first i86 Tuesday
Rheumatology
Background/Aims The Giant Cell Arteritis Score (GCAPS) was developed by the specialist team in So... more Background/Aims The Giant Cell Arteritis Score (GCAPS) was developed by the specialist team in Southend, Essex, UK in 2018. It is a clinically focused tool to aid diagnosis of GCA by providing a pre-test probability, with a threshold of greater than 9 denoting higher risk of GCA requiring further diagnostic testing. So far, it has been validated externally in patients in 2 centres. In all cases, scoring was completed by a rheumatology consultant. We are keen to validate it in our setting, a district general hospital without rapid access to vascular ultrasound, to determine whether it was a valid and reliable tool for assessing which patients required temporal artery biopsy and which patients could rapidly taper steroids following a negative result. We also aimed to see whether scoring could be completed by clinicians other than rheumatology consultants. Methods We retrospectively applied the GCAPS score to all patients referred as possible GCA to our service between November 2021 - ...
Rheumatology Advances in Practice
Introduction/Background Polyarteritis nodosa (PAN) was first described in 1866 as a necrotising v... more Introduction/Background Polyarteritis nodosa (PAN) was first described in 1866 as a necrotising vasculitis predominantly involving medium-sized arteries. It is a multiorgan disorder which can cause a range of symptoms from cutaneous ulcers to gastrointestinal haemorrhage. For many patients, the cause remains elusive, however a close relationship has been demonstrated between PAN and hepatitis B infection. We describe a case of a 45-year-old who presented with acute abdomen to the emergency department. She was admitted under the general surgical team and common surgical conditions were ruled out. Imaging later revealed coeliac and splenic pseudoaneurysm. Description/Method A 45-year-old woman presented with acute epigastric pain. It was colicky in nature and radiated to the right upper quadrant with some associated vomiting. On examination she looked unwell with a tachycardia but normal blood pressure and temperature. The abdomen was rigid with positive Murphy’s sign. There were no j...
BMJ Case Reports, 2021
Abdominal pain is a very common presentation in the accident and emergency department. However, v... more Abdominal pain is a very common presentation in the accident and emergency department. However, vasculitis is not the usual first differential diagnosis. This paper discusses a case of polyarteritis nodosa presenting with acute abdominal pain alone. Common surgical conditions were obviously considered, but they were not found to cause the patient’s problems. We describe how investigations led to this diagnosis discussed in detail in this paper. It is important to remember that prompt recognition of unusual life-threatening conditions can lead to timely intervention.
Rheumatology, 2020
The guideline will be developed using the methods and processes outlined in Creating Clinical Gui... more The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol (1). This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence (NICE) accreditation.
Rheumatology Advances in Practice, 2020
Case report - Introduction We present what we believe to be the first reported case of post COVID... more Case report - Introduction We present what we believe to be the first reported case of post COVID-19 reactive arthritis, in a previously medically well 16-year-old with no past or family history of inflammatory arthritis. Case report - Case description Our patient was a previously medically fit 16-year-old of Caucasian origin who tested positive for COVID-19 in late March 2020. She developed with a 4-day illness with fever, cough, and myalgia from which she made a full and uncomplicated recovery. Ten days later she developed a new erythematous itchy rash on her legs, trunk, and face and a progressive polyarthralgia affecting her MCPs, wrists, shoulders, hips, and knees. The rash typically lasted for 2 days at one site and was non-scarring. This was associated with a low-grade fever. There were no associated mouth ulcers, photosensitivity, alopecia, Raynaud’s, GI disturbance or respiratory symptoms. She had no relevant family history of autoimmunity, psoriasis or inflammatory bowel d...
In contrast to systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), where cardiovasc... more In contrast to systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), where cardiovascular problems are frequent, extra-articular disease manifestations of cardiovascular disease are not commonly reported in patients with Sjögren’s syndrome (SS), and SS disease-activity measures do not feature cardiovascular disease. The prevalence appears to be higher than in the general population but lower than in RA and SLE populations, possibly due to the lower prevalence of smoking among the SS population. In contrast, respiratory disease is a well-recognized complication of SS. In this chapter cardiovascular and lung manifestations of SS mechanisms are discussed, together with therapies, as well as long-term complications including lymphoma and amyloidosis.
Introduction: The first few months after symptom onset represents a pathologically distinct phase... more Introduction: The first few months after symptom onset represents a pathologically distinct phase in rheumatoid arthritis (RA). We used relevant experimental models to define the pathological role of interferon-γ (IFN-γ) during early inflammatory arthritis. Methods: We studied IFN-γ's capacity to modulate interleukin-1β (IL-1β) induced degenerative responses using RA fibroblast-like synoviocytes (FLS), a bovine articular cartilage explant (BACE)/RA-FLS co-culture model and an experimental inflammatory arthritis model (murine antigen-induced arthritis (AIA)). Results: IFN-γ modulated IL-1β driven matrix metalloproteinases (MMP) synthesis resulting in the down-regulation of MMP-1 and MMP-3 production in vitro. IFN-γ did not affect IL-1β induced tissue inhibitor of metalloproteinase-1 (TIMP-1) production by RA FLS but skewed the MMP/TIMP-1 balance sufficiently to attenuate glycosaminoglycan-depletion in our BACE model. IFN-γ reduced IL-1β expression in the arthritic joint and preve...
Rheumatology, Apr 1, 2018
Recent years have seen an upsurge in clinical trial activity in primary Sjö gren's syndrome. This... more Recent years have seen an upsurge in clinical trial activity in primary Sjö gren's syndrome. This session will provide an update on ongoing trials, explore the rationale behind the investigational therapies and discuss recent trial data. Disclosures: The author has declared no conflicts of interest.
Annals of the Rheumatic Diseases
Background Smoking has been associated with an increased risk of developing rheumatoid arthritis ... more Background Smoking has been associated with an increased risk of developing rheumatoid arthritis (RA), more severe disease and poor response to disease modifying drugs (DMARD). Motivation is the most important aspect of giving up smoking and also awareness of its ill-effects, self-confidence and support. Objectives We have looked at the immediate effect on patient motivation to stop smoking by creating awareness of its ill-effects. Methods We surveyed Rheumatology outpatients with an anonymous questionnaire including demographics, smoking status, education status, employment status and awareness of the ill-effects of smoking. Motivation to stop smoking was assessed by 10cm Visual analogue scale (VAS) before and after receiving information on adverse effects of smoking on RA. The information provided was about increased risk of RA, severe disease and poor response to DMARD. Results 100 unselected patients completed the questionnaire: 74% female; 46% RA; 22% current smokers; 37% never smokers; 41% ex-smokers. 68% of patients in all categories had attended secondary school. A higher proportion of never smokers had attended University compared with current smokers [20% (8/37) vs. 5% (1/22)]. A higher proportion of current smokers were unemployed as compared with never smokers [32% (7/22) vs. 8% (3/37)]. 50% of patients stated that they had never asked about smoking during consultations. When asked how important smoking is in arthritis, 55% of all patients scored >8/10 on a VAS (0=not bad /10=very bad). There was no significant difference in understanding the importance of smoking on arthritis between current smokers (VAS mean; SD 7.06; 2.35) and never smokers (VAS mean; SD 7.37; 2.15) (p=0.115) and between current smokers and ex-smokers (Mean; SD 7.74; 1.87) (p=0.23). 73% (16/22) of current smokers motivation to give up smoking score increased after they were given information on adverse effects of smoking on RA (mean VAS 4.43 before; 5.79 after) (p=0.03). 27% (6/22) did not change, none decreased. 50% (11/22) of patients felt lack of support and help prevented them stopping smoking. Preferred methods for smoking cessation help were: leaflets 41%; verbal advice 9%; GP review 18%. 54% (22/41) of ex-smokers were happy to speak to the current smokers to provide tips on stopping smoking. Conclusions This small study suggests that brief educational intervention may help motivate patients to give up smoking. Lack of support is a common difficulty patients perceive when they try to give up smoking. As RA outcomes are worsened by smoking, clinicians need to be more proactive about promoting smoking cessation. Outpatient appointments provide a good opportunity for this. Disclosure of Interest None declared
Annals of the Rheumatic Diseases
Background We introduced a nurse led Rheumatology Advice Line in 2004 to offer telephone advice t... more 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
Annals of the Rheumatic Diseases
Background Herpes Zoster infection is a common and painful condition with potential for serious c... more 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
Rheumatology
Background: A high proportion of patients with SS have systemic features at some point in the cou... more Background: A high proportion of patients with SS have systemic features at some point in the course of their condition, with the highest prevalence historically reported in the anti-Ro/La-positive group. We reviewed our own well-characterized cohort of patients with primary SS to determine the frequency of clinically significant systemic features. Methods: We undertook a retrospective case note review to determine the prevalence of significant systemic associations. All patients satisfied the American-European Consensus Group (AECG) criteria and were either Ro antibody positive and/or had a positive minor salivary gland biopsy. Results: The cohort included a total of 245 patients and was comprised of 164 Ro þ (13 males, 151 females) and 81 Ro À but lip biopsy-positive patients (7 males, 74 females). Systemic disease was reported in 91 (55.5%) of the antibody-positive and 44 (54%) of the antibody-negative group. Some patients had more than one systemic complication. The prevalence of thyroid disease, lung involvement, liver disease, renal involvement, coeliac disease and osteoporosis were similar in both patient populations (see Table 1). Subacute cutaneous lupus (SCLE), immune thrombocytopaenia (ITP), myositis, monoclonal gammopathy of uncertain significance (MGUS), lymphoma, corneal melt and renal stones were seen only in the antibody-positive group. However, neurological disease was observed
Rheumatology
Background: Smoking has been associated with increased risk of developing RA, more severe disease... more Background: Smoking has been associated with increased risk of developing RA, more severe disease and poor response to DMARDs. Giving up smoking is difficult and requires awareness of the ill effects of smoking, motivation, self-confidence and support. We looked at the effect on patient motivation for giving up smoking through a process of creating awareness of the ill effects of smoking. Methods: We surveyed rheumatology outpatients with an anonymous questionnaire of demographics, smoking status, education status, employment status and awareness of the ill effects of smoking. Motivation to stop smoking was assessed on a 10 cm visual analogue scale (VAS) before and after receiving information on the adverse effects of smoking on RA. The information provided included the increased risk of RA, the severity of disease and poor response to DMARDs. Results: Eighty-two unselected patients completed the questionnaire; 61 (74%) were female and 42 (51%) had RA. Nineteen (23%) were current smokers, 30 (37%) were never smokers and 33 (40%) were exsmokers. Sixty-five per cent of patients in all categories had attended secondary school. Never smokers had attended university more often compared with current smokers [20% (6/30) vs 5% (1/19), P ¼ 0.07]. More current smokers were unemployed compared with never smokers [37% (7/19) vs 6% (2/30), P ¼ 0.0039]. Fifty-two per cent (43/82) of patients felt that they were never asked about smoking status during consultations. Using a VAS asking how important smoking is in arthritis, 55% (45/82) of patients scored >8/10 (0 ¼ not bad, 10 ¼ very bad). There was no significant difference in understanding the importance of smoking on arthritis between current smokers and never smokers (P ¼ 0.18) and between current smokers and ex-smokers (P ¼ 0.58) (Table 1). Seventy-four per cent (14/19) of current smokers showed an improvement in motivation to give up smoking after they were given information on the adverse effects of smoking on RA (mean VAS 4.17 before vs 6.17 after, P < 0.01), while 26% (5/19) showed no improvement. No patient had decreased motivation. Fifty-three per cent (10/19) of patients felt a lack of support and help prevented them from stopping smoking. Thirty-seven per cent of patients wanted smoking cessation advice via leaflets, 10% preferred verbal advice and 16% wanted to see a general practitioner. Fifty-five per cent (18/33) of ex-smokers were happy to speak to current smokers to provide tips on stopping smoking.
Rheumatology
Background: There remains very limited evidence on which to base therapy for the treatment of pat... more Background: There remains very limited evidence on which to base therapy for the treatment of patients with RA-related interstitial lung
Rheumatology
Background: Anti-TNF therapy increases the risk of reactivation of tuberculosis (TB). Pre-treatme... more Background: Anti-TNF therapy increases the risk of reactivation of tuberculosis (TB). Pre-treatment screening should include a clinical examination, history of any prior TB, a chest radiograph and, if appropriate, a tuberculin skin test (TST). For patients on immunosuppressive therapy, a TST is not helpful due to false negatives. Therefore for immunosuppressed patients British Thoracic Society (BTS) guidelines recommend an individual risk assessment is made; if the annual risk of TB is greater than the risk of drug-induced hepatitis, then i114 Wednesday
Rheumatology
Background: Plasma exchange offers the quickest short-term answer by removing harmful autoantibod... more Background: Plasma exchange offers the quickest short-term answer by removing harmful autoantibodies and immune complexes in Behç et's disease. Methods: A 67 year old woman who initially presented generally unwell with multiple purpuric vasculitic areas involving hard palate, nose, face, flanks and limbs. The lesions became necrotic and large areas of tissue were lost. She also developed swelling of the left orbit with proptosis. She was treated with broad spectrum antibiotics for presumed infection within the left eye. Her initial ophthalmology review suggested uveitis complicating vasculitis and she was treated with i.v. methylprednisolone pulses. She was then treated with three cycles of plasma exchange and i.v. CYC pulses. A diagnosis of probable Behç et's was made on the basis of pathergy, vasculitis, uveitis and oral ulceration. She had plastic surgical input for wound management and skin grafting. She also had left orbital extraction as her eye could not be saved. Then she developed deep vein thrombosis in right leg and treated with warfarin. She was discharged home after a period of rehabilitation and remained reasonably well on prednisolone and AZA. Nine months after this episode, she had a relapse of her vasculitis in her foot with ulceration and i.v. CYC was restarted within 2 days of the