VASCULITIS DISEASE ACTIVITY SCORES BEFORE AND DURING THE COVID-19 PANDEMIC: A COMPARISON OF FACE-TO-FACE CLINICIAN SCORING AND PROMS COLLECTED USING REMOTE MONITORING IN A SINGLE-CENTRE COHORT

BackgroundDuring the COVID-19 pandemic, asynchronous consultations were introduced for patients with vasculitis. To assess disease activity without of face-to-face clinical reviews and blood testing, patients submitted patient reported outcome measures (PROMs) via electronic survey forms, which were subsequently triaged by clinicians.Objectives1. To investigate how patients' vasculitis disease activity was affected by the COVID-19 pandemic through retrospective comparison of clinician-assessed scores recorded pre-pandemic with intra-pandemic self-reported patient reported outcome measures (PROMs) and disease scores submitted by patients remotely.2. To assess patients' clinical outcomes, including allocation of follow-up and further management/treatment escalation during this period.3. To validate self-reported BVAS scores against an existing PROM.MethodsThis is a retrospectively study of patients with a known diagnosis of vasculitis under the care of the Nuffield Orthopaedic Centre, Oxford. For the purposes of this study, we included patients with all vasculitis diagnoses.Clinician-reported scores (Bristol Vasculitis Activity score v.3, BVAS) were recorded during in-person clinics pre-pandemic (defined as 01/01/2019-31/12/2019) [1].Patients' self-reported BVAS (SR-BVAS) and AAV-PRO (ANCA-associated vasculitis patient-reported outcomes) scores were submitted by patients via electronic forms containing the requisite questionnaires sent out during-pandemic (defined as 01/12/2020-31/03/22) [2].SR-BVAS has not been validated but was collected to allow clinical comparison to disease activity scores completed by clinicians. Response were stored and analysed in a secure database. Score comparison was performed using Wilcoxon Sign Rank testing. Clinical outcome data was collected from the local Electronic Patient Record. Data analysis was performed in Microsoft Excel and R (version 4.2.1).ResultsWe noted a significantly higher overall level of patient-reported disease activity during the pandemic than was recorded in clinics prior. In the total cohort of all vasculitis patients for whom we had data, the median BVAS increased from 2 pre-pandemic (N = 335, range 0-21) to 6 intra-pandemic (N = 143, range 0-42) (p <0.001). The overall proportion of patients with severe/active disease (defined as BVAS ≥4) increased from 27% to 36% during the pandemic period.In a smaller cohort of 64 patients for whom we had paired pre- and during-pandemic scores, increased disease activity was reported (p<0.01). Notably, the number with a BVAS consistent with severe disease increased from 7 (11%) to 19 (30%).There was a significant positive correlation between SR-BVAS and AAV-PRO (r=0.61, p< 0.001) submitted by patients during-pandemic;however, at low BVAS (≤3), the AAV-PRO ranged widely (28-87)Follow-up data was available for all 64 patients in this cohort: 8/19 (42%) with a during-pandemic SR-BVAS ≥4 were seen in clinic within 3 months (telemedicine or face-to-face).ConclusionPatients reported worsening of vasculitis disease activity during the COVID-19 pandemic. This may be attributable to impacts on well-being or access to healthcare services. We note that disease activity scores in vasculitis may be limited in their ability to capture the whole picture disease activity in the absence of clinical assessment [3]. 42% of patients with self-reported high disease activity were seen within 3 months. There was a significant positive correlation between AAV-PRO and SR-BVAS, suggesting it has some use as a PROM.References[1]Mukhtyar C, Lee R, Brown D, Carruthers D, Dasgupta B, Dubey S, et al.. Ann Rheum Dis. 2009 Dec;68(12):1827–32.[2]Malley T, Jackman J, Manderson S, Saldana Pena L, Evans E, Barrett J, et al. Ann Rheum Dis. 2021 Jun 1;80(Suppl 1):289.[3]Luqmani RA. Nephrology Dialysis Transplantation. 2015 Apr 1;30(suppl_1):i76–82.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Using Novel Remote Electronic Monitoring to Measure and Manage the Rheumatology Clinic Backlog Generated by Covid-19

Background/Aims During the COVID-19 pandemic we were unable to provide regular outpatient services for patients with chronic rheumatic diseases. A ''backlog'' of 6812 patients without an allocated follow-up appointment accrued by September 2021. We quantified this cohort and analysed attempts to deliver care remotely (using video, telephone, and electronic remote management forms (RMFs)). Methods We selected a 12-month ''window'' (May 2020-May 2021) and analysed the number of patients awaiting follow-up during this period. This was initially 3259 patients out of the total backlog 6812. We revisited the number of patients remaining in that cohort on four occasions between September 2021 and September 2022: at baseline, then at 1-, 2-, 6- and 12-month intervals. Each audit cycle was conducted using the same methodology. Alongside usual follow up pathways, (face to face, video or telephone), we implemented remote management forms (RMFs) for different disease groups which were designed by the department;they contained a triage questionnaire, including calculation of disease severity scores, and questions about medications. These were sent out by clinicians to some patients in lieu of a telephone, video or face to face appointments. Data from RMFs was stored in a secure database for clinician review. Data analysis performed in Microsoft Excel and R (version 4.2.1). Results The number of patients without allocated follow-up appointments reduced from 3259 to 326 between Sep-21 and Sep-22. This is a 90% reduction in the backlog over a 12-month period, with a 71% reduction achieved by 6 months. There was a significant, progressive reduction in the number of patients over time (p<0.001 - Chi-square test for trend). Of the 1956 RMFs completed between Sep-21 - Mar-22, only 261 patients recorded a previous appointment date. 154/261 (59%) were completed by patients waiting in the ''window'' of May-20 - May- 21. This indicates a preferential use of RMFs targeting backlog patients. Between 2-8% of the total backlog patients were managed using RMFs based on available data. Conclusion We have significantly reduced the size of our backlog of outpatient follow-up due to COVID-19 over a 12-month period. In-addition these results likely underestimate the effect of RMFs due to this dataset being incomplete. Remote management made a sizeable contribution to this reduction, meaning some of this reduction was achieved without face-to-face encounters. The use of 1956 forms over a 6- month period shows robust integration of our RMFs into outpatient services disrupted by COVID-19 and provides evidence for remote management as a useful tool in outpatient management, with relevance to areas such as Patient Initiated Follow Up pathways. Further work is needed to clarify where remote management is best deployed and which patient groups benefit most from this.

Comparing Ankylosing Spondylitis Disease Activity during the Covid-19 Pandemic Using Patient-Reported Outcome Measures with Face-Toface Clinical Evaluation of Disease Scores Prepandemic

Background/Aims During the COVID-19 pandemic, asynchronous consultations were introduced for patients with ankylosing spondylitis (AS). To assess disease activity in the absence of face-to-face clinical review and blood testing, patients submitted patient-reported outcome measures (PROMs) via electronic survey forms which were subsequently triaged by clinicians. We compared pre-pandemic clinician-reported scores with intra-pandemic self-reported scores and assessed clinical outcomes including allocation of follow-up and further management/ treatment escalation. Methods Clinician-reported scores were obtained in-person pre-pandemic (defined as 01/01/2019-01/03/2020). Self-reported BASDAI scores were submitted by patients via electronic forms sent out duringpandemic (defined as 01/12/2020-31/03/22). The responses were stored and analysed in a secure database. These scores are analogous to disease activity scores completed by clinicians during outpatient appointments. Score comparison was performed using Wilcoxon Sign Rank testing. We used the need for a follow-up within 3 months as target for those with severe disease. Data analysis was performed in Microsoft Excel and R (version 4.2.1). Results We noted a significantly higher overall level of patient-reported disease activity during the pandemic. In the total cohort of AS patients, the median BASDAI Score collected during-pandemic increased from 5.30 (n=124, range 0-10) compared to 2.80 pre-pandemic (n=590, range 0-12) (p<0.001). The proportion of patients with severe/active disease (defined as BASDAI >4) increased from 36% pre- to 65% during pandemic. In a smaller cohort of 34 patients for whom we had both pre- and during-pandemic scores, all patient parameters worsened during the pandemic. Notably, median BASDAI increased from 2.65 to 5.62 (p<0.0001). Patients with severe AS increased from 10 (29.4%) to 21 (61.8%) intra-pandemic. Follow-up data was available for 12/21 patients with severe AS during-pandemic. 7/12 patients (58%) received a follow-up appointment within one month;11/12 (91%) were seen within three months. On subsequent clinician assessment, only 7 (58%) of patients with self-reported severe AS were felt to have active disease;treatment was escalated for 3 patients. Conclusion There was a significantly higher reported level of AS disease activity during the COVID-19 pandemic, with 62 % of patients qualifying for biologic therapy (BASDAI >4). In a focussed sample, 91% of patients with new severe disease during-pandemic were followed up within the target of 3 months. The BASDAI score is independent from clinical examination and inflammatory markers, and therefore self-reported score should reliably reflect a patient's perception of disease activity. Further work is required to determine the reason for the increased disease activity observed during pandemic, and for the disparity between clinician impression and score results.

Evaluating the Use of Patient Reported Outcome Measures to Assess Intra-Pandemic Psoriatic Arthritis Disease Activity and Comparing Them with Pre-Pandemic Clinical Assessments

Background/Aims In our department, patient reported outcome measures (PROMs), including RAPID-3 and PSAID12, were employed during the COVID-19 pandemic in asynchronous consultations for patients with psoriatic arthritis (PsA). We compared pre-pandemic DAS28-CRP with intrapandemic PROMs to assess changes in disease activity since the pandemic. Whilst previous studies have primarily compared PsA PROMs with clinician-assessed scores (e.g. PASDAS), we compare PsA PROMs with clinicians' overall assessment of disease activity;this judgement considers PROMs, serology studies and individual patient feedback. Finally, we assess whether patients with PROMs indicating active disease were followed up appropriately. Methods Clinician-assessed scores were collected between 01/01/2019-01/03/ 2020 (''pre-pandemic''). Between 01/12/2020-31/03/2022 (''intrapandemic''), patient data from electronic surveys were analysed in a secure database for calculation of PROMs. These data, alongside blood results and patient comments, informed clinicians' triage decisions. Clinical outcome data were collected from electronic patient records;>=3 months follow-up appointment allocation was the target for patients with active disease (moderate/high disease activity). Data analysis was performed using r (version 4.2.2). Results In our pre-pandemic cohort (n=393), 79.8% of patients were in remission (per DAS28-CRP). Conversely, the intra-pandemic cohort (n=231) showed remission rates of 14.3% (per PSAID12) and 0% (RAPID-3). Indeed, 33.7% (based on PSAID12) vs 75.8% (RAPID-3) had moderate/ high disease activity. These results were validated in a paired cohort (n=38, score recorded in both windows). Disease activity worsened during the pandemic for 63.2% (PSAID12) and 97.4% (RAPID-3) of patients. PSAID-12 correlated positively with RAPID-3 (r=0.52, p<0.001), especially when RAPID-3 >=6.5 (r=0.75, p<0.001). When comparing PROMs with clinicians' assessment of PsA activity in our paired cohort, PSAID12 and RAPID-3 accurately reflected disease status in 70.6% and 58.8% of patients respectively. 3/9 and 9/27 patients with active disease, based on PSAID12 and RAPID-3 respectively, were seen within three months. Conversely, 7/10 patients who clinicians had deemed to have active disease were seen within three months. Conclusion Despite approximately 80% of patients being in pre-pandemic remission, the majority reported active intra-pandemic PsA. Whilst RAPID-3 skewed patients towards active disease, PSAID12 skewed patients towards remission/low disease activity. PSAID-12 and RAPID- 3 have been previously correlated;however, here we suggest that they could be used interchangeably in patients with high disease activity. PSAID-12 was a better predictor of clinicians' assessment of disease activity, although neither PROM correlated well with >=3 months followup appointment allocation. Although RAPID-3 and PSAID12 helped inform clinicians' decisions, neither alone sufficiently reflects patients' disease states. Remote management is practicable, but future studies should validate these findings across a larger cohort and assess the utility of different PROMs across PsA disease activity categories. Furthermore, multivariate analysis is warranted to ascertain which (combination of) variable(s) (e.g., PROMs, serology results, tender/ swollen joint count) best correlates with clinician judgement.

Catastrophic Antiphospholipid Crisis Triggered by Anticoagulant Switch

Case report - Introduction: The COVID-19 pandemic led to drastic changes for some patients on warfarin for venous thromboembolic (VTE) disease and atrial fibrillation. Warfarin monitoring necessitates frequent interaction with healthcare workers, which is sufficiently risky for COVID-19 transmission. As a result, selected patients were swapped over to novel oral anticoagulants (NOACs). Our patient was changed without investigating for antiphospholipid syndrome (APLS);it later transpired he was triple antibody positive. He presented in a crisis and we describe his narrative. Patients on warfarin due to presumed unprovoked venous thromboembolic disease should not be swapped to NOACs without completing, or checking, previous antiphospholipid antibody testing. Case report - Case description: A 73-year-old gentleman presented locally in August 2020 with erythema over the anterolateral surface of his left leg. He was initially treated with antibiotics for presumed cellulitis. Within a few days this lesion became necrotic and rapidly spread. At this point, he was transferred to a tertiary rheumatology centre. Within days to weeks, he developed several necrotic lesions affecting his trunk and limbs, with facial sparing noted. Approximately 30-35% of his whole-body surface became involved. He soon developed an oxygen requirement, with CTPA demonstrating lymphocytic interstitial pneumonitis without evidence of pulmonary emboli (PE). Throughout his admission, he had several other pathologies such as hyponatraemia that required level 2 care and severe noninfectious diarrhoea. Skin biopsy identified thrombotic vasculopathy. Serology confirmed triple positive antiphospholipid antibody status and a dsDNA titre of>400 iU/mL. This was the first-time serology had been undertaken despite a history of three deep vein thrombosis (DVT) episodes and two PE incidents. He had no history of SLE symptoms. His initial management for vasculitis secondary to APLS at the point of limited necrosis consisted of IV methylprednisolone followed by rituximab and PO prednisolone. While there was some delay in the progression of his disease, new areas of necrosis arose, leading to the patient receiving cyclophosphamide. Low molecular weight heparin was used for anticoagulation. This gentleman later developed proteinuria and neurological symptoms, fulfilling the criteria for catastrophic antiphospholipid syndrome. He received plasma exchange, without an improvement. He developed complications from his disease and treatment, including poor wound healing. It became apparent his condition would not improve and active treatments were stopped. He passed away 6 weeks after initial presentation. Prior to his admission to hospital, his warfarin was swapped to a NOAC. This is thought to have been the trigger behind catastrophic thrombosis. Case report - Discussion: After excluding other conditions such as necrotising fasciitis, this gentleman was rapidly started on IV methylprednisolone to halt any further progression. This is because glucocorticoids have the greatest evidence base for managing this poorly understood acute disease manifestation. After this failed to manage his condition, he was given a further immunosuppressive agent in the form of rituximab. This was used after his serology confirmed triple antibody status. It was hoped this would stop any further immunological mediated disease progression. Oral prednisolone was started at 40mg at this stage and kept under review with a tapering schedule. Cyclophosphamide was given within a few days of rituximab, with hope of a quicker onset of action. A careful MDT decision was made on these drug choices, particularly regarding their combined use and appreciating their side effect profiles. Cyclophosphamide has evidence behind its use, especially for those with APLS associated with lupus. While he did not develop any infections related to treatment, his condition progressed. Case reports suggest that plasma exchange can be useful in the management of catastrophic antiphospholipid syndrome, so the team recommen ed this. Consent at this stage became tricky due to his altered mental status, but it was felt he did demonstrate capacity for this specific decision. As his condition did not improve after this level of immunosuppression, the team reached the decision that no other treatments would likely change the outcome. He remained on oral steroids for the remainder of his admission. The other management facet of APLS crises pertains to anticoagulation. Low molecular weight heparin was recommended by the haematologists. His NOAC was stopped after the diagnosis was confirmed. Warfarin was restarted later in his admission given he had been well on this for years. Case report - Key learning points: This fascinating case exemplifies the importance of completing an antiphospholipid antibody screen for patients who present with unprovoked venous thromboembolic disease. NOACs are commonly used anticoagulant medications. Several case reports have demonstrated that patients with antiphospholipid syndrome experience breakthrough thromboembolic events when treated with NOACs. The highest risk is associated with history of arterial thrombosis and those with triple positive antibody status. Three clinical trials have either been completed or are in the process of investigating whether NOACs sufficiently prevent thromboembolic disease in these patients. The TRAPS study compared rivaroxaban to warfarin in those with triple antibody positive antiphospholipid syndrome. The study was terminated early given that higher adverse events were observed in the rivaroxaban arm (19%, n11/59) versus warfarinised patients (3%, n2/61). The RAPS study found no difference in thromboembolic risk and results from the ASTRO-APS study looking into apixaban are awaited. There is insufficient evidence to suggest that NOACs prevent VTE in a similar fashion to warfarin, so many still advocate the use of warfarin. The optimal immune management of this acute complication is not well elucidated, with a shortfall in mechanistic pathological understanding. The conference will generate discussion on this subject matter in detail. During the COVID-19 pandemic, it has been observed for patients to change anticoagulation from warfarin to NOACs. Given NOACs do not require monitoring, this medication change reduces the number of interactions patients have with healthcare services. We postulate this change triggered the crisis in our patient, where we suggest continuation of warfarin would have been ideal. This is due to the history of several unprovoked thromboembolic events without a prior antiphospholipid screen being completed. Dissemination of learning points from this case are imperative to ensure decision-making encompasses patients who may have undiagnosed antiphospholipid syndrome.

Catastrophic Antiphospholipid Crisis Triggered by Anticoagulant Switch

Case report - Introduction: The COVID-19 pandemic led to drastic changes for some patients on warfarin for venous thromboembolic (VTE) disease and atrial fibrillation. Warfarin monitoring necessitates frequent interaction with healthcare workers, which is sufficiently risky for COVID-19 transmission. As a result, selected patients were swapped over to novel oral anticoagulants (NOACs). Our patient was changed without investigating for antiphospholipid syndrome (APLS);it later transpired he was triple antibody positive. He presented in a crisis and we describe his narrative. Patients on warfarin due to presumed unprovoked venous thromboembolic disease should not be swapped to NOACs without completing, or checking, previous antiphospholipid antibody testing. Case report - Case description: A 73-year-old gentleman presented locally in August 2020 with erythema over the anterolateral surface of his left leg. He was initially treated with antibiotics for presumed cellulitis. Within a few days this lesion became necrotic and rapidly spread. At this point, he was transferred to a tertiary rheumatology centre. Within days to weeks, he developed several necrotic lesions affecting his trunk and limbs, with facial sparing noted. Approximately 30-35% of his whole-body surface became involved. He soon developed an oxygen requirement, with CTPA demonstrating lymphocytic interstitial pneumonitis without evidence of pulmonary emboli (PE). Throughout his admission, he had several other pathologies such as hyponatraemia that required level 2 care and severe noninfectious diarrhoea. Skin biopsy identified thrombotic vasculopathy. Serology confirmed triple positive antiphospholipid antibody status and a dsDNA titre of>400 iU/mL. This was the first-time serology had been undertaken despite a history of three deep vein thrombosis (DVT) episodes and two PE incidents. He had no history of SLE symptoms. His initial management for vasculitis secondary to APLS at the point of limited necrosis consisted of IV methylprednisolone followed by rituximab and PO prednisolone. While there was some delay in the progression of his disease, new areas of necrosis arose, leading to the patient receiving cyclophosphamide. Low molecular weight heparin was used for anticoagulation. This gentleman later developed proteinuria and neurological symptoms, fulfilling the criteria for catastrophic antiphospholipid syndrome. He received plasma exchange, without an improvement. He developed complications from his disease and treatment, including poor wound healing. It became apparent his condition would not improve and active treatments were stopped. He passed away 6 weeks after initial presentation. Prior to his admission to hospital, his warfarin was swapped to a NOAC. This is thought to have been the trigger behind catastrophic thrombosis. Case report - Discussion: After excluding other conditions such as necrotising fasciitis, this gentleman was rapidly started on IV methylprednisolone to halt any further progression. This is because glucocorticoids have the greatest evidence base for managing this poorly understood acute disease manifestation. After this failed to manage his condition, he was given a further immunosuppressive agent in the form of rituximab. This was used after his serology confirmed triple antibody status. It was hoped this would stop any further immunological mediated disease progression. Oral prednisolone was started at 40mg at this stage and kept under review with a tapering schedule. Cyclophosphamide was given within a few days of rituximab, with hope of a quicker onset of action. A careful MDT decision was made on these drug choices, particularly regarding their combined use and appreciating their side effect profiles. Cyclophosphamide has evidence behind its use, especially for those with APLS associated with lupus. While he did not develop any infections related to treatment, his condition progressed. Case reports suggest that plasma exchange can be useful in the management of catastrophic antiphospholipid syndrome, so the team recommen ed this. Consent at this stage became tricky due to his altered mental status, but it was felt he did demonstrate capacity for this specific decision. As his condition did not improve after this level of immunosuppression, the team reached the decision that no other treatments would likely change the outcome. He remained on oral steroids for the remainder of his admission. The other management facet of APLS crises pertains to anticoagulation. Low molecular weight heparin was recommended by the haematologists. His NOAC was stopped after the diagnosis was confirmed. Warfarin was restarted later in his admission given he had been well on this for years. Case report - Key learning points: This fascinating case exemplifies the importance of completing an antiphospholipid antibody screen for patients who present with unprovoked venous thromboembolic disease. NOACs are commonly used anticoagulant medications. Several case reports have demonstrated that patients with antiphospholipid syndrome experience breakthrough thromboembolic events when treated with NOACs. The highest risk is associated with history of arterial thrombosis and those with triple positive antibody status. Three clinical trials have either been completed or are in the process of investigating whether NOACs sufficiently prevent thromboembolic disease in these patients. The TRAPS study compared rivaroxaban to warfarin in those with triple antibody positive antiphospholipid syndrome. The study was terminated early given that higher adverse events were observed in the rivaroxaban arm (19%, n11/59) versus warfarinised patients (3%, n2/61). The RAPS study found no difference in thromboembolic risk and results from the ASTRO-APS study looking into apixaban are awaited. There is insufficient evidence to suggest that NOACs prevent VTE in a similar fashion to warfarin, so many still advocate the use of warfarin. The optimal immune management of this acute complication is not well elucidated, with a shortfall in mechanistic pathological understanding. The conference will generate discussion on this subject matter in detail. During the COVID-19 pandemic, it has been observed for patients to change anticoagulation from warfarin to NOACs. Given NOACs do not require monitoring, this medication change reduces the number of interactions patients have with healthcare services. We postulate this change triggered the crisis in our patient, where we suggest continuation of warfarin would have been ideal. This is due to the history of several unprovoked thromboembolic events without a prior antiphospholipid screen being completed. Dissemination of learning points from this case are imperative to ensure decision-making encompasses patients who may have undiagnosed antiphospholipid syndrome.

THE IMPACT of TELEMEDICINE CONSULTATIONS for RHEUMATOID ARTHRITIS, GIANT CELL ARTERITIS, OSTEOARTHRITIS and CRYSTAL ARTHRITIS during COVID19 PANDEMIC

Background: Rheumatology departments across the UK have adapted to the COVID-19 pandemic, implementing novel methods of working via remote consultations. Objectives: We wanted to explore the rates of telemedicine consultations for patients with Rheumatoid Arthritis (RA), Giant cell arteritis (GCA), Osteoarthritis (OA), and Crystal arthritis (CA). We also wanted to check how effective the tele-medicine consultations had been in terms of avoiding the need for a face-to-face appointment. Methods: No telemedicine consultations took place before the COVID-19 pandemic in patients diagnosed with GCA, RA, CA and OA. We assessed the number of telemedicine consultations (telephone or videocall) using data from the departmental database covering September 2020 to December 2021. We analysed the rates of face-to-face versus telemedicine appointments for both new referrals and follow-up consultations. The statistical analysis was conducted using chi-square test. Results: There were 20,648 patients assessed in our department from September 2020 to December 2021. In total 1786 face-to-face and 2079 telemedi-cine consultations were conducted for GCA (18%), RA (66%), OA (13%) and CA (3%). The highest percentage of telemedicine consultations versus face-to-face for new referrals were observed for OA (30% Vs 70%) followed by RA (14% Vs 86%), CA (12% Vs 88%) and GCA (2% Vs 98%) (Table 1). Combining all these conditions, 68% of clinicians felt the telemedicine appointment avoided a face-to-face appointment. However, 33% of clinicians seeing new patients with RA did not feel the telemedicine appointment avoided a face-to-face appointment. In contrast, follow-up appointments were mainly conducted by telemedicine when compared with face-to-face;RA (65% Vs 35%), GCA (53%Vs 47%), OA (51% Vs 49%) and CA (61% Vs 39%). For the follow-ups, an overall majority of 90% of telemedicine consultations avoided the need for a face-to-face appointment, particularly observed for patients with CA and GCA (98% and 93% respectively). We noted that patients with RA were more likely than GCA to have a telemedicine follow-up (p value<0.00001). Conclusion: Telemedicine appointments for new referrals and follow-up patients with Rheumatological diagnoses has been a new development because of COVID-19 pandemic. Our analysis shows that most of our new RA, GCA, OA, and CA referrals are still being seen face-to-face but most follow-up appointments are telemedicine consultations. In most cases, clinicians felt that telemed-icine consultations avoided the need for a face-to-face appointment.

A REDUCTION in NEW REFERRALS for RHEUMATOID ARTHRITIS, OSTEOARTHRITIS and CRYSTAL ARTHRITIS COMPARED to GCA during COVID19 PANDEMIC

Background: The COVID-19 pandemic has had profound effects on the Rheumatology department;we wanted to see if consequently referrals for Rheumatoid arthritis (RA), Crystal Arthritis (CA), Osteoarthritis (OA) and Giant cell arteritis (GCA) were affected. A greater understanding of the impact may enable adequate number of clinics and resources to be made available where needed. Objectives: To evaluate the impact of COVID-19 pandemic on volume of new referrals to the Rheumatology department for RA, CA, OA and GCA. Methods: A retrospective analysis of data was conducted from the period of January 2016 to December 2021. The Rheumatology department database was closely analysed and information about new referrals for GCA, RA, OA and CA were evaluated. Statistical analysis was conducted using t-test to compare the mean value pre and during the COVID19 outbreak (2020). Results: From 2016 to 2021 a total number of 9998 new patients were referred to the Rheumatology department. There were 2768 new referrals for GCA (15%), RA (34%), OA (40%) and CA (11%) made during this period. In 2020, there was a signifcant decrease in OA, RA and CA referrals (p value 0.000004, 0.00017, 0.0042 respectively) but an insignifcant decrease in GCA referrals (p value 0.243). Conclusion: During COVID19 pandemic in 2020 there was a signifcant reduction in the number of new referrals for RA, OA, and CA in contrast to GCA where the referrals have been constant. This may be due to the detrimental consequences of untreated GCA with regards to risk of sight loss. However, with less RA referrals, this may result in a delayed diagnosis with an impact on the disease course.

Remote clinical management: Incorporating electronic assessment of patients with rheumatic diseases into standard clinical pathways during the COVID-19 pandemic: A pilot study

Background: Many patients with rheumatic disease require immunosuppressive medication putting them at high risk of COVID-19 infection. Reduced staffing in rheumatology due to redeployment to COVID-19 work, limited out patient capacity and patient vulnerability have had a major impact on our ability to review our patients to assess their condition and treatment (by face-to-face, video or telephone consultations). Novel strategies are essential to safely and effectively treat patients with rheumatic disease whilst minimising their risk of exposure to COVID-19 infection. Objectives: The objective was to develop a digital solution to help deliver safe, efficient and effective care for patients with rheumatic diseases. The aim was to produce a system that allowed us to integrate data recorded directly by patients with information held in our electronic health records to provide a virtual review of care. Methods: An online questionnaire was used to collect clinical information, including validated disease activity measures, to conduct a remote assessment in 175 patients awaiting follow-up appointments. This assessment was integrated within our electronic health records (EHR). The questionnaire contained measures of disease activity (DAS28 or BASDAI);patient reported outcomes;patient preferences regarding the urgency and type of appointment;any recent problems or changes in medication. This information was imported into a database for clinician review, together with previous clinical records and results of relevant investigations, to inform clinical decisions and to decide on the safest and most appropriate timing for follow-up. Report letters were sent to the patient and their primary care providers. Results: Of the 175 patients (149 with RA and 26 with AS), 108 patients (89/149 [60%] with RA [mean age=64;female=65%] and 19/26 [73%] with AS [mean age=45;female=54%]) submitted responses over a 6-week period based on which clinical decisions were made. The mean questionnaire completion time was 19 minutes for RA responders and 16 minutes for AS responders. Non responders (67/175 [mean age=61;female=63%]) remained on our list of patients awaiting follow-up arrangements to be made. Sixty-nine responders (64%) had stable disease therefore did not require any changes to their treatment and were offered an appointment within the next 6 months, of whom 12 (11%) requested face-to-face follow-up. Of the remaining 39 -with less stable disease -requiring more rapid follow-up assessment, 22 patients (56%) required a face-to-face consultation to consider treatment change. So far 9 of these patients have had follow-up, of whom 6 necessitated treatment escalation (Methotrexate increase n=2;anti-inflammatory increase n=2;intramuscular steroid n=1;anti-TNF escalation n=1). Thirty-nine patients (36%) provided feedback on the process of completing the questionnaire, 85% of whom used a mobile phone and the remainder used a computer or tablet. The majority (70%) found it “extremely easy” or 'somewhat“extremely difficult” 0%. Conclusion: We have created and tested a system of remote clinical management for patients with RA and AS. Amongst the 108 responders, just 31% required a face-to-face appointment, with treatment changes made accordingly. With a backlog of 3,800 awaiting allocation to follow-up appointments, remote clinical management will allow us to safely and efficiently prioritise patients requiring urgent follow-up for treatment optimisation. We will integrate this system into our standard care pathway beyond the COVID-19 pandemic to streamline our service, deliver effective care and provide evidence to support the use of costly biologic drugs.1 We plan to investigate the barriers for non-responders.

An evaluation of a daily fast-track diagnosticultrasound service for patients with suspected newonset giant cell arteritis during the COVID-19pandemic

Background/AimsCOVID-19 has reinforced the necessity for a faster and more accuratediagnostic pathway for suspected giant cell arteritis (GCA) patients sothat unnecessary use of glucocorticoids can be avoided/minimised.During the COVID-19 pandemic, we replaced a twice weekly servicewith a 5 day per week ultrasound-based fast-track pathway within asecondary/tertiary hospital. The aim was to determine the impact of amore frequent diagnostic service for GCA, based on rapid access toultrasound and clinical evaluation on the diagnostic certainty inevaluating patients with newly suspected GCA.MethodsWe reviewed records from patients referred between November 2019to July 2020, comparing those seen during 17 weeks 'pre-COVID', using the twice weekly service, with patients seen during 17 weeks of a5 day per week service, termed 'intra-COVID'. All patients underwentclinical evaluation and an eight-site ultrasound of temporal and axillaryarteries. Those with hypoechoic, non-compressible peri-luminalarterial wall-thickening (or halo sign) were considered ultrasound'positive'.ResultsWe audited 139 patients with suspected GCA (63 pre-COVID period vs76 intra-COVID). A clinical diagnosis of GCA was made in 33.3% preCOVID and 42% intra-COVID (p = 0.289). Ultrasound sensitivityimproved from 38.1% to 68.6% (p < 0.0001), whilst specificity remainedunchanged (100%, p < 0.0001) for both periods. The proportion ofpatients seen within seven days of referral improved by 61.6%(p < 0.0001), from 31.7% (pre-COVID) to 93.3% (intra-COVID). Themedian number of days from referral to assessment fell over four-fold, from 12.5 (interquartile range [IQR]=8.25) to 3 (IQR=3.5) respectively.Median number of days of steroid exposure fell over seven-fold from 15days (IQR=11.25) pre-COVID to 2 days (IQR=5) intra-COVID.Similar proportions in both periods were empirically commenced onsteroids prior to assessment (71% vs 68% respectively, p= 0.700).Mean number of 'halos' increased from 0.25 (standard deviation[SD]1.19) pre-COVID to 3.05 (SD= 1.82) intra-COVID. The was nosignificant difference in the number of GCA visual complications(p = 0.894). Ultrasound positivity was associated with fewer days ofsteroid exposure: the median number of days on steroids innegative versus positive scans was 16 and 5.5 (pre-COVID);compared to 2.5 and 1 days (intra-COVID). The proportion of patientswithout GCA who were empirically commenced on steroids reducedfrom 71.4% to 56.8% (pre-COVID vs intra-COVID, p = 0.158) andmedian days steroid exposure reduced from 9.5 (IQR=17.5) to 1(IQR=5), respectively.ConclusionA regular, daily ultrasound service for diagnosing suspected GCAsignificantly improved diagnostic accuracy and reduced unnecessarysteroid exposure in patients who did not have GCA. The sensitivity ofultrasound improved by 30.5% and the delay from steroid exposure todiagnosis was reduced by 76%. An ultrasound-based daily fast-trackservice significantly improved the diagnostic certainty of suspectedGCA, especially during the COVID-19 pandemic when availability oftemporal artery biopsy was very limited.

Treatment of Giant Cell Arteritis and Takayasu Arteritis-Current and Future.

PURPOSE OF REVIEW: Guidelines for the management of large vessel vasculitides have been recently updated by several scientific societies. We have evaluated the current recommendations for treatment of giant cell arteritis (GCA) and Takayasu arteritis (TA) and addressed potential future therapeutic strategies. RECENT FINDINGS: While glucocorticoids (GCs) remain the gold standard for induction of remission, many patients relapse and acquire high cumulative GC exposure. Thus, GC-sparing therapies such as methotrexate are recommended for selected patients with GCA and all patients with TA. Recent high-quality evidence shows that tocilizumab is an effective GC-sparing agent in GCA. Non-biologic and biologic immunomodulators also appear to have GC-sparing properties in TA. Tocilizumab is now considered to be part of the standard treatment for GCA, particularly with relapsing disease, but questions on its use such as length of treatment and monitoring of disease activity remain open. High-quality evidence to guide treatment of TA is still lacking.