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Sidgwick GP, Weston R, Mahmoud AM, Schiro A, Serracino-Inglott F, Tandel SM, Skeoch S, Bruce IN, Jones AM, Alexander MY, Wilkinson FL. Novel Glycomimetics Protect against Glycated Low-Density Lipoprotein-Induced Vascular Calcification In Vitro via Attenuation of the RAGE/ERK/CREB Pathway. Cells 2024; 13:312. [PMID: 38391925 PMCID: PMC10887290 DOI: 10.3390/cells13040312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
Heparan sulphate (HS) can act as a co-receptor on the cell surface and alterations in this process underpin many pathological conditions. We have previously described the usefulness of mimics of HS (glycomimetics) in protection against β-glycerophosphate-induced vascular calcification and in the restoration of the functional capacity of diabetic endothelial colony-forming cells in vitro. This study aims to investigate whether our novel glycomimetic compounds can attenuate glycated low-density lipoprotein (g-LDL)-induced calcification by inhibiting RAGE signalling within the context of critical limb ischemia (CLI). We used an established osteogenic in vitro vascular smooth muscle cell (VSMC) model. Osteoprotegerin (OPG), sclerostin and glycation levels were all significantly increased in CLI serum compared to healthy controls, while the vascular calcification marker osteocalcin (OCN) was down-regulated in CLI patients vs. controls. Incubation with both CLI serum and g-LDL (10 µg/mL) significantly increased VSMC calcification vs. controls after 21 days, with CLI serum-induced calcification apparent after only 10 days. Glycomimetics (C2 and C3) significantly inhibited g-LDL and CLI serum-induced mineralisation, as shown by a reduction in alizarin red (AR) staining and alkaline phosphatase (ALP) activity. Furthermore, secretion of the osteogenic marker OCN was significantly reduced in VSMCs incubated with CLI serum in the presence of glycomimetics. Phosphorylation of cyclic AMP response element-binding protein (CREB) was significantly increased in g-LDL-treated cells vs. untreated controls, which was attenuated with glycomimetics. Blocking CREB activation with a pharmacological inhibitor 666-15 replicated the protective effects of glycomimetics, evidenced by elevated AR staining. In silico molecular docking simulations revealed the binding affinity of the glycomimetics C2 and C3 with the V domain of RAGE. In conclusion, these findings demonstrate that novel glycomimetics, C2 and C3 have potent anti-calcification properties in vitro, inhibiting both g-LDL and CLI serum-induced VSMC mineralisation via the inhibition of LDLR, RAGE, CREB and subsequent expression of the downstream osteogenic markers, ALP and OCN.
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Affiliation(s)
- Gary P. Sidgwick
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
| | - Ria Weston
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
| | - Ayman M. Mahmoud
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
| | - Andrew Schiro
- Cardiovascular Research Institute, University of Manchester, Manchester M13 9PL, UK;
- Vascular Unit, Manchester University Hospitals NHS Foundation Trust, Manchester M13 9WL, UK
| | - Ferdinand Serracino-Inglott
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
- Cardiovascular Research Institute, University of Manchester, Manchester M13 9PL, UK;
- Vascular Unit, Manchester University Hospitals NHS Foundation Trust, Manchester M13 9WL, UK
| | - Shikha M. Tandel
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
| | - Sarah Skeoch
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester M13 9PL, UK; (S.S.); (I.N.B.)
- National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9PL, UK
- Royal National Hospital for Rheumatic Diseases, Bath BA1 1RL, UK
| | - Ian N. Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester M13 9PL, UK; (S.S.); (I.N.B.)
- National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9PL, UK
| | - Alan M. Jones
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
- School of Pharmacy, University of Birmingham, Birmingham B15 2TT, UK
| | - M. Yvonne Alexander
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
| | - Fiona L. Wilkinson
- Department of Life Sciences, Manchester Metropolitan University, Manchester M1 5GD, UK (R.W.); (A.M.M.); (F.S.-I.); (S.M.T.); (A.M.J.); (M.Y.A.)
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Md Yusof MY, Smith EMD, Ainsworth S, Armon K, Beresford MW, Brown M, Cherry L, Edwards CJ, Flora K, Gilman R, Griffiths B, Gordon C, Howard P, Isenberg D, Jordan N, Kaul A, Lanyon P, Laws PM, Lightsone L, Lythgoe H, Mallen CD, Marks SD, Maxwell N, Moraitis E, Nash C, Pepper RJ, Pilkington C, Psarras A, Rostron H, Skeates J, Skeoch S, Tremarias D, Wincup C, Zoma A, Vital EM. Management and treatment of children, young people and adults with systemic lupus erythematosus: British Society for Rheumatology guideline scope. Rheumatol Adv Pract 2023; 7:rkad093. [PMID: 38058676 PMCID: PMC10695902 DOI: 10.1093/rap/rkad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/20/2023] [Indexed: 12/08/2023] Open
Abstract
The objective of this guideline is to provide up-to-date, evidence-based recommendations for the management of SLE that builds upon the existing treatment guideline for adults living with SLE published in 2017. This will incorporate advances in the assessment, diagnosis, monitoring, non-pharmacological and pharmacological management of SLE. General approaches to management as well as organ-specific treatment, including lupus nephritis and cutaneous lupus, will be covered. This will be the first guideline in SLE using a whole life course approach from childhood through adolescence and adulthood. The guideline will be developed with people with SLE as an important target audience in addition to healthcare professionals. It will include guidance related to emerging approved therapies and account for National Institute for Health and Care Excellence Technology Appraisals, National Health Service England clinical commissioning policies and national guidance relevant to SLE. The guideline will be developed using the methods and rigorous processes outlined in 'Creating Clinical Guidelines: Our Protocol' by the British Society for Rheumatology.
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Affiliation(s)
- Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Eve M D Smith
- Department of Women’s and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | | | - Kate Armon
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michael W Beresford
- Department of Women’s and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | | | - Lindsey Cherry
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Christopher J Edwards
- Musculoskeletal Research Unit, NIHR Southampton Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Kalveer Flora
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Rebecca Gilman
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Natasha Jordan
- Department of Adolescent Rheumatology, St James’s Hospital and Children’s Health Ireland, Dublin, Ireland
| | - Arvind Kaul
- Department of Rheumatology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Peter Lanyon
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Laws
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Liz Lightsone
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Christian D Mallen
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Elena Moraitis
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Department, University College of London Great Ormond Street Institute of Child Health, London, UK
| | - Clare Nash
- Pharmacy Department, Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Ruth J Pepper
- Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Antonios Psarras
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Heather Rostron
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jade Skeates
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | - Chris Wincup
- Department of Clinical and Academic Rheumatology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Asad Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Astley JR, Biancardi AM, Hughes PJC, Marshall H, Collier GJ, Chan H, Saunders LC, Smith LJ, Brook ML, Thompson R, Rowland‐Jones S, Skeoch S, Bianchi SM, Hatton MQ, Rahman NM, Ho L, Brightling CE, Wain LV, Singapuri A, Evans RA, Moss AJ, McCann GP, Neubauer S, Raman B, Wild JM, Tahir BA. Implementable Deep Learning for Multi-sequence Proton MRI Lung Segmentation: A Multi-center, Multi-vendor, and Multi-disease Study. J Magn Reson Imaging 2023; 58:1030-1044. [PMID: 36799341 PMCID: PMC10946727 DOI: 10.1002/jmri.28643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Recently, deep learning via convolutional neural networks (CNNs) has largely superseded conventional methods for proton (1 H)-MRI lung segmentation. However, previous deep learning studies have utilized single-center data and limited acquisition parameters. PURPOSE Develop a generalizable CNN for lung segmentation in 1 H-MRI, robust to pathology, acquisition protocol, vendor, and center. STUDY TYPE Retrospective. POPULATION A total of 809 1 H-MRI scans from 258 participants with various pulmonary pathologies (median age (range): 57 (6-85); 42% females) and 31 healthy participants (median age (range): 34 (23-76); 34% females) that were split into training (593 scans (74%); 157 participants (55%)), testing (50 scans (6%); 50 participants (17%)) and external validation (164 scans (20%); 82 participants (28%)) sets. FIELD STRENGTH/SEQUENCE 1.5-T and 3-T/3D spoiled-gradient recalled and ultrashort echo-time 1 H-MRI. ASSESSMENT 2D and 3D CNNs, trained on single-center, multi-sequence data, and the conventional spatial fuzzy c-means (SFCM) method were compared to manually delineated expert segmentations. Each method was validated on external data originating from several centers. Dice similarity coefficient (DSC), average boundary Hausdorff distance (Average HD), and relative error (XOR) metrics to assess segmentation performance. STATISTICAL TESTS Kruskal-Wallis tests assessed significances of differences between acquisitions in the testing set. Friedman tests with post hoc multiple comparisons assessed differences between the 2D CNN, 3D CNN, and SFCM. Bland-Altman analyses assessed agreement with manually derived lung volumes. A P value of <0.05 was considered statistically significant. RESULTS The 3D CNN significantly outperformed its 2D analog and SFCM, yielding a median (range) DSC of 0.961 (0.880-0.987), Average HD of 1.63 mm (0.65-5.45) and XOR of 0.079 (0.025-0.240) on the testing set and a DSC of 0.973 (0.866-0.987), Average HD of 1.11 mm (0.47-8.13) and XOR of 0.054 (0.026-0.255) on external validation data. DATA CONCLUSION The 3D CNN generated accurate 1 H-MRI lung segmentations on a heterogenous dataset, demonstrating robustness to disease pathology, sequence, vendor, and center. EVIDENCE LEVEL 4. TECHNICAL EFFICACY Stage 1.
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Affiliation(s)
- Joshua R. Astley
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
- Department of Oncology and MetabolismThe University of SheffieldSheffieldUK
| | - Alberto M. Biancardi
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Paul J. C. Hughes
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Helen Marshall
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Guilhem J. Collier
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Ho‐Fung Chan
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Laura C. Saunders
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Laurie J. Smith
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Martin L. Brook
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
| | - Roger Thompson
- Sheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | | | - Sarah Skeoch
- Royal National Hospital for Rheumatic DiseasesRoyal United Hospital NHS Foundation TrustBathUK
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Sciences CentreManchesterUK
| | | | | | - Najib M. Rahman
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC)University of OxfordOxfordUK
| | - Ling‐Pei Ho
- MRC Human Immunology UnitUniversity of OxfordOxfordUK
| | - Chris E. Brightling
- The Institute for Lung Health, NIHR Leicester Biomedical Research CentreUniversity of LeicesterLeicesterUK
| | - Louise V. Wain
- The Institute for Lung Health, NIHR Leicester Biomedical Research CentreUniversity of LeicesterLeicesterUK
- Department of Health sciencesUniversity of LeicesterLeicesterUK
| | - Amisha Singapuri
- The Institute for Lung Health, NIHR Leicester Biomedical Research CentreUniversity of LeicesterLeicesterUK
| | - Rachael A. Evans
- University Hospitals of Leicester NHS TrustUniversity of LeicesterLeicesterUK
| | - Alastair J. Moss
- The Institute for Lung Health, NIHR Leicester Biomedical Research CentreUniversity of LeicesterLeicesterUK
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
| | - Gerry P. McCann
- The Institute for Lung Health, NIHR Leicester Biomedical Research CentreUniversity of LeicesterLeicesterUK
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC)University of OxfordOxfordUK
| | - Betty Raman
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC)University of OxfordOxfordUK
| | | | - Jim M. Wild
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
- Insigneo Institute for In Silico MedicineThe University of SheffieldSheffieldUK
| | - Bilal A. Tahir
- POLARIS, Department of Infection, Immunity & Cardiovascular DiseaseThe University of SheffieldSheffieldUK
- Department of Oncology and MetabolismThe University of SheffieldSheffieldUK
- Insigneo Institute for In Silico MedicineThe University of SheffieldSheffieldUK
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Mulhearn B, Ellis J, Skeoch S, Pauling J, Tansley S. Incidence of giant cell arteritis is associated with COVID-19 prevalence: A population-level retrospective study. Heliyon 2023; 9:e17899. [PMID: 37483752 PMCID: PMC10359857 DOI: 10.1016/j.heliyon.2023.e17899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023] Open
Abstract
Background Following the first wave of the COVID-19 pandemic, it was observed that giant cell arteritis (GCA) diagnoses increased at the Royal National Hospital for Rheumatic Diseases (RNHRD) in Bath, UK. This finding may support the viral aetiology hypothesis of GCA. Better understanding of the causes of GCA may help improve diagnostic and treatment strategies leading to better outcomes for patients. Objectives The study aims to estimate the local incidence of GCA during the early COVID-19 pandemic (2020-2021) and compare it to pre-pandemic (2015-2019) data. This study will also evaluate the temporal relationship between COVID-19 infections and GCA diagnoses. Methods Annual incidence rates of GCA were calculated between 2015 and 2021. Local COVID-19 prevalence was estimated by measuring the number of hospital beds taken up by COVID-19 positive patients. Poisson statistics were used to compare the annual mean incidence of GCA between 2019 and 2020, and Granger causality tested the temporal relationship between COVID-19 prevalence and GCA incidence. Results There were 60 (95% confidence interval [CI] 46-77) GCA diagnoses made in 2020 compared to 28 (CI 19-41) in 2019 (P = 0.016). Peaks in the number of COVID-19 inpatients correlated with peaks in GCA diagnoses. Granger causality testing found a statistically significant association between these peaks with a lag period of 40-45 days. Conclusion The incidence of GCA in Bath was significantly increased in 2020 and 2021 compared to 2015-2019. The lag period between peaks was 40-45 days, suggesting that the COVID-19 virus may be a precipitating factor for GCA. More work is currently underway to interrogate the causal relationship between these two diseases.
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Affiliation(s)
- Ben Mulhearn
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK
- Department of Life Sciences, The University of Bath, Claverton Down, Bath, BA2 7AY, UK
| | - Jessica Ellis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK
- Department of Life Sciences, The University of Bath, Claverton Down, Bath, BA2 7AY, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK
- Department of Life Sciences, The University of Bath, Claverton Down, Bath, BA2 7AY, UK
| | - John Pauling
- Department of Life Sciences, The University of Bath, Claverton Down, Bath, BA2 7AY, UK
- North Bristol Hospital NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Sarah Tansley
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK
- Department of Life Sciences, The University of Bath, Claverton Down, Bath, BA2 7AY, UK
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Tibiletti M, Eaden JA, Naish JH, Hughes PJC, Waterton JC, Heaton MJ, Chaudhuri N, Skeoch S, Bruce IN, Bianchi S, Wild JM, Parker GJM. Imaging biomarkers of lung ventilation in interstitial lung disease from 129Xe and oxygen enhanced 1H MRI. Magn Reson Imaging 2023; 95:39-49. [PMID: 36252693 DOI: 10.1016/j.mri.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare imaging biomarkers from hyperpolarised 129Xe ventilation MRI and dynamic oxygen-enhanced MRI (OE-MRI) with standard pulmonary function tests (PFT) in interstitial lung disease (ILD) patients. To evaluate if biomarkers can separate ILD subtypes and detect early signs of disease resolution or progression. STUDY TYPE Prospective longitudinal. POPULATION Forty-one ILD (fourteen idiopathic pulmonary fibrosis (IPF), eleven hypersensitivity pneumonitis (HP), eleven drug-induced ILD (DI-ILD), five connective tissue disease related-ILD (CTD-ILD)) patients and ten healthy volunteers imaged at visit 1. Thirty-four ILD patients completed visit 2 (eleven IPF, eight HP, ten DIILD, five CTD-ILD) after 6 or 26 weeks. FIELD STRENGTH/SEQUENCE MRI was performed at 1.5 T, including inversion recovery T1 mapping, dynamic MRI acquisition with varying oxygen levels, and hyperpolarised 129Xe ventilation MRI. Subjects underwent standard spirometry and gas transfer testing. ASSESSMENT Five 1H MRI and two 129Xe MRI ventilation metrics were compared with spirometry and gas transfer measurements. STATISTICAL TEST To evaluate differences at visit 1 among subgroups: ANOVA or Kruskal-Wallis rank tests with correction for multiple comparisons. To assess the relationships between imaging biomarkers, PFT, age and gender, at visit 1 and for the change between visit 1 and 2: Pearson correlations and multilinear regression models. RESULTS The global PFT tests could not distinguish ILD subtypes. Percentage ventilated volumes were lower in ILD patients than in HVs when measured with 129Xe MRI (HV 97.4 ± 2.6, CTD-ILD: 91.0 ± 4.8 p = 0.017, DI-ILD 90.1 ± 7.4 p = 0.003, HP 92.6 ± 4.0 p = 0.013, IPF 88.1 ± 6.5 p < 0.001), but not with OE-MRI. 129Xe reported more heterogeneous ventilation in DI-ILD and IPF than in HV, and OE-MRI reported more heterogeneous ventilation in DI-ILD and IPF than in HP or CTD-ILD. The longitudinal changes reported by the imaging biomarkers did not correlate with the PFT changes between visits. DATA CONCLUSION Neither 129Xe ventilation nor OE-MRI biomarkers investigated in this study were able to differentiate between ILD subtypes, suggesting that ventilation-only biomarkers are not indicated for this task. Limited but progressive loss of ventilated volume as measured by 129Xe-MRI may be present as the biomarker of focal disease progresses. OE-MRI biomarkers are feasible in ILD patients and do not correlate strongly with PFT. Both OE-MRI and 129Xe MRI revealed more spatially heterogeneous ventilation in DI-ILD and IPF.
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Affiliation(s)
- Marta Tibiletti
- Bioxydyn Limited, Rutherford House, Manchester Science Park, Manchester M15 6SZ, United Kingdom
| | - James A Eaden
- POLARIS, University of Sheffield MRI Unit, Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Josephine H Naish
- Bioxydyn Limited, Rutherford House, Manchester Science Park, Manchester M15 6SZ, United Kingdom; MCMR, Manchester University NHS Foundation Trust, Wythenshawe, Manchester, UK
| | - Paul J C Hughes
- POLARIS, University of Sheffield MRI Unit, Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - John C Waterton
- Bioxydyn Limited, Rutherford House, Manchester Science Park, Manchester M15 6SZ, United Kingdom; Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Matthew J Heaton
- Bioxydyn Limited, Rutherford House, Manchester Science Park, Manchester M15 6SZ, United Kingdom
| | - Nazia Chaudhuri
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Ian N Bruce
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen Bianchi
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim M Wild
- POLARIS, University of Sheffield MRI Unit, Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK; Insigneo Insititute for in silico medicine, Sheffield, UK
| | - Geoff J M Parker
- Bioxydyn Limited, Rutherford House, Manchester Science Park, Manchester M15 6SZ, United Kingdom; Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
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Carter LM, Gordon C, Yee CS, Bruce I, Isenberg D, Skeoch S, Vital EM. Easy-BILAG: a new tool for simplified recording of SLE disease activity using BILAG-2004 index. Rheumatology (Oxford) 2022; 61:4006-4015. [PMID: 35077529 PMCID: PMC9536795 DOI: 10.1093/rheumatology/keab883] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/16/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE BILAG-2004 index is a comprehensive disease activity instrument for SLE but administrative burden and potential frequency of errors limits its use in routine practice. We aimed to develop a tool for more accurate, time-efficient scoring of BILAG-2004 index with full fidelity to the existing instrument. METHODS Frequency of BILAG-2004 items was collated from a BILAG-biologics registry (BILAG-BR) dataset. Easy-BILAG prototypes were developed to address known issues affecting speed and accuracy. After expert verification, accuracy and usability of the finalized Easy-BILAG was validated against standard format BILAG-2004 in a workbook exercise of 10 case vignettes. Thirty-three professionals ranging in expertise from 14 UK centres completed the validation exercise. RESULTS Easy-BILAG incorporates all items present in ≥5% BILAG-BR records, plus full constitutional and renal domains into a rapid single page assessment. An embedded glossary and colour-coding assists domain scoring. A second page captures rarer manifestations when needed. In the validation exercise, Easy-BILAG yielded higher median scoring accuracy (96.7%) than standard BILAG-2004 documentation (87.8%, P = 0.001), with better inter-rater agreement. Easy-BILAG was completed faster (59.5 min) than the standard format (80.0 min, P = 0.04) for 10 cases. An advantage in accuracy was observed with Easy-BILAG use among general hospital rheumatologists (91.3 vs 75.0, P = 0.02), leading to equivalent accuracy as tertiary centre rheumatologists. Clinicians rated Easy-BILAG as intuitive, convenient, and well adapted for routine practice. CONCLUSION Easy-BILAG facilitates more rapid and accurate scoring of BILAG-2004 across all clinical settings, which could improve patient care and biologics prescribing. Easy-BILAG should be adopted wherever BILAG-2004 assessment is required.
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Affiliation(s)
- Lucy M Carter
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster
| | - Ian Bruce
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, University of Manchester, Manchester
| | - David Isenberg
- Department of Rheumatology, Division of Medicine, University College London, London and
| | - Sarah Skeoch
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds
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Janagan S, Guly C, Skeoch S, Robson JC. Comment on: Benchmarking tocilizumab use for giant cell arteritis. Rheumatol Adv Pract 2022; 6:rkac069. [PMID: 36133959 PMCID: PMC9479882 DOI: 10.1093/rap/rkac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Shalini Janagan
- Department of Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol, UK
| | - Catherine Guly
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol, UK
| | - Sarah Skeoch
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals , Bath, UK
| | - Joanna C Robson
- Department of Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust , Bristol, UK
- Rheumatology Research, Faculty of Health and Applied Science, University of the West of England , Bristol, UK
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Nishtala P, Mchugh N, Tillett W, Skeoch S, Humphreys J, Pauling J, Isupova O, Mcgrogan A, Snowball J, Roy S. POS1411 ARTIFICIAL INTELLIGENCE FOR IDENTIFYING NEW DISEASE CLUSTERS IN PATIENTS WITH PSORIATIC ARTHRITIS/PSORIASIS: A PROOF-OF-CONCEPT STUDY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundPsoriatic arthritis (PsA)/Psoriasis (PsO) patients present with multiple long-term conditions (MLTCs), and more than half of PsA patients have ≥1 LTC, which have an impact on the quality of life. We used the Clinical Practice Research Datalink (CPRD) in the UK to determine multimorbidity in patients with PsA/PsO. CPRD is a database of routinely collected UK patient data that can be used to examine multimorbidity over the life course of the disease. A understanding of clusters and timing may allow the development of tailored programmes for surveillance and early interventions to reduce MLTcs in PSA/PO.ObjectivesThe overall objective of our study was to use CPRD to identify and interpret new and frequently-occurring disease clusters in the PsA/PsO population.MethodsWe identified PsA/PsO patients from the CPRD GOLD for the UK from 2009 to 2018 with at least one year of follow up but excluded patients in practices that had migrated to Aurum, a different electronic health record system held by CPRD. All patients were matched to controls at a 1: 4 ratio by age, sex, practice. We analysed 40 common MLTCs outlined by Barnett et al. to identify and interpret multimorbidity clusters. Multimorbidity clusters were identified using the network bi-clustering. Our methodology can be divided into three steps- (a) Separate the “case” and the “control” population, (b) Create a patient-condition matrix for each of “case” and “control” population and (c) From the patient-condition matrix in each case use a the Euclidean distance criterion to compute a similarity matrix of all the possible conditions among those patients.ResultsWe identified 67,827 incident or prevalent PsA/PsO patients aged 20 years and above who were matched to 271,308 controls by age, sex and practice (Table 1). The median number of long-term conditions (LTCs) was higher in the cases than in the controls.Table 1.CharacteristicCASE, N = 67,827CONTROL, N = 271,308Age Group, n (%)<206,491 (9.6%)27,897 (10%)20-5442,357 (62.4%)169,008(62.3%)55 and above19,148 (28.2%)74,403 (27.4%)Ethnicity, n (%)White28,200 (41.6%)93,485 (34.5%)Black, S.Asian and other956 (1.4%)3,735 (1.4%)Unknown38,671 (57%)174,088(64.2%)Sex, n (%)F35,431 (52%)141,724 (52%)BMI category, n (%)20 to <2511,183 (16.5%)43,240 (15.9%)25 to <3013,565 (20%)45,783 (16.9%)30 to <357,584 (11.2%)22,690 (8.4%)35 to 403,048 (4.5%)8,172 (3.0%)Alcohol status, n (%)Non-drinker/ Ex-drinker8,649/2,159 (15.9%)33,983/7,579 (15.3%)Drinker/Heavy drinker47,316/3,030 (74.2%)180,888/8,831 (69.9%)Smoking status, n (%)Ex-smoker/Non-smoker14,137/29,289 (64%)48,110/142,295 (70.2%)Smoker24,018 (35%)71,779 (26%)Long term condition, Median (IQR)1.00 (0.00, 3.00)1.00 (0.00, 2.00)We present the results obtained via spectral clustering on the similarity matrix obtained in each “case” and “control” population via Euclidean distance. There are 40 LTCs which are represented via two clusters in the “case” and the “control” population network (Figure 1). The LTCs in the same cluster are strongly connected within themselves compared to those in the other cluster. The noticeable part was clustering of diabetes, hypertension and chronic heart diseases in one group, especially in the “case” population over the “control” population. Interestingly depression, dementia and chronic heart diseases were in the same group in the clustering results for both the “case” and the “control” population. There are a central group of diseases (HYP, DEM, DIV, CHD etc.) in Figure 1, which seems to be connected with both sets of clusters. As mentioned earlier, diabetes has connections with these central groups of diseases, and it tends to be more pronounced in the “case” population.Figure 1.ConclusionMLTCs including diabetes, hypertension, chronic kidney disease and heart disease occurred together more commonly in patients with PsA/PsO than those without PsA/PsO.The future goal is to identify frequently occurring clusters of MLTCs in the immune-mediated inflammatory disease population.Disclosure of InterestsPrasad Nishtala: None declared, Neil McHugh: None declared, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Celgene, Eli-Lilly, Janssen, and UCB, Sarah Skeoch: None declared, Jenny Humphreys: None declared, John Pauling: None declared, Olga Isupova: None declared, Anita McGROGAN: None declared, Julia Snowball: None declared, Sandipan Roy: None declared
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Jayatilleke CNR, Anilkumar A, Janagan S, Marshall RW, Skeoch S, Guly C, Sin FE, Austin K, Al-Sweedan L, Bourn A, Clarke L, Gunawardena H, Boyce B, Knights S, Pauling JD, Reilly E, Reynolds TD, Villar S, Robson JC. AB0589 TOCILIZUMAB FOR GIANT CELL ARTERITIS: BASELINE AND TWELVE MONTH AUDIT DATA FROM THE UK BRISTOL AND BATH MULTIDISCIPLINARY MEETING. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.2872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundGiant Cell Arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Treatment is with high dose glucocorticoids. Steroid-sparing agents and Tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. TCZ has only been permitted for a maximum of one year; this time limitation was extended during the Covid-19 pandemic (1). The monthly virtual Bristol and Bath regional MDT started in November 2018.ObjectivesWe aimed to review: 1) Baseline data on all patients referred to the Bristol and Bath TCZ for GCA MDT, including demographics, clinical presentation and previous steroid-sparing agents used and 2) 12 month follow up data including number of completions, adverse effects, and flares on treatment.MethodsThe TCZ MDT referral proforma, adapted from the NHS England Blueteq approval form, was reviewed for all patients referred. 12 month follow up data was obtained from clinic letters.ResultsBaseline dataThirty-eight cases were referred between November 2018 and September 2021. Of these, 31 were approved for TCZ usage; 100% fulfilled the criteria for either refractory (n=11) or relapsing (n=20) disease. Mean age was 74 years and 74.2% were female. Average disease duration was 161.5 days for the refractory and 827.3 days for the relapsing group.77.4% had cranial GCA, 48.4% had large vessel involvement, 45.2% had visual symptoms and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%).64.5% had trialled a steroid-sparing agent at time of referral (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), 35.5% had received intravenous methylprednisolone and 58% were receiving greater than 40mg prednisolone at the time of referral.Glucocorticoid adverse effects of osteoporosis, weight gain, cataracts and hypertension were each seen in 19.4%; whilst diabetes, neuropsychiatric symptoms and sleep disturbance were each reported in 16.1%.Those with ocular involvement tended to be referred earlier than those without (478.2 days vs 648.1 days), were referred on higher doses of glucocorticoids (71.4% vs 47.1% on ≥ 40mg) and had less steroid-sparing agents prior to referral.Follow up dataIn December 2021, a follow-up audit revealed 14/31 patients had completed at least 12 months of tocilizumab; 5 of these had had an extension under Covid-19 exceptional guidance (mean duration of 5.2 months). Of the remaining 17: 3 patients had stopped early (1 death, 1 moved away, 1 due to adverse effects of headache and gastro-intestinal side effects), 4 had not started tocilizumab and 10 had not completed 12 months of treatment at that point.Adverse events in the 14 patients at 12 months included: liver abnormalities (2/14; 14.3%), neutropenia (2/14; 14.3%), thrombocytopaenia (1/14; 7.1%), soft tissue infections (3/14; 21.4%), urinary tract infection (1/14; 7.1%) and lipid derangement (4/14 28.6%). One case of GCA relapse occurred on TCZ (mild headache and raised inflammatory markers settled on small increase in prednisolone). After 12 months, mean prednisolone dose was 3mg (range 0-15mg).ConclusionAll patients approved for Tocilizumab in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Follow up data suggests that TCZ was effective in allowing glucocorticoid weaning and disease control, but with some adverse effects. Future work to follow up patients after stopping Tocilizumab would be informative, as the twelve month limitation on treatment is likely to be re-instated.References[1]https://www.england.nhs.uk/coronavirus/publication/tocilizumab-for-giant-cell-arteritis-gca-during-the-covid-19-pandemic-rps-2007/Disclosure of InterestsChandrin N. R. Jayatilleke: None declared, Aishwarya Anilkumar: None declared, Shalini Janagan: None declared, Robert W Marshall: None declared, Sarah Skeoch: None declared, Catherine Guly Grant/research support from: Eli Lilly and Company - paid consultant for a research trial, Fang En Sin: None declared, Keziah Austin: None declared, Laith Al-Sweedan: None declared, Alexandra Bourn: None declared, Lynsey Clarke: None declared, Harsha Gunawardena: None declared, Baashar Boyce: None declared, Sally Knights: None declared, John D Pauling: None declared, Elizabeth Reilly: None declared, Timothy D Reynolds: None declared, Sarah Villar: None declared, Joanna C Robson: None declared
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Mulhearn B, Ellis J, Smith S, Tansley SL, Skeoch S. P014 Giant Cell Arteritis Patient Pathway: A Multi-Disciplinary Approach to Service Improvement in the time of COVID-19. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Aims
The RNHRD is a tertiary rheumatology centre offering a fast-track GCA assessment service. A 2018 departmental audit highlighted areas of good practice including timely assessment of cases but demonstrated irregularities in follow up processes. COVID-19 dramatically changed the way we could deliver our GCA service. Additionally, we saw increases in referrals, confirmed diagnoses and complex disease in our local population during the pandemic. This prompted us to undertake a service improvement project. Our main aims were to optimise follow up in line with national guidelines, enhance patient safety and improve the patient experience.
Methods
We undertook a service review, starting by mapping the patients’ journey. Guidelines were reviewed and stakeholders consulted. We identified several areas for improvement including; consultant-led risk stratification of patients, formalised follow up pathways and closer collaborative working with relevant departments. Additionally, we sought to streamline our processes to accommodate the increased COVID-19 workload.
Results
A risk stratified follow up pathway was created. Patients are stratified at initial review, by consultants, into low and high-risk pathways. Follow up intervals have been standardised in line with BSR guidance. Follow up patients are reviewed in a dedicated clinic; medical and nursing clinics run supervised by a vasculitis specialist. Patients transfer between different clinics, dependent on clinical stability. Patient information provided has been standardised, with increased emphasis on flare management and steroid side effects. In collaboration with patients this is being incorporated into a “GCA patient passport”, offering a consistent information resource for patients and clinicians. The nurse-led patient advice line is used frequently by GCA patients. All GCA queries are now directed to the on-call registrar, to ensure same day responses. Temporal artery ultrasound is well utilised and completed efficiently; 82% of scans between September 2019 and September 2021 occurred within 48 hours of referral. Via close working with vascular ultrasound, we have been able to create dedicated daily ultrasound capacity. Collaborative working with our Ophthalmology department has increased; communication channels between departments have been agreed, and education sessions have been provided. Processes for new GCA patients were streamlined, for example moving location of reviews. This ensured ongoing timely review of new GCA patients despite increased referral numbers.
Conclusion
COVID-19 had a significant impact on service delivery but provided a catalyst to develop our service. By engaging with stakeholders across disciplines, and reacting to patient feedback, we have been able to institute effective and meaningful change. This process is iterative and we plan further assessment of outcomes including co-morbidities and complications. Further formal patient surveys and development of a GCA expert patient group are underway and will inform further service development.
Disclosure
B. Mulhearn: None. J. Ellis: None. S. Smith: None. S.L. Tansley: None. S. Skeoch: None.
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Affiliation(s)
- Ben Mulhearn
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Jessica Ellis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Sarah Smith
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Sarah L Tansley
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
- Pharmacy and Pharmacology, University of Bath, Bath, UNITED KINGDOM
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
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Ellis J, Ibbotson L, Mulhearn B, Skeoch S. P016 Steroid prescribing and risk of adrenal insufficiency: an audit of giant cell arteritis cases. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
On 13th August 2020 a joint National Patient Safety Alert (NPSA) was issued regarding the introduction of a new steroid emergency card to support recognition and treatment of adrenal crisis. Providers must ensure patients are assessed regarding their risk of adrenal insufficiency, and where appropriate issued a steroid emergency card. Rheumatology departments frequently prescribe patients long-term courses of steroids as treatment for inflammatory disease, placing these patients at risk of secondary adrenal insufficiency. We identified new giant cell arteritis (GCA) patients as a well-defined patient group at high risk for secondary adrenal insufficiency. As such we decided to audit our steroid prescribing practice in these patients, in light of the NPSA.
Methods
All new confirmed cases of GCA treated at the Royal United Hospital for Rheumatic Diseases between 1/1/19 and 31/12/20 were identified (n = 90). Standards for audit were developed in accordance with the NPSA advice. In addition to issuing emergency cards we assessed whether patients were informed of the risk of adrenal insufficiency, symptoms suggestive of adrenal insufficiency and sick day rules. A thorough review of all available clinical notes was undertaken for all patients to assess compliance with the above standards. Data collection was completed on 16/8/21.
Results
No patients were given steroid emergency cards at their first visit; four were given cards during measured follow up. 5/90 patients were given written information about risk of adrenal insufficiency at their first visit; a further six were informed during measured follow up. 1/90 patients were given written information about signs/symptoms of adrenal insufficiency at their first visit; a further six were informed during measured follow. No patients were given written information about sick day rules at their first visit; a further 9 were informed during measured follow up. Qualitative record review suggested that inconsistencies in follow up pathways may have compounded these issues.
Conclusion
Existing departmental practices to inform GCA patients regarding the risk of secondary adrenal insufficiency, and ensure provision of steroid emergency cards are inadequate. Our audit only measured in house documentation, it is possible that primary care prescribers may also be addressing some of these areas. We have already instigated several measures to address these issues. Our GCA service has been amended as part of a wider service improvement project - frequency of follow has improved and dedicated GCA clinics created. Patients are given standardised written information on steroids and a personalised reduction plan. Education sessions have been provided to medical and nursing teams. Wider trust initiatives including electronic prescribing of emergency cards have been introduced, and their incorporation into our service is ongoing. Re-audit is planned in 6 months (January 2022).
Disclosure
J. Ellis: None. L. Ibbotson: None. B. Mulhearn: None. S. Skeoch: None.
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Affiliation(s)
- Jessica Ellis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Lucy Ibbotson
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Ben Mulhearn
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
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Jayatilleke C, Janagan S, Marshall R, Skeoch S, Guly CM, Sin FE, Sweedan LAL, Anilkumar A, Austin K, Bourn A, Clarke L, Gunawardena H, Johnson A, Knights S, Pauling JD, Reilly E, Reynolds TD, Villar S, Robson JC. P293 Tocilizumab for refractory or relapsing giant cell arteritis: audit data from the Bristol and Bath regional multidisciplinary meetings 2018-2021. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
Giant cell arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Patients can present with cranial, ocular or large vessel (LVV-GCA) involvement. Treatment is with high dose glucocorticoids. Steroid-sparing agents and tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. We reviewed the case mixture of patients referred to the Bristol and Bath regional MDT.
Methods
The Bristol and Bath regional MDT started in November 2018 and runs monthly. A referral proforma was designed, adapted from the NHS England Blueteq approval form for TCZ in GCA (definitions of refractory and relapsing disease), with tick boxes for clinical features, investigations, treatment, glucocorticoid adverse events and a free text clinical vignette. All referral proformas were reviewed.
Results
Audit data from all cases referred, between November 2018 and September 2021, were analysed. 38 cases of GCA were discussed with 31 cases approved for TCZ usage. Of the approved, 100% fulfilled the criteria for either refractory (n = 11) or relapsing (n = 20) disease. Mean age of approved cases was 74 years with three quarters being female (74.2%). Average disease duration was 161.5 days for the refractory group and 827.3 days for the relapsing group. Over three quarters of cases (77.4%) had cranial GCA, 48.4% had LVV-GCA, 45.2% had visual symptoms (reduction in visual acuity, blurring or diplopia) and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%). Almost two-thirds (64.5%) had previously had a steroid-sparing agent (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), one third (35.5%) had received intravenous methylprednisolone and more than half (58%) were receiving greater than 40mg prednisolone at the time of referral. Common glucocorticoid adverse effects (each seen in 19.4% of cases) included osteoporosis, weight gain, cataracts or hypertension, whilst diabetes, neuropsychiatric symptoms or sleep disturbance were each reported in 16.1% of cases. The majority of patients with ocular involvement had cranial symptoms (71%). Patients with ocular involvement tended to be referred earlier than those with no ocular involvement (478.2 days vs 648.1 days), were on a higher dose of glucocorticoids at time of referral (71.4% vs 47.1% on more than 40mg) and had fewer steroid-sparing agents prior to referral.
Conclusion
All patients approved for TCZ in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel vasculitis involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Patients with ocular involvement were referred slightly earlier with less use of other steroid sparing treatments prior to TCZ in our cohort.
Disclosure
C. Jayatilleke: None. S. Janagan: None. R. Marshall: Other; Has received sponsorship from UCB Pharma to attend educational conferences in the last 2 years. S. Skeoch: None. C.M. Guly: None. F. En Sin: None. L. AL Sweedan: None. A. Anilkumar: None. K. Austin: None. A. Bourn: None. L. Clarke: None. H. Gunawardena: None. A. Johnson: None. S. Knights: None. J.D. Pauling: None. E. Reilly: None. T.D. Reynolds: None. S. Villar: None. J.C. Robson: None.
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Affiliation(s)
- Chandrin Jayatilleke
- Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Shalini Janagan
- Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Robert Marshall
- Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Sarah Skeoch
- Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath, Bath, UNITED KINGDOM
| | - Catherine M Guly
- Opthalmology, Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Fang En Sin
- Rheumatology, North Bristol NHS Trust, Bristol, UNITED KINGDOM
| | - Laith AL Sweedan
- Rheumatology, Yeovil District Hospital NHS Trust, Yeovil, UNITED KINGDOM
| | - Aishwarya Anilkumar
- Rheumatology, Bristol royal infirmary,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Keziah Austin
- Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath, Bath, UNITED KINGDOM
| | - Alexandra Bourn
- Rheumatology, Yeovil District Hospital NHS Trust, Yeovil, UNITED KINGDOM
| | - Lynsey Clarke
- Rheumatology, North Bristol NHS Trust, Bristol, UNITED KINGDOM
| | | | - Ah Johnson
- Rheumatology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UNITED KINGDOM
| | - Sally Knights
- Rheumatology, Yeovil District Hospital NHS Trust, Yeovil, UNITED KINGDOM
| | - John D Pauling
- Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath, Bath, UNITED KINGDOM
| | - Elizabeth Reilly
- Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Timothy D Reynolds
- Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Weston, UNITED KINGDOM
| | - Sarah Villar
- Rheumatology, North Bristol NHS Trust, Bristol, UNITED KINGDOM
| | - Joanna C Robson
- Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
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Mulhearn B, Ellis J, Somoskeoy T, Bourn A, Knights S, Skeoch S, Tansley S. P290 Baseline monocyte count may help make a diagnosis of giant cell arteritis: results of routinely collected audit data from two centres. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Aims
Giant cell arteritis is a large vessel vasculitis classically affecting the head and neck. If untreated it leads to permanent vision loss. Diagnosis of GCA is based on clinical judgement of the likelihood of GCA combined with blood tests, imaging and/or temporal artery biopsy. Biopsy is considered the gold standard, but access has been restricted at many centres during the pandemic. It is recognised that some patients will have a negative ultrasound but still deemed to have GCA based on the clinical history and physical findings. In a previous audit at Yeovil District Hospital, we evaluated factors associated with biopsy-proven GCA to explore how routine tests help guide diagnosis, particularly in cases where initial imaging is negative and biopsy is unavailable. This audit found that the baseline monocyte count had good diagnostic accuracy compared to classical inflammatory markers and clinical parameters (area under the curve [AUC] 0.81, 95% confidence interval [CI] 0.67-0.95, p = 0.0034). Although novel, this finding involved a small number of patients and requires further investigation. We aimed to repeat the audit in a larger cohort and investigate blood biomarkers, including monocytes, in GCA patients as defined by physician diagnosis.
Methods
At the Royal National Hospital for Rheumatic Diseases, data were collected retrospectively on patients that were referred between 01/2020 and 09/2021 from hospital records, the GP referral, and pathology systems. A positive diagnosis of GCA was determined by presentation, inflammatory response, vascular imaging and clinical course, and was confirmed by a rheumatologist. Sensitivity, specificity and ROC analysis were calculated for each biomarker, including monocyte count, platelets, CRP, and plasma viscosity (PV).
Results
301 referrals were made to the GCA clinic over the period audited. 109/301 (36%) were diagnosed with GCA, of which 98/109 (90%) had imaging studies and 62/98 (67%) had had a positive test. 55/301 referrals had already started glucocorticoids before baseline blood monitoring. ROC analysis found monocyte count was predictive of GCA (AUC 0.83, 95%CI 0.77-0.90, p < 0.0001). A cut-off value of ≥ 0.9 x 106/L gave a specificity of > 95% and a positive likelihood ratio (LR) of 10 for a diagnosis of GCA in this cohort. However, monocytes were heavily influenced by glucocorticoids and after ≥1 dose there was a drop in sensitivity of 20%.
Conclusion
In a second, larger cohort of GCA cases, we have again identified monocytes as a potential biomarker of GCA. However, they appear to be highly sensitive to glucocorticoids and their use as a biomarker may be limited to glucocorticoid-naïve patients. A prospective research study is now being planned to take these findings further.
Disclosure
B. Mulhearn: None. J. Ellis: None. T. Somoskeoy: None. A. Bourn: None. S. Knights: None. S. Skeoch: None. S. Tansley: None.
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Affiliation(s)
- Ben Mulhearn
- Pharmacy and Pharmacology, University of Bath, Bath, UNITED KINGDOM
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Jessica Ellis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Tamas Somoskeoy
- Medicine, Yeovil District Hospital NHS Foundation Trust, Yeovil, UNITED KINGDOM
| | - Alexandra Bourn
- Rheumatology, Yeovil District Hospital NHS Foundation Trust, Yeovil, UNITED KINGDOM
| | - Sally Knights
- Rheumatology, Yeovil District Hospital NHS Foundation Trust, Yeovil, UNITED KINGDOM
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Sarah Tansley
- Pharmacy and Pharmacology, University of Bath, Bath, UNITED KINGDOM
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
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Carter LM, Gordon C, Yee CS, Bruce IN, Isenberg D, Skeoch S, Vital E. POS0748 EASY-BILAG: A NEW TOOL FOR FASTER AND MORE ACCURATE RECORDING OF BILAG-2004 DISEASE ACTIVITY IN SLE. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:BILAG-2004 index is an important disease activity instrument for SLE which is widely used in clinical trials and in treatment commissioning. It is more comprehensive and responsive than SLEDAI. However, BILAG-2004 may be difficult or time-consuming to complete during routine clinic visits. To derive the eventual scores from A (highly active) to E (no current or prior disease involvement) for each of the 9 organ domains, the current BILAG-2004 relies on a separate index form, glossary and scoring algorithm.Objectives:The Easy-BILAG project aimed to develop and validate a simplified tool for scoring the original BILAG-2004 index more rapidly and accurately in routine clinical care.Methods:Data from the UK BILAG-Biologics Registry (BILAG-BR) were used to measure the frequency with which the 97 BILAG-2004 clinical items occurred in a population with active SLE. These data and a series of prototypes were used to draft a new tool for simplified scoring of the BILAG-2004 index - the “Easy-BILAG”. After preliminary testing, a validation study was conducted to test accuracy, speed and usability of Easy-BILAG compared to the standard BILAG-2004 template. Rheumatologists and specialty trainees from centres around the UK were invited to score BILAG-2004 disease activity in a timed workbook of 10 exemplar case vignettes, using either Easy-BILAG or standard BILAG-2004 reference documents. The case vignettes tested clinicians in scoring both frequent and uncommon SLE manifestations as well as longitudinal scoring of items in flare and remission. All workbooks contained an overview and detailed instructions on BILAG-2004.Results:Among 2395 submissions to BILAG-BR the 6 most frequently scored clinical items were each present in more than 20% of records; arthralgia (72%), mild skin eruption (47%), moderate arthritis (38%), mild mucosal ulceration (34%), mild alopecia (34%), pleurisy / pericarditis (22%). Twenty-five items were active in less than 1% of assessments. Easy-BILAG was therefore designed to enhance the visibility of the most frequently scored items and capture all clinical items scoring >5% in a rapid single-page assessment. All remaining, less common items, are scored, only when necessary, on a second page. Easy-BILAG incorporates an abridged glossary definition immediately adjacent to clinical each item. A new colour-blindness compatible, colour-coding system directs clinicians instantly to the overall A-E score for each domain.In the validation exercise, clinicians were asked to identify active disease and assign BILAG-2004 scores, from A-E, for all 9 organ domains in a workbook of 10 case vignettes. Twenty clinicians, with a range of prior experience, have so far participated. Among clinicians working with the standard BILAG-2004 reference documents (n = 11), scoring 10 case vignettes took 90 +/- 9 minutes (mean +/- SEM) to complete. Clinicians using Easy-BILAG (n = 9) completed the exercise significantly faster at 66 +/- 8 minutes (p = 0.05). Crucially, Easy-BILAG yielded significantly higher percentage accuracy (mean +/- SEM) at 95.3 +/- 0.8 % across all domains, as compared with 81.8 +/- 6.2 % achieved by clinicians using standard BILAG-2004 documentation (p = 0.05). The difference was most apparent when specifically comparing accuracy across domains where the case exercises registered active disease. Here, Easy-BILAG showed no decline in accuracy at 94.9 +/- 1.0 % compared 75.7 +/- 5.3% achieved with standard BILAG-2004 documents (p = 0.005). In a usability survey, all (9/9) clinicians testing the Easy-BILAG template rated it as intuitive and simple to navigate.Conclusion:Easy-BILAG facilitates more rapid and accurate scoring of BILAG-2004 and provides a format which is amenable to use in routine clinical practice. Following completion of validation, it will be made widely available to clinicians.Figure 1.Illustration of the Easy-BILAG template shows format, colour scheme and method of scoring highest prevalence items mucocutaneous and musculoskeletal domain.Disclosure of Interests:Lucy Marie Carter: None declared, Caroline Gordon: None declared, Chee-Seng Yee: None declared, Ian N. Bruce Speakers bureau: GlaxoSmithKline, UCB Pharma, Consultant of: AstraZeneca, Eli Lilly, GlaxoSmithKline, ILTOO Pharma, MedImmune, Merck Serono, Grant/research support from: Genzyme Sanofi, GlaxoSmithKline, David Isenberg: None declared, Sarah Skeoch: None declared, Edward Vital Consultant of: Roche, GSK and AstraZeneca, Grant/research support from: GSK and AstraZeneca
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Mulhearn B, Ellis J, Skeoch S, Pauling J, Tansley S. OP0281 EXCESS GIANT CELL ARTERITIS CASES ARE ASSOCIATED WITH PEAKS IN COVID-19 PREVALENCE. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Immediately following the first wave of the COVID-19 pandemic, the number of giant cell arteritis (GCA) diagnoses noticeably increased at the Royal National Hospital for Rheumatic Diseases in Bath, UK. Furthermore, there was an increase in the proportion of patients with visual complications [1]. The finding supports the viral hypothesis of GCA aetiopathogenesis as previously described [2]. This not only has ramifications for understanding the underlying disease mechanisms in GCA but also has implications for the provision of local GCA services which may have already be affected by the pandemic.Objectives:The objective of the study was to estimate the incidence of giant cell arteritis during the COVID-19 pandemic years of 2020 – 2021 and compare it to 2019 data. Given that there have now been two distinct peaks of COVID-19 as reflected by hospital admissions of COVID-19-positive patients this has allowed us to investigate if there is a temporal relationship between the prevalence of COVID-19 and the incidence of GCA.Methods:The incidence of GCA was calculated by assessing emailed referrals to the GCA service and the hospital electronic medical records to identity positive cases from 2019 to the current date. Local COVID-19 prevalence was estimated by measuring the number of hospital beds taken up by COVID-19 positive patients, available publicly in a UK Government COVID-19 dataset [3].Results:There were 61 (95% Poisson distribution confidence interval [CI] 47 - 78) probable or definite GCA diagnoses made in 2020 compared to 28 (CI 19 – 40) in 2019 (Figure 1). This is an excess of 33 cases in 2020, or an increase in 118%. Given that 41% of the hospital’s catchment population is over 50, this equates to an annual incidence rate of 13.7 per 100,000 in 2019 and 29.8 per 100,000 in 2020. This compares to a previously estimated regional incidence rate of 21.6 per 100,000 for the South West of the UK [4].Figure 1. Prevalence of hospital COVID-19 and incidence of GCA (2019 – 2021). Graph showing the number of hospital beds occupied by COVID-19-positive patients in 2020 – 2021 (blue circles), number of daily GCA diagnoses in 2020 – 2021 (red circles), and previous GCA diagnoses in 2019 (green circles). The broken lines represent moving averages with a period of 7 days for COVID-19 cases and 28 days for GCA diagnoses.A peak in COVID-19-positive inpatients was seen on 10th April 2020 with a corresponding peak of GCA diagnoses on 29th May 2020, giving a lag period of approximately 6 weeks between these peaks (Figure 1).Conclusion:The incidence of GCA in Bath was significantly increased in 2020 compared to 2019. This may be the result of the widespread infection of the local population with the COVID-19 virus as a precipitating factor. Possible mechanisms include, but are not limited to, endothelial disruption by the virus, immune system priming towards T helper cell type 1 (Th1) cellular immunity and/or activation of the monocyte-macrophage system. More work is currently underway to assess the causal relationship between the two diseases.There was a lag period of 6 weeks between the peak during the first wave of the pandemic and the rise in GCA cases. We shall be closely monitoring the number of referrals that follow the current wave of the pandemic.References:[1]Luther R, Skeoch S, Pauling JD, et al. Increased number of cases of giant cell arteritis and higher rates of ophthalmic involvement during the era of COVID-19. Rheumatol Adv Pract 2020;4:1–4. doi:10.1093/rap/rkaa067[2]Russo MG, Waxman J, Abdoh AA, et al. Correlation between infection and the onset of the giant cell (temporal) arteritis syndrome. Arthritis Rheum 1995;38:374–80. doi:10.1002/art.1780380312[3]England PH. GOV.UK Coronavirus (COVID-19) in the UK. 2021.https://coronavirus.data.gov.uk/details/download (accessed 25 Jan 2021).[4]Smeeth L, Cook C, Hall AJ. Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the United Kingdom, 1990-2001. Ann Rheum Dis 2006;65:1093–8. doi:10.1136/ard.2005.046912Disclosure of Interests:Ben Mulhearn Speakers bureau: Novartis UK, 2019, Grant/research support from: Chugai, 2019, Jessica Ellis: None declared, Sarah Skeoch: None declared, John Pauling: None declared, Sarah Tansley: None declared
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Carter LM, Gordon C, Yee CS, Bruce I, Isenberg DA, Skeoch S, Vital EM. O19 Easy-BILAG: a new tool for simplified recording of SLE disease activity using BILAG-2004. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab246.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Aims
BILAG-2004 index is required to prescribe and monitor biologics in SLE. It is more comprehensive and responsive than the SLEDAI and widely used in clinical trials. However, it may be time-consuming and does require training for accurate use. The original format requires a separate index form, glossary and scoring algorithm. Further, the eventual scores from A (highly active) to E (no disease involvement) which are required to make treatment decisions, can be difficult to calculate during in routine clinical practice.The Easy-BILAG project aimed to develop and validate a simplified tool to score the original BILAG-2004 index more rapidly and with fewer errors, for use in routine clinical care.
Methods
The BILAG group identified four areas to address: (i) many items must be scored, but most are rare; (ii) glossary definitions are not always followed; (iii) the final score is not easily calculated at the time of assessment; (iv) training is time-consuming. Data from the BILAG-Biologics Registry were used to measure the frequency of each of 97 BILAG-2004 items in an active SLE population. These data and a series of prototypes were used to design a new tool for simplified scoring of the BILAG-2004 index - the “Easy-BILAG”. This instrument content was tested using exemplar paper cases. A validation study was then designed to test the Easy-BILAG compared to the standard BILAG-2004 scoring method for completion time and accuracy.
Results
2395 assessments from the BILAG-BR were analysed. There was marked variation in item frequency. The 7 most frequent items were each present in more than 20% of records: arthralgia (72%), mild skin eruption (47%), moderate arthritis (38%), mild mucosal ulceration (34%), mild alopecia (34%), pleurisy / pericarditis (22%). 16 more items were scored in 5-20% of assessments; 36 items in 1-5% of assessments, and 25 items in < 1% of assessments. The Easy-BILAG was designed to capture items scoring >5% in a rapid single-page assessment. Items are arranged in a logical sequence of clinical assessment. An abridged glossary definition is cited immediately adjacent to each item. A new colour-coding system directs clinicians instantly to the overall A-E score for each domain (colour-blindness compatible). This single page assessment covered 68% of all assessments of biologic-treated patients. The remaining items are scored on a back page only in cases where necessary, as indicated by screening questions on the main page. The overall accuracy and usability of the Easy-BILAG template is now undergoing a validation against test series of standardized case vignettes by a sample of consultants and specialty trainees with a range of experience across England and Wales.
Conclusion
Easy-BILAG allows rapid scoring of BILAG-2004 in routine clinical practice. Following completion of validation, it will be made widely available to clinicians.
Disclosure
L.M. Carter: None. C. Gordon: None. C. Yee: None. I. Bruce: None. D.A. Isenberg: None. S. Skeoch: None. E.M. Vital: None.
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Affiliation(s)
- Lucy M Carter
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences,, University of Birmingham, Birmingham, UNITED KINGDOM
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster Royal Infirmary, Doncaster, UNITED KINGDOM
| | - Ian Bruce
- Arthritis Research UK Epidemiology Unit, Faculty of Biology Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UNITED KINGDOM
| | - David A Isenberg
- Centre for Rheumatology, University College London, London, UNITED KINGDOM
| | - Sarah Skeoch
- Department of Rheumatology, Royal United Hospitals Bath NHS Trust, Bath, UNITED KINGDOM
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
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Pauling JD, Skeoch S, Paik JJ. The clinicoserological spectrum of inflammatory myopathy in the context of systemic sclerosis and systemic lupus erythematosus. Indian J Rheumatol 2021; 15:81-90. [PMID: 33790525 DOI: 10.4103/injr.injr_136_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The autoimmune rheumatic diseases (ARDs) are characterised by a pathological triad composed of autoimmunity/inflammation, microangiopathy and aberrant tissue remodelling. Disease terms such as idiopathic inflammatory myopathy (IIM), scleroderma/systemic sclerosis (SSc), and systemic lupus erythematosus (SLE) are helpful clinically but disguise the considerable overlap that exists within these 'distinct' disorders. This is perhaps best demonstrated by inflammatory myopathy, which can be present in SSc or SLE, but can itself be absent in clinically amyopathic IIM. Archetypal clinical manifestations of ARD (such as Raynaud's phenomenon) are frequently present, albeit with varying prominence, within each of these diseases. This is certainly the case for inflammatory myositis, which has long been recognised as an important clinical feature of both SSc and SLE. Progress in elucidating the clinicoserological spectrum of autoimmune rheumatic diseases has identified autoantibody specificities that are strongly associated with 'overlap' disease and the presence of inflammatory myositis in SSc and SLE. In this review, we shall describe the prevalence, burden, prognostic value and management considerations of IIM in the context of both SSc and SLE. A major emphasis on the value of autoantibodies shall highlight the value of these tools in predicting the future occurrence of inflammatory myositis in both SSc and SLE. Where applicable, unmet research needs shall be highlighted. The review emphasises the importance of myopathy as a common feature across all the ARDs, and highlights specific antibody specificities that are strongly associated with myopathy in the context of SLE and SSc.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (part of the Royal United Hospitals NHS Foundation Trust), Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases (part of the Royal United Hospitals NHS Foundation Trust), Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Julie J Paik
- Johns Hopkins Myositis Center. 5200 Eastern Avenue, MFL Building, Center Tower Suite 4500, Baltimore, MD USA
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Luther R, Skeoch S, Pauling JD, Curd C, Woodgate F, Tansley S. Increased number of cases of giant cell arteritis and higher rates of ophthalmic involvement during the era of COVID-19. Rheumatol Adv Pract 2020; 4:rkaa067. [PMID: 33364547 PMCID: PMC7749786 DOI: 10.1093/rap/rkaa067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022] Open
Abstract
Objectives Our centre offers a fast-track assessment service for patients with suspected GCA and this service continued to operate during the coronavirus disease 2019 (COVID-19) pandemic. During and immediately following the peak of the COVID-19 pandemic in the UK we observed an increase in the number of patients diagnosed with GCA as well as an increased number of patients with visual complications. Our aim was to investigate this further. Methods The electronic medical records of all patients referred for GCA fast-track assessment from January 2019 were reviewed. A complete list of patients undergoing temporal artery ultrasound and temporal artery biopsy for investigation of GCA dating back to 2015 was also available. Results In the 12 week period between April and June 2020, 24 patients were diagnosed with GCA. Six (25%) had associated visual impairment. In contrast, during 2019, 28 new diagnoses of GCA were made in total and just 10% of patients suffered visual involvement. The number of patients diagnosed with GCA in April–June 2020 was nearly 5-fold that of the same time period the previous year. GCA diagnoses between April and June 2020 were supported by imaging (temporal artery ultrasound or CT-PET) in 72% of cases. We noted a higher proportion of male patients and a lower median age but no clear difference in the duration of symptoms prior to assessment. Conclusions The reasons behind our observations remain unclear. However, our findings support the viral aetiopathogenesis hypothesis for GCA and demonstrate the importance of maintaining access to urgent rheumatology services during periods of healthcare disruption.
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Affiliation(s)
- Rosamond Luther
- Royal National Hospital for Rheumatic Diseases and Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases and Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases and Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Christopher Curd
- Royal National Hospital for Rheumatic Diseases and Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Felicity Woodgate
- Royal National Hospital for Rheumatic Diseases and Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Tansley
- Royal National Hospital for Rheumatic Diseases and Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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Reilly E, Skeoch S, Hardcastle S, Pauling JD, Rowe M, Ahmed T, Allard A, Boyce B, Korendowych E, Lapraik C, Tillett W, Sengupta R. Evaluation of a patient self-stratification methodology to identify those in need of shielding during COVID-19. Clin Med (Lond) 2020; 20:e212-e214. [PMID: 32917745 DOI: 10.7861/clinmed.2020-0469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The logistical challenges of rapidly and accurately identifying those patients who needed to shield during the COVID-19 pandemic were unprecedented. We report our experiences of meeting this challenge for >9,000 patients with rheumatic and musculoskeletal disease at our centre, incorporating an element of guided patient self-stratification. Our results indicate that patients are able to stratify their own risk accurately using the BSR COVID-19 risk stratification guidance.
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Affiliation(s)
- Elizabeth Reilly
- Royal United Hospitals Bath NHS Trust, Bath, UK and University of Bath, Bath, UK
| | | | | | - John D Pauling
- Royal United Hospitals Bath NHS Trust, Bath, UK and senior lecturer, University of Bath, Bath, UK
| | - Megan Rowe
- Royal United Hospitals Bath NHS Trust, Bath, UK
| | | | | | | | | | | | - William Tillett
- Royal United Hospitals Bath NHS Trust, Bath, UK and senior lecturer, University of Bath, Bath, UK
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Tibiletti M, Naish J, Heaton MJ, Waterton J, Hughes P, Eaden JA, Skeoch S, Chaudhuri N, Bruce I, Bianchi SM, Wild J, Parker GJ. Oxygen enhanced MRI biomarkers of lung function in interstitial lung disease. Imaging 2020. [DOI: 10.1183/13993003.congress-2020.4330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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21
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Eaden JA, Skeoch S, Waterton JC, Chaudhuri N, Bianchi SM. How consistently do physicians diagnose and manage drug-induced interstitial lung disease? Two surveys of European ILD specialist physicians. ERJ Open Res 2020; 6:00286-2019. [PMID: 32201691 PMCID: PMC7073420 DOI: 10.1183/23120541.00286-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/12/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Currently there are no general guidelines for diagnosis or management of suspected drug-induced (DI) interstitial lung disease (ILD). The objective was to survey a sample of current European practice in the diagnosis and management of DI-ILD, in the context of the prescribing information approved by regulatory authorities for 28 licenced drugs with a recognised risk of DI-ILD. Methods Consultant physicians working in specialist ILD centres across Europe were emailed two surveys via a website link. Initially, opinion was sought regarding various diagnostic and management options based on seven clinical ILD case vignettes and five general questions regarding DI-ILD. The second survey involved 29 statements regarding the diagnosis and management of DI-ILD, derived from the results of the first survey. Consensus agreement was defined as 75% or greater. Results When making a diagnosis of DI-ILD, the favoured investigations used (other than computed tomography) included pulmonary function tests, bronchoscopy and blood tests. The preferred method used to decide when to stop treatment was a pulmonary function test. In the second survey, the majority of the statements were accepted by the 33 respondents, with only four of 29 statements not achieving consensus when the responses “agree” and “strongly agree” were combined as one answer. Conclusion The two surveys provide guidance for clinicians regarding an approach to the diagnosis and management of DI-ILD in which the current evidence base is severely lacking, as demonstrated by the limited information provided by the manufacturers of the drugs associated with a high risk of DI-ILD that we reviewed. Two surveys illustrating current European practice in the diagnosis and management of drug-induced interstitial lung disease provide guidance for clinicians in a condition in which the present evidence base is lackinghttp://bit.ly/35A9YPk
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Affiliation(s)
- James A Eaden
- POLARIS, Academic Radiology, Dept of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital NHS Foundation Trust, Bath, UK.,Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - John C Waterton
- Centre for Imaging Sciences, Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Bioxydyn Ltd, Manchester, UK
| | - Nazia Chaudhuri
- University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
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Eaden J, Hughes P, Collier G, Norquay G, Weatherly N, Austin M, Smith L, Lithgow J, Swift A, Renshaw S, Buch M, Leonard C, Skeoch S, Chaudhuri N, Parker G, Bianchi S, Wild J. Longitudinal change in hyperpolarised 129-xenon MR spectroscopy in interstitial lung disease. Imaging 2019. [DOI: 10.1183/13993003.congress-2019.pa3158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Eaden J, Chan HF, Hughes P, Weatherly N, Austin M, Smith L, Lithgow J, Swift A, Renshaw S, Buch M, Leonard C, Skeoch S, Chaudhuri N, Parker G, Bianchi S, Wild J. Hyperpolarised 129-xenon diffusion-weighted MRI in interstitial lung disease. Imaging 2019. [DOI: 10.1183/13993003.congress-2019.pa3157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Williams T, Karunaratne D, Skeoch S. Giant cell arteritis: a real life evaluation of service quality at the Royal National Hospital for Rheumatic Diseases, Bath. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3-s62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Williams T, Karunaratne D, Skeoch S. Giant cell arteritis: a real life evaluation of service quality at the Royal National Hospital for Rheumatic Diseases, Bath. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3s-s62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Haque S, Skeoch S, Rakieh C, Edlin H, Ahmad Y, Ho P, Gorodkin R, Alexander MY, Bruce IN. Progression of subclinical and clinical cardiovascular disease in a UK SLE cohort: the role of classic and SLE-related factors. Lupus Sci Med 2018; 5:e000267. [PMID: 30538814 PMCID: PMC6257381 DOI: 10.1136/lupus-2018-000267] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/23/2018] [Accepted: 09/09/2018] [Indexed: 11/09/2022]
Abstract
Objectives We aimed to describe the rate and determinants of carotid plaque progression and the onset of clinical cardiovascular disease (CVD) in a UK SLE cohort. Methods Female patients with SLE of white British ancestry were recruited from clinics in the North-West of England and had a baseline clinical and CVD risk assessment including measurement of carotid intima–media thickness (CIMT) and plaque using B-mode Doppler ultrasound. Patients were followed up (>3.5 years after baseline visit) and had a repeat carotid Doppler to assess progression of plaque and CIMT. Clinical CVD events between visits were also noted. Results Of 200 patients with a baseline scan, 124 (62%) patients had a second assessment at a median (IQR) of 5.8 (5.2–6.3) years follow-up. New plaque developed in 32 (26%) (4.5% per annum) patients and plaque progression was observed in 52 (41%) patients. Factors associated with plaque progression were older age (OR 1.13; 95% CI 1.06 to 1.20), anticardiolipin (OR 3.36; 1.27 to 10.40) and anti-Ro (OR 0.31; 0.11 to 0.86) antibodies. CVD events occurred in 7.2% over 5.8 years compared with 1.0% predicted using the Framingham risk score (p<0.001). Higher triglycerides (OR 3.6; 1.23 to 10.56), cyclophosphamide exposure ‘ever’ (OR 16.7; 1.46 to 63.5) and baseline Systemic Lupus International Collaborating Clinics damage index score (OR 9.62; 1.46 to 123) independently predicted future CVD events. Conclusion Accelerated atherosclerosis remains a major challenge in SLE disease management. A more comprehensive approach to CVD risk management taking into account disease factors such as severity and anticardiolipin antibody status may be necessary to improve CVD outcomes in this high-risk population.
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Affiliation(s)
- Sahena Haque
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Rheumatology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Chadi Rakieh
- The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Helena Edlin
- Department of Vascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Yasmeen Ahmad
- Peter Maddison Rheumatology Centre, Llandudno Hospital, Manchester, UK
| | - Pauline Ho
- The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachel Gorodkin
- The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M Yvonne Alexander
- Centre for Bioscience, School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Skeoch S, Weatherley N, Swift AJ, Oldroyd A, Johns C, Hayton C, Giollo A, Wild JM, Waterton JC, Buch M, Linton K, Bruce IN, Leonard C, Bianchi S, Chaudhuri N. Drug-Induced Interstitial Lung Disease: A Systematic Review. J Clin Med 2018; 7:jcm7100356. [PMID: 30326612 PMCID: PMC6209877 DOI: 10.3390/jcm7100356] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/04/2018] [Accepted: 10/08/2018] [Indexed: 02/06/2023] Open
Abstract
Background: Drug-induced interstitial lung disease (DIILD) occurs as a result of numerous agents, but the risk often only becomes apparent after the marketing authorisation of such agents. Methods: In this PRISMA-compliant systematic review, we aimed to evaluate and synthesise the current literature on DIILD. Results: Following a quality assessment, 156 full-text papers describing more than 6000 DIILD cases were included in the review. However, the majority of the papers were of low or very low quality in relation to the review question (78%). Thus, it was not possible to perform a meta-analysis, and descriptive review was undertaken instead. DIILD incidence rates varied between 4.1 and 12.4 cases/million/year. DIILD accounted for 3–5% of prevalent ILD cases. Cancer drugs, followed by rheumatology drugs, amiodarone and antibiotics, were the most common causes of DIILD. The radiopathological phenotype of DIILD varied between and within agents, and no typical radiological pattern specific to DIILD was identified. Mortality rates of over 50% were reported in some studies. Severity at presentation was the most reliable predictor of mortality. Glucocorticoids (GCs) were commonly used to treat DIILD, but no prospective studies examined their effect on outcome. Conclusions: Overall high-quality evidence in DIILD is lacking, and the current review will inform larger prospective studies to investigate the diagnosis and management of DIILD.
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Affiliation(s)
- Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9PL, UK.
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath BA1 1RL, UK.
| | - Nicholas Weatherley
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK.
| | - Andrew J Swift
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK.
| | - Alexander Oldroyd
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9PL, UK.
| | - Christopher Johns
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK.
| | - Conal Hayton
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M6 8HD, UK.
| | - Alessandro Giollo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Leeds Biomedical Research Centre, University of Leeds, Leeds LS2 9JT, UK.
- Rheumatology Unit, Department of Medicine, University of Verona, 37134 Verona, Italy.
| | - James M Wild
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK.
| | - John C Waterton
- Bioxydyn Limited, Rutherford House, Manchester Science Park, Manchester M15 6SZ, UK.
- Centre for Imaging Sciences, Division of Informatics Imaging & Data Sciences, School of Health Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9PL, UK.
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Leeds Biomedical Research Centre, University of Leeds, Leeds LS2 9JT, UK.
| | - Kim Linton
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9PL, UK.
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9PL, UK.
- The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M6 8HD, UK.
| | - Colm Leonard
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M6 8HD, UK.
| | - Stephen Bianchi
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK.
| | - Nazia Chaudhuri
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M6 8HD, UK.
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Skeoch S, Langford-Smith A, Wilkinson F, Parker B, Waterton J, Bruce IN, Alexander Y. 236 Levels of circulating endothelial derived microvesicles in patients with rheumatoid arthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UNITED KINGDOM
| | - Alex Langford-Smith
- Healthcare Science Research Centre, Manchester Metropolitan University, Manchester, UNITED KINGDOM
| | - Fiona Wilkinson
- Healthcare Science Research Centre, Manchester Metropolitan University, Manchester, UNITED KINGDOM
| | - Ben Parker
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Foundation Trust, Manchester, UNITED KINGDOM
| | - John Waterton
- Centre for Imaging Sciences, University of Manchester, Manchester, UNITED KINGDOM
| | - Ian N Bruce
- NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UNITED KINGDOM
| | - Yvonne Alexander
- Healthcare Science Research Centre, Manchester Metropolitan University, Manchester, UNITED KINGDOM
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Skeoch S, Wilkinson F, Langford-Smith A, Waterton J, Bruce IN, Alexander Y. 235 Serum osteopontin levels are associated with the subclinical cardiovascular disease in patients with rheumatoid arthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Fiona Wilkinson
- Healthcare Science Research Centre, Manchester Metropolitan University, Manchester, UNITED KINGDOM
| | - Alex Langford-Smith
- Healthcare Science Research Centre, Manchester Metropolitan University, Manchester, UNITED KINGDOM
| | - John Waterton
- Centre for Imaging Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Yvonne Alexander
- Healthcare Science Research Centre, Manchester Metropolitan University, Manchester, UNITED KINGDOM
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Skeoch S, Welsh P, Gwinnutt J, Humphreys J, Chipping J, MacGregor A, Verstappen S, Symmons D, Sattar N, Bruce IN. O10 The association of high sensitivity troponin levels with subsequent cardiovascular mortality in an inflammatory arthritis cohort: results from the Norfolk arthritis register. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UNITED KINGDOM
| | - James Gwinnutt
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Jennifer Humphreys
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | | | | | - Suzanne Verstappen
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Deborah Symmons
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UNITED KINGDOM
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal and Dermatological Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UNITED KINGDOM
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UNITED KINGDOM
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Skeoch S, Hubbard Cristinacce PL, Dobbs M, Naish J, Woodhouse N, Ho M, Waterton JC, Parker GJM, Bruce IN. Evaluation of non-contrast MRI biomarkers in lupus nephritis. Clin Exp Rheumatol 2017; 35:954-958. [PMID: 28850028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To investigate the association of novel non-contrast MRI biomarkers with standard measurements of renal function and renal disease activity in lupus. METHODS A pilot study of lupus nephritis (LN) and lupus non-nephritis (LNN) patients, and healthy volunteers (HV), was undertaken. Multi-modal renal MRI was performed including sequences for arterial spin labelling (ASL) measuring blood flow, diffusion tensor imaging (DTI), measuring microstructural disruption, and effective transverse relaxation time (T2*) which is a biomarker of micro-haemorrhage. MRI measurements were compared with urinary protein creatinine ratio (uPCR) and estimated glomerular filtration rate (eGFR) measurements in the whole study population, then differences in imaging measurements between the groups were explored. RESULTS 21 patients (6 LN, 8 LNN and 7 HV) completed the study, although ASL data were not available in 4 subjects. In the whole cohort, eGFR correlated significantly with the apparent diffusion coefficient measurement from DTI in the medulla (r=0.47, p=0.03). uPCR correlated strongly with the fractional anisotropy (FA) DTI measurement in the cortex and moderately with T2* measurements (rho=-0.71, p<0.001 and rho=-0.53, p=0.013, respectively). Delayed blood flow to the medulla was found in LN subjects and there was a trend towards lower FA values in the cortex, suggesting micro-structural disruption (p=0.04 and p=0.07, respectively). CONCLUSIONS This preliminary study demonstrates that non-contrast renal MRI biomarkers are associated with standard measures of disease activity in lupus. The potential utility of these non-invasive biomarkers warrants further investigation, as there is an unmet need for reliable biomarkers of disease activity in lupus nephritis.
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Affiliation(s)
- Sarah Skeoch
- Arthritis Res. Ctr. Epidemiology, Musculoskeletal Res. & Dermatological Sciences, Academic Health Science Ctr., Univ.of Manchester; and The Kellgren Ctr. for Rheumatology, NIHR Manchester Musculoskeletal Biomed. Res. Ctr., Central Manchester Univ., UK
| | - Penny L Hubbard Cristinacce
- Centre for Imaging Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Mark Dobbs
- Centre for Imaging Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Josephine Naish
- Centre for Imaging Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Neil Woodhouse
- Department of Radiology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK; formerly AstraZeneca R & D, Alderley Park, Macclesfield, UK
| | - Meilien Ho
- formerly AstraZeneca R & D, Alderley Park, Macclesfield, UK
| | - John C Waterton
- Centre for Imaging Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester; formerly AstraZeneca R & D, Alderley Park, Macclesfield, UK
| | - Geoff J M Parker
- Centre for Imaging Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester; and Bioxydyn Limited, Rutherford House, Pencroft Way, Manchester, UK
| | - Ian N Bruce
- Arthritis Res. Ctr. Epidemiology, Musculoskeletal Res. & Dermatological Sciences, Academic Health Science Ctr., Univ.of Manchester; and The Kellgren Ctr. for Rheumatology, NIHR Manchester Musculoskeletal Biomed. Res. Ctr., Central Manchester Univ., UK
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Ngamjanyaporn P, McCarthy EM, Sergeant JC, Reynolds J, Skeoch S, Parker B, Bruce IN. Clinicians approaches to management of background treatment in patients with SLE in clinical remission: results of an international observational survey. Lupus Sci Med 2017; 4:e000173. [PMID: 29238601 PMCID: PMC5724341 DOI: 10.1136/lupus-2016-000173] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 01/07/2017] [Accepted: 01/11/2017] [Indexed: 11/19/2022]
Abstract
Background The definition of remission in systemic lupus erythematosus (SLE) remains unclear, especially how background treatment should be interpreted. Objective To determine preferences of clinicians in treatment of patients in clinical remission from SLE and to assess how previous severity, duration of remission and serology influence changes in treatment. Methods We undertook an internet-based survey of clinicians managing patients with SLE. Case scenarios were constructed to reflect different remission states, previous organ involvement, serological abnormalities, duration of remission and current treatment (hydroxychloroquine (HCQ), steroids and/or immunosuppressive (ISS) agents). Results 130 clinicians from 30 countries were surveyed. The median (range) duration of practice and number of patients with SLE seen each month was 13 (2–42) years and 30 (2–200), respectively. Management decisions in all scenarios varied with greater caution in treatment reduction with shorter duration of remission, extent of serological abnormalities and previous disease severity. Even with mild disease, normal serology and a 5-year clinical remission, 113 (86.9%) clinicians continue to prescribe HCQ. Persistent abnormal serology in any scenario led to a reluctance to reduce or discontinue medications. Prescribing in remission, particularly of steroids and HCQ, varied significantly according to geographical location. Conclusions Clinicians preferences in withdrawing or reducing treatment in patients with SLE in clinical remission vary considerably. Serological abnormalities, previous disease severity and duration of remission all influence the decision to reduce treatment. It is unusual for clinicians to stop HCQ even after prolonged periods of clinical remission. Any definition(s) of remission needs to take into consideration such evidence on how maintenance treatments are managed.
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Affiliation(s)
- Pintip Ngamjanyaporn
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Eoghan M McCarthy
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jamie C Sergeant
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - John Reynolds
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Benjamin Parker
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Bharucha T, Rutherford A, Skeoch S, Alavi A, Brown M, Galloway J. Diagnostic yield of FDG-PET/CT in fever of unknown origin: a systematic review, meta-analysis, and Delphi exercise. Clin Radiol 2017; 72:764-771. [PMID: 28600002 DOI: 10.1016/j.crad.2017.04.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/04/2017] [Accepted: 04/18/2017] [Indexed: 12/16/2022]
Abstract
AIM To perform a systematic review, meta-analysis and Delphi exercise to evaluate diagnostic yield of combined 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography and computed tomography (FDG-PET/CT) in fever of unknown origin (FUO). MATERIALS AND METHODS Four databases were searched for studies of FDG-PET/CT in FUO 1/1/2000-1/12/2015. Exclusions were non-English language, case reports, non-standard FDG radiotracer, and significant missing data. Quality was assessed by two authors independently using a standardised tool. Pooled diagnostic yield was calculated using a random-effects model. An iterative electronic and face-to-face Delphi exercise generated interspeciality consensus. RESULTS Pooled diagnostic yield was 56% (95% confidence interval [CI]: 50-61%, I2=61%) from 18 studies and 905 patients. Only five studies reported results of previous imaging, and subgroup analysis estimated diagnostic yield beyond conventional CT at 32% (95% CI: 22-44%; I2=66%). Consensus was established that FDG-PET/CT is increasingly available with an emerging role, but there is prevailing variability in practice. CONCLUSION There is insufficient evidence to support the value of FDG-PET/CT in investigative algorithms of FUO. A paradigm shift in research is needed, involving prospective studies recruiting at diagnosis of FUO, with updated case definitions and hard outcome measures. Although these studies will be a significant undertaking with multicentre collaboration, their completion is vital for balancing both radiation exposure and costs against the possible benefits of utilising FDG-PET/CT.
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Affiliation(s)
- T Bharucha
- Division of Infection and Immunity, University College London, London, UK; Royal Free Hospital NHS Foundation Trust, London, UK.
| | - A Rutherford
- NIHR Guy's and St Thomas' Biomedical Research Centre, London, UK; Rheumatology Department, King's College London, London, UK
| | - S Skeoch
- Rheumatology Department, University of Manchester, Manchester, UK
| | - A Alavi
- Radiology Department, Hospital of the University of Philadelphia, Pennsylvania, USA
| | - M Brown
- Faculty of Infectious Diseases and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK; Hospital for Tropical Diseases, University College London Hospital NHS Foundation Trust, UK
| | - J Galloway
- Rheumatology Department, King's College London, London, UK; Rheumatology Department, King's College Hospital NHS Foundation Trust, London, UK
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Green D, Skeoch S, Alexander MY, Kalra PA, Parker B. The Association of Baseline and Longitudinal Change in Endothelial Microparticle Count with Mortality in Chronic Kidney Disease. Nephron Clin Pract 2017; 135:252-260. [PMID: 28118643 DOI: 10.1159/000452344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/07/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with a unique milieu of vascular pathology, and effective biomarkers of active vascular damage are lacking. A candidate biomarker is the quantification of circulating endothelial microparticles (EMPs). This study observed baseline and longitudinal EMP change (δEMP) and established the association of these with all-cause mortality and cardiovascular events in CKD. METHOD An observational study in adults with CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2). EMPs were quantified by flow cytometry of platelet poor plasma in 2 samples 12 months apart and categorised as EMP if AnnexinV+/CD31+/CD42b- EMPs were compared between primary renal diagnoses, and correlations between EMP/δEMP and other parameters made. Adjusted hazard ratios (HRs) for time to all-cause mortality and cardiovascular events were calculated for log-transformed EMP and δEMP using a Cox proportional hazard model. RESULTS There were 123 patients (age 63 ± 11 years, systolic blood pressure 135 ± 18 mm Hg, eGFR 32 ± 16 mL/min/1.73 m2). The median baseline EMP count was 144/μL (range 10-714/μL). EMPs were numerically the highest in autosomal dominant polycystic kidney disease (253 [41-610]). An increase in urine protein:creatinine ratio was associated with an increase in EMP (co-efficient 0.21, p = 0.02). The adjusted HR for all-cause mortality for EMP was 8.20 (1.67-40.2, p = 0.01) and for δEMP was 2.69 (0.04-165, p = 0.64). There was no association between EMP or δEMP and cardiovascular events. CONCLUSION Although EMP count was a significant marker of mortality risk, longitudinal change was not. This may reflect disease-specific EMP behaviour and the limitation of EMP as a generalised biomarker in CKD.
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Affiliation(s)
- Darren Green
- Institute of Population Health, University of Manchester, Manchester, UK
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Abstract
Rheumatoid arthritis (RA) has long been associated with increased cardiovascular risk, but despite substantial improvements in disease management, mortality remains high. Atherosclerosis is more prevalent in RA than in the general population, and atherosclerotic lesions progress at a faster rate and might be more prone to rupture, causing clinical events. Cells and cytokines implicated in RA pathogenesis are also involved in the development and progression of atherosclerosis, which is generally recognized as an inflammatory condition. The two diseases also share genetic and environmental risk factors, which suggests that patients who develop RA might also be predisposed to developing cardiovascular disease. In RA, inflammation and atherosclerosis are closely linked. Inflammation mediates its effects on atherosclerosis both through modulation of traditional risk factors and by directly affecting the vessel wall. Treatments such as TNF inhibitors might have a beneficial effect on cardiovascular risk. However, whether this benefit is attributable to effective control of inflammation or whether targeting specific cytokines, implicated in atherosclerosis, provides additional risk reduction is unclear. Further knowledge of the predictors of cardiovascular risk, the effects of early control of inflammation and of drug-specific effects are likely to improve the recognition and management of cardiovascular risk in patients with RA.
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Affiliation(s)
- Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, Brunswick Street, Manchester M13 9PL, UK
| | - Ian N Bruce
- NIHR Manchester Musculoskeletal Biomedical Research Unit, and Kellgren Centre for Rheumatology, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
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Skeoch S, Williams H, Cristinacce P, Hockings P, James J, Alexander Y, Waterton J, Bruce I. Evaluation of carotid plaque inflammation in patients with active rheumatoid arthritis using (18)F-fluorodeoxyglucose PET-CT and MRI: a pilot study. Lancet 2015; 385 Suppl 1:S91. [PMID: 26312914 DOI: 10.1016/s0140-6736(15)60406-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Rheumatoid arthritis is associated with a 50% increased risk in cardiovascular mortality. Inflammation is thought to accelerate atherosclerosis and might also lead to an inflammatory rupture-prone plaque phenotype. We tested the hypothesis that patients with active rheumatoid arthritis also have carotid plaque inflammation and that plaque inflammation correlates with clinical and serological markers of inflammation. METHODS Patients with active rheumatoid arthritis, defined as the Disease Activity Score in 28 joints (DAS28) score of more than 3·2, were recruited to a single centre study in the UK. Patients with carotid plaque on ultrasound underwent carotid MRI followed by (18)F-fluorodeoxyglucose ((18)F-FDG) PET-CT. Scans were co-registered and analysed by a physicist, masked to clinical information. The maximum standardised uptake values (SUV(max)) were measured in the plaque area. The association of SUV with DAS28, C-reactive protein, and CD4+CD28- T-cell frequency was tested with non-parametric statistics. Ethics approval and informed consent were obtained. FINDINGS Scans were done in 13 patients, nine of whom were women. Median age was 60 years (IQR 57-65), disease duration was 11 years (6-25), and DAS28 score was 4·52 (4·32-5·13). None had a history or symptoms of clinical cardiovascular disease or took statins. All plaques caused less than 70% stenosis, and tracer uptake in plaque was seen on PET in all 13 patients. Median SUV(max) was 2·18 (IQR 2·00-2·65), and all cases had an SUV(max) greater than 1·6 (the threshold for defining carotid plaque inflammation). There was a significant association with SUV(max) and C-reactive protein (r=0·58, p=0·04) and quartiles of CD4+CD28- T-cell frequency (p=0·045), but not with low-density lipoprotein concentrations (r=-0·49, p=0·09) or DAS28 score (r=0·38, p=0·20). No association was found with age (r=0·13, p=0·69) or sex (p=0·64). INTERPRETATION In this small pilot study, plaque inflammation was seen in all patients and correlated with C-reactive protein. Whether this finding represents simultaneous joint and plaque inflammation, which might improve on treatment of joint disease, remains to be determined. CD4+CD28- T-cells are known to predict cardiovascular events in patients with angina. Their association with plaque inflammation in this study suggests a possible role in cardiovascular risk prediction in rheumatoid arthritis. Larger studies are warranted to investigate these findings further. FUNDING North West England MRC Clinical Pharmacology and Therapeutics Clinical Research Fellowship, National Institute for Health Research, AstraZeneca-University of Manchester Strategic Alliance Fund.
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Affiliation(s)
- Sarah Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Musculoskeletal Biomedical Research Unit, University of Manchester, Manchester, UK.
| | - Heather Williams
- Biomedical Imaging Institute, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Penny Cristinacce
- Biomedical Imaging Institute, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Hockings
- Drug Safety and Metabolism, AstraZeneca, Molindal, Sweden; MedTech West, Chalmers University of Technology, Gothenburg, Sweden
| | - Jacqueline James
- Department of Nuclear Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Yvonne Alexander
- Healthcare Science Research Institute, Manchester Metropolitan University, Manchester, UK
| | - John Waterton
- AstraZeneca Personalised Healthcare & Biomarkers, Alderley Park, Macclesfield, UK
| | - Ian Bruce
- The Kellgren Centre for Rheumatology, NIHR Manchester, Manchester, UK
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Skeoch S, Hubbard P, Williams H, Xu D, Jie S, Balu N, Zhang W, James J, Hatsukami T, Yuan C, Alexander Y, Hockings P, Waterton J, Bruce I. O42. Imaging Atherosclerotic Plaque Inflammation in Rheumatoid Arthritis: Methodology and Initial Findings in a Single Centre Cohort Study. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu092.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Skeoch S, Haque S, Pemberton P, Bruce IN. Cell adhesion molecules as potential biomarkers of nephritis, damage and accelerated atherosclerosis in patients with SLE. Lupus 2014; 23:819-24. [PMID: 24647443 PMCID: PMC4232262 DOI: 10.1177/0961203314528061] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 02/21/2014] [Indexed: 11/25/2022]
Abstract
Objectives The aim of the current study was to compare levels of vascular cell adhesion molecule-1 (VCAM-1) and E-selectin in lupus patients and controls and to investigate their association with clinical phenotype, disease activity and damage. Methods We compared levels of serum VCAM-1 and E-selectin in 178 female lupus patients and 69 age-and sex-matched controls. Using linear regression we also examined the association between these markers and disease activity, damage, renal and skin involvement as well as clinical and subclinical cardiovascular disease. Results E-selectin was increased in patients compared to controls (median (IQR) 10.5 (6.85, 13.9) vs 7.86 (5.39, 10.4) ng/ml; p < 0.001). E-selectin was also associated with overall damage and carotid plaque (β (95% confidence interval): 0.27 (0.029, 0.511) and 0.26 (0.148, 0.507)). Whilst there was no significant difference in VCAM-1 levels between groups overall, we found a significant association between VCAM-1 and with active renal disease (β (95% confidence interval): 1.10 (0.69, 1.51)). Conclusions E-selectin may act as a marker of cardiovascular risk in SLE, whilst VCAM-1 may have a role as a non-invasive biomarker for lupus nephritis activity.
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Affiliation(s)
- S Skeoch
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - S Haque
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK Department of Rheumatology, University Hospital of South Manchester, Manchester, UK
| | - P Pemberton
- Specialist Assay Laboratory, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - I N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Skeoch S, Dobbs M, Hubbard P, Naish J, Woodhouse N, Ho M, Waterton J, Parker G, Bruce I. OP0169 Assessment of Lupus Nephritis Disease Activity Using Non-Contrast MRI: A Pilot Study. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Skeoch S, Verstappen S, Chipping J, Marshall T, Symmons D, Bruce I. SAT0081 Seropositivity is Associated with Increased Arterial Stiffness in Rheumatoid Arthritis Patients: Results from the Norfolk Arthritis Register. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Skeoch S, Haque S, Parker B, Ahmad Y, Teh L, Bruce I. THU0165 High rate of cardiovascular events in lupus patients at 5 year follow up and association of classical and lupus related risk factors. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2012-eular.2130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cornell P, Trehane A, Thompson P, Rahmeh F, Greenwood M, Baqai TJ, Cambridge S, Shaikh M, Rooney M, Donnelly S, Tahir H, Ryan S, Kamath S, Hassell A, McCuish WJ, Bearne L, Mackenzie-Green B, Price E, Williamson L, Collins D, Tang E, Hayes J, McLoughlin YM, Chamberlain V, Campbell S, Shah P, McKenna F, Cornell P, Westlake S, Thompson P, Richards S, Homer D, Gould E, Empson B, Kemp P, Richards AG, Walker J, Taylor S, Bari SF, Alachkar M, Rajak R, Lawson T, O'Sullivan M, Samant S, Butt S, Gadsby K, Flurey CA, Morris M, Hughes R, Pollock J, Richards P, Hewlett S, Edwards KR, Rowe I, Sanders T, Dunn K, Konstantinou K, Hay E, Jones LE, Adams J, White P, Donovan-Hall M, Hislop K, Barbosa Boucas S, Nichols VP, Williamson EM, Toye F, Lamb SE, Rodham K, Gavin J, Watts L, Coulson N, Diver C, Avis M, Gupta A, Ryan SJ, Stangroom S, Pearce JM, Byrne J, Manning VL, Hurley M, Scott DL, Choy E, Bearne L, Taylor J, Morris M, Dures E, Hewlett S, Wilson A, Adams J, Larkin L, Kennedy N, Gallagher S, Fraser AD, Shrestha P, Batley M, Koduri G, Scott DL, Flurey CA, Morris M, Hughes R, Pollock J, Richards P, Hewlett S, Kumar K, Raza K, Nightingale P, Horne R, Chapman S, Greenfield S, Gill P, Ferguson AM, Ibrahim F, Scott DL, Lempp H, Tierney M, Fraser A, Kennedy N, Barbosa Boucas S, Hislop K, Dziedzic K, Arden N, Burridge J, Hammond A, Stokes M, Lewis M, Gooberman-Hill R, Coales K, Adams J, Nutland H, Dean A, Laxminarayan R, Gates L, Bowen C, Arden N, Hermsen L, Terwee CB, Leone SS, vd Zwaard B, Smalbrugge M, Dekker J, vd Horst H, Wilkie R, Ferguson AM, Nicky Thomas V, Lempp H, Cope A, Scott DL, Simpson C, Weinman J, Agarwal S, Kirkham B, Patel A, Ibrahim F, Barn R, Brandon M, Rafferty D, Sturrock R, Turner D, Woodburn J, Rafferty D, Paul L, Marshall R, Gill J, McInnes I, Roderick Porter D, Woodburn J, Hennessy K, Woodburn J, Steultjens M, Siddle HJ, Hodgson RJ, Hensor EM, Grainger AJ, Redmond A, Wakefield RJ, Helliwell PS, Hammond A, Rayner J, Law RJ, Breslin A, Kraus A, Maddison P, Thom JM, Newcombe LW, Woodburn J, Porter D, Saunders S, McCarey D, Gupta M, Turner D, McGavin L, Freeburn R, Crilly A, Lockhart JC, Ferrell WR, Goodyear C, Ledingham J, Waterman T, Berkin L, Nicolaou M, Watson P, Lillicrap M, Birrell F, Mooney J, Merkel PA, Poland F, Spalding N, Grayson P, Leduc R, Shereff D, Richesson R, Watts RA, Roussou E, Thapper M, Bateman J, Allen M, Kidd J, Parsons N, Davies D, Watt KA, Scally MD, Bosworth A, Wilkinson K, Collins S, Jacklin CB, Ball SK, Grosart R, Marks J, Litwic AE, Sriranganathan MK, Mukherjee S, Khurshid MA, Matthews SM, Hall A, Sheeran T, Baskar S, Muether M, Mackenzie-Green B, Hetherington A, Wickrematilake G, Williamson L, Daniels LE, Gwynne CE, Khan A, Lawson T, Clunie G, Stephenson S, Gaffney K, Belsey J, Harvey NC, Clarke-Harris R, Murray R, Costello P, Garrett E, Holbrook J, Teh AL, Wong J, Dogra S, Barton S, Davies L, Inskip H, Hanson M, Gluckman P, Cooper C, Godfrey K, Lillycrop K, Anderton T, Clarke S, Rao Chaganti S, Viner N, Seymour R, Edwards MH, Parsons C, Ward K, Thompson J, Prentice A, Dennison E, Cooper C, Clark E, Cumming M, Morrison L, Gould VC, Tobias J, Holroyd CR, Winder N, Osmond C, Fall C, Barker D, Ring S, Lawlor D, Tobias J, Davey Smith G, Cooper C, Harvey NC, Toms TE, Afreedi S, Salt K, Roskell S, Passey K, Price T, Venkatachalam S, Sheeran T, Davies R, Southwood TR, Kearsley-Fleet L, Hyrich KL, Kingsbury D, Quartier P, Patel G, Arora V, Kupper H, Mozaffarian N, Kearsley-Fleet L, Baildam E, Beresford MW, Davies R, Foster HE, Mowbray K, Southwood TR, Thomson W, Hyrich KL, Saunders E, Baildam E, Chieng A, Davidson J, Foster H, Gardner-Medwin J, Wedderburn L, Thomson W, Hyrich K, McErlane F, Beresford M, Baildam E, Chieng SE, Davidson J, Foster HE, Gardner-Medwin J, Lunt M, Wedderburn L, Thomson W, Hyrich K, Rooney M, Finnegan S, Gibson DS, Borg FA, Bale PJ, Armon K, Cavelle A, Foster HE, McDonagh J, Bale PJ, Armon K, Wu Q, Pesenacker AM, Stansfield A, King D, Barge D, Abinun M, Foster HE, Wedderburn L, Stanley K, Morrissey D, Parsons S, Kuttikat A, Shenker N, Garrood T, Medley S, Ferguson AM, Keeling D, Duffort P, Irving K, Goulston L, Culliford D, Coakley P, Taylor P, Hart D, Spector T, Hakim A, Arden N, Mian A, Garrood T, Magan T, Chaudhary M, Lazic S, Sofat N, Thomas MJ, Moore A, Roddy E, Peat G, Rees F, Lanyon P, Jordan N, Chaib A, Sangle S, Tungekar F, Sabharwal T, Abbs I, Khamashta M, D'Cruz D, Dzifa Dey I, Isenberg DA, Chin CW, Cheung C, Ng M, Gao F, Qiong Huang F, Thao Le T, Yong Fong K, San Tan R, Yin Wong T, Julian T, Parker B, Al-Husain A, Yvonne Alexander M, Bruce I, Jordan N, Abbs I, D'cruz D, McDonald G, Miguel L, Hall C, Isenberg DA, Magee A, Butters T, Jury E, Yee CS, Toescu V, Hickman R, Leung MH, Situnayake D, Bowman S, Gordon C, Yee CS, Toescu V, Hickman R, Leung MH, Situnayake D, Bowman S, Gordon C, Lazarus MN, Isenberg DA, Ehrenstein M, Carter LM, Isenberg DA, Ehrenstein MR, Chanchlani N, Gayed M, Yee CS, Gordon C, Ball E, Rooney M, Bell A, Reynolds JA, Ray DW, O'Neill T, Alexander Y, Bruce I, Sutton EJ, Watson KD, Isenberg D, Rahman A, Gordon C, Yee CS, Lanyon P, Jayne D, Akil M, D'Cruz D, Khamashta M, Lutalo P, Erb N, Prabu A, Edwards CJ, Youssef H, McHugh N, Vital E, Amft N, Griffiths B, Teh LS, Zoma A, Bruce I, Durrani M, Jordan N, Sangle S, D'Cruz D, Pericleous C, Ruiz-Limon P, Romay-Penabad Z, Carrera-Marin A, Garza-Garcia A, Murfitt L, Driscoll PC, Giles IP, Ioannou Y, Rahman A, Pierangeli SS, Ripoll VM, Lambrianides A, Heywood WE, Ioannou J, Giles IP, Rahman A, Stevens C, Dures E, Morris M, Knowles S, Hewlett S, Marshall R, Reddy V, Croca S, Gerona D, De La Torre Ortega I, Isenberg DA, Leandro M, Cambridge G, Reddy V, Cambridge G, Isenberg DA, Glennie M, Cragg M, Leandro M, Croca SC, Isenberg DA, Giles I, Ioannou Y, Rahman A, Croca SC, Isenberg DA, Giles I, Ioannou Y, Rahman A, Artim Esen B, Pericleous C, MacKie I, Ioannou Y, Rahman A, Isenberg DA, Giles I, Skeoch S, Haque S, Pemberton P, Bruce I. BHPR: Audit and Clinical Evaluation * 103. Dental Health in Children and Young Adults with Inflammatory Arthritis: Access to Dental Care. Rheumatology (Oxford) 2013. [DOI: 10.1093/rheumatology/ket196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Heathfield S, Parker B, Zeef L, Bruce I, Alexander Y, Collins F, Stone M, Wang E, Williams AS, Wright HL, Thomas HB, Moots RJ, Edwards SW, Bullock C, Chapman V, Walsh DA, Mobasheri A, Kendall D, Kelly S, Bayley R, Buckley CD, Young SP, Rump-Goodrich L, Middleton J, Chen L, Fisher R, Kollnberger S, Shastri N, Kessler BM, Bowness P, Nazeer Moideen A, Evans L, Osgood L, Williams AS, Jones SA, Nowell MA, Mahadik Y, Young S, Morgan M, Gordon C, Harper L, Giles JL, Paul Morgan B, Harris CL, Rysnik OJ, McHugh K, Kollnberger S, Payeli S, Marroquin O, Shaw J, Renner C, Bowness P, Nayar S, Cloake T, Bombardieri M, Pitzalis C, Buckley C, Barone F, Barone F, Nayar S, Cloake T, Lane P, Coles M, Buckley C, Williams EL, Edwards CJ, Cooper C, Oreffo RO, Dunn S, Crawford A, Wilkinson M, Le Maitre C, Bunning R, Daniels J, Phillips KLE, Chiverton N, Le Maitre CL, Kollnberger S, Shaw J, Ridley A, Wong-Baeza I, McHugh K, Keidel S, Chan A, Bowness P, Gullick NJ, Abozaid HS, Jayaraj DM, Evans HG, Scott DL, Choy EH, Taams LS, Hickling M, Golor G, Jullion A, Shaw S, Kretsos K, Bari SF, Rhys-Dillon B, Amos N, Siebert S, Phillips KLE, Chiverton N, Bunning RD, Haddock G, Cross AK, Le Maitre CL, Kate I, Phillips E, Cross A, Chiverton N, Haddock G, Bunning RAD, Le Maitre CL, Ceeraz S, Spencer J, Choy E, Corrigall V, Crilly A, Palmer H, Lockhart J, Plevin R, Ferrell WR, McInnes I, Hutchinson D, Perry L, DiCicco M, Humby F, Kelly S, Hands R, Buckley C, McInnes I, Taylor P, Bombardieri M, Pitzalis C, Mehta P, Mitchell A, Tysoe C, Caswell R, Owens M, Vincent T, Hashmi TM, Price-Forbes A, Sharp CA, Murphy H, Wood EF, Doherty T, Sheldon J, Sofat N, Goff I, Platt PN, Abdulkader R, Clunie G, Ismajli M, Nikiphorou E, Young A, Tugnet N, Dixey J, Banik S, Alcorn D, Hunter J, Win Maw W, Patil P, Hayes F, Main Wong W, Borg FA, Dasgupta B, Malaviya AP, Ostor AJ, Chana JK, Ahmed AA, Edmonds S, Hayes F, Coward L, Borg F, Heaney J, Amft N, Simpson J, Dhillon V, Ayalew Y, Khattak F, Gayed M, Amarasena RI, McKenna F, Amarasena RI, McKenna F, Mc Laughlin M, Baburaj K, Fattah Z, Ng N, Wilson J, Colaco B, Williams MR, Adizie T, Dasgupta B, Casey M, Lip S, Tan S, Anderson D, Robertson C, Devanny I, Field M, Walker D, Robinson S, Ryan S, Hassell A, Bateman J, Allen M, Davies D, Crouch C, Walker-Bone K, Gainsborough N, Gullick NJ, Lutalo PM, Davies UM, Walker-Bone K, Mckew JR, Millar AM, Wright SA, Bell AL, Thapper M, Roussou T, Cumming J, Hull RG, Thapper M, Roussou T, McKeogh J, O'Connor MB, Hassan AI, Bond U, Swan J, Phelan MJ, Coady D, Kumar N, Farrow L, Bukhari M, Oldroyd AG, Greenbank C, McBeth J, Duncan R, Brown D, Horan M, Pendleton N, Littlewood A, Cordingley L, Mulvey M, Curtis EM, Cole ZA, Crozier SR, Georgia N, Robinson SM, Godfrey KM, Sayer AA, Inskip HM, Cooper C, Harvey NC, Davies R, Mercer L, Galloway J, Low A, Watson K, Lunt M, Symmons D, Hyrich K, Chitale S, Estrach C, Moots RJ, Goodson NJ, Rankin E, Jiang CQ, Cheng KK, Lam TH, Adab P, Ling S, Chitale S, Moots RJ, Estrach C, Goodson NJ, Humphreys J, Ellis C, Bunn D, Verstappen SM, Symmons D, Fluess E, Macfarlane GJ, Bond C, Jones GT, Scott IC, Steer S, Lewis CM, Cope A, Mulvey MR, Macfarlane GJ, Symmons D, Lovell K, Keeley P, Woby S, Beasley M, McBeth J, Viatte S, Plant D, Lunt M, Fu B, Parker B, Galloway J, Solymossy C, Worthington J, Symmons D, Dixey J, Young A, Barton A, Williams FM, Osei-Bordom DC, Popham M, MacGregor A, Spector T, Little J, Herrick A, Pushpakom S, Ennis H, McBurney H, Worthington J, Newman W, Ibrahim I, Plant D, Hyrich K, Morgan A, Wilson A, Isaacs J, Barton A, Sanderson T, Hewlett S, Calnan M, Morris M, Raza K, Kumar K, Cardy CM, Pauling JD, Jenkins J, Brown SJ, McHugh N, Nikiphorou E, Mugford M, Davies C, Cooper N, Brooksby A, Bunn D, Symmons D, MacGregor A, Dures E, Ambler N, Fletcher D, Pope D, Robinson F, Rooke R, Hewlett S, Gorman CL, Reynolds P, Hakim AJ, Bosworth A, Weaver D, Kiely PD, Skeoch S, Jani M, Amarasena R, Rao C, Macphie E, McLoughlin Y, Shah P, Else S, Semenova O, Thompson H, Ogunbambi O, Kallankara S, Patel Y, Baguley E, Jani M, Halsey J, Severn A, Bukhari M, Selvan S, Price E, Husain MJ, Brophy S, Phillips CJ, Cooksey R, Irvine E, Siebert S, Lendrem D, Mitchell S, Bowman S, Price E, Pease CT, Emery P, Andrews J, Bombardieri M, Sutcliffe N, Pitzalis C, Lanyon P, Hunter J, Gupta M, McLaren J, Regan M, Cooper A, Giles I, Isenberg D, Griffiths B, Foggo H, Edgar S, Vadivelu S, Coady D, McHugh N, Ng WF, Dasgupta B, Taylor P, Iqbal I, Heron L, Pilling C, Marks J, Hull R, Ledingham J, Han C, Gathany T, Tandon N, Hsia E, Taylor P, Strand V, Sensky T, Harta N, Fleming S, Kay L, Rutherford M, Nicholl K, Kay L, Rutherford M, Nicholl K, Eyre T, Wilson G, Johnson P, Russell M, Timoshanko J, Duncan G, Spandley A, Roskell S, Coady D, West L, Adshead R, Donnelly SP, Ashton S, Tahir H, Patel D, Darroch J, Goodson NJ, Boulton J, Ellis B, Finlay R, Lendrem D, Mitchell S, Bowman S, Price E, Pease CT, Emery P, Andrews J, Bombardieri M, Sutcliffe N, Pitzalis C, Lanyon P, Hunter J, Gupta M, McLaren J, Regan M, Cooper A, Giles I, Isenberg D, Vadivelu S, Coady D, McHugh N, Griffiths B, Foggo H, Edgar S, Ng WF, Murray-Brown W, Priori R, Tappuni T, Vartoukian S, Seoudi N, Picarelli G, Fortune F, Valesini G, Pitzalis C, Bombardieri M, Ball E, Rooney M, Bell A, Merida AA, Isenberg D, Tarelli E, Axford J, Giles I, Pericleous C, Pierangeli SS, Ioannou J, Rahman A, Alavi A, Hughes M, Evans B, Bukhari M, Parker B, Zaki A, Alexander Y, Bruce I, Hui M, Garner R, Rees F, Bavakunji R, Daniel P, Varughese S, Srikanth A, Andres M, Pearce F, Leung J, Lim K, Regan M, Lanyon P, Oomatia A, Petri M, Fang H, Birnbaum J, Amissah-Arthur M, Gayed M, Stewart K, Jennens H, Braude S, Gordon C, Sutton EJ, Watson KD, Gordon C, Yee CS, Lanyon P, Jayne D, Isenberg D, Rahman A, Akil M, McHugh N, Ahmad Y, Amft N, D'Cruz D, Edwards CJ, Griffiths B, Khamashta M, Teh LS, Zoma A, Bruce I, Dey ID, Kenu E, Isenberg D, Pericleous C, Garza-Garcia A, Murfitt L, Driscoll PC, Isenberg D, Pierangeli S, Giles I, Ioannou Y, Rahman A, Reynolds JA, Ray DW, O'Neill T, Alexander Y, Bruce I, Segeda I, Shevchuk S, Kuvikova I, Brown N, Bruce I, Venning M, Mehta P, Dhanjal M, Mason J, Nelson-Piercy C, Basu N, Paudyal P, Stockton M, Lawton S, Dent C, Kindness K, Meldrum G, John E, Arthur C, West L, Macfarlane MV, Reid DM, Jones GT, Macfarlane GJ, Yates M, Loke Y, Watts R, MacGregor A, Adizie T, Christidis D, Dasgupta B, Williams M, Sivakumar R, Misra R, Danda D, Mahendranath KM, Bacon PA, Mackie SL, Pease CT. Basic science * 232. Certolizumab pegol prevents pro-inflammatory alterations in endothelial cell function. Rheumatology (Oxford) 2012. [DOI: 10.1093/rheumatology/kes108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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