RSS 1.0Primary Care, Community and Therapies
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Ethnicity-specific patterns of epigenetic age acceleration in rheumatoid arthritisRheumatoid arthritis (RA) is an age-related chronic inflammatory disease which may include accelerated biological ageing processes in its pathogenesis. To determine if increased biological age is associated with risk of RA and/or is present once disease is established. We used DNA methylation to compare biological age (epigenetic age) of immune cells in adults at risk of RA and those with confirmed RA, including twins discordant for RA. The established RA studies were secondary analyses of existing DNA methylation data. Sub-group analysis considered the influence of ethnicity. Four epigenetic clocks were used to determine DNA methylation age. DNA methylation age was no different in adults at risk of RA in the Leiden Clinically Suspect Arthralgia (CSA) cohort (n = 38 developed RA, n = 24 did not), and there was also no difference in DNA methylation age between 77 UK twins discordant for RA, or adults with established RA from the Swedish EIRA cohort (n = 342) compared to healthy controls (n = 328). A sub-group analysis of RA patients of South Asian ethnicity (10 RA patients, 14 healthy controls) showed DNA methylation age acceleration of 3.3 years (p = 0.00014) using the mean DNA methylation age of four epigenetic clocks. Our study suggests that epigenetic age acceleration may be differentially influenced by South Asian ethnicity, but that RA was not generally associated with accelerated epigenetic age. The higher epigenetic age in the South Asian patients may explain the earlier age of onset in this minority ethnic population.
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Perceptions, expectations and experiences of recovery before and after anterior cruciate ligament reconstruction : the patient voice - a protocol for a qualitative systematic review with meta-aggregationIntroduction: Anterior cruciate ligament (ACL) injuries are a common yet significant musculoskeletal problem and are increasingly prevalent outside of elite athlete populations. As a result, individuals may undergo ACL reconstruction (ACLR), but long-term complications frequently persist. Individuals commonly believe that post-ACLR, they will eventually return to preinjury levels of function. However, for multiple reasons, the reality is that more than half fail to reach this preinjury level. Rehabilitation has traditionally focused on physical factors, which have been researched extensively. More recently, psychological factors affecting recovery have been examined. However, most literature focuses on 'outcome', with the patient voice, in terms of their views and perceptions of ACLR neglected. Therefore, the aim of this systematic review is to understand individuals' perceptions, expectations and experiences pre-ACLR and post-ACLR and to understand key factors influencing this journey. Such knowledge would assist in maximising the chances of successful recovery. Methods and analysis: This meta-aggregative systematic review protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Medline, CINAHL, EMBASE and SportDiscus databases, grey literature and key journals will be searched from inception. Qualitative research of any study design that includes individuals aged 16+ years who are awaiting or have undergone ACL reconstruction will be included. Studies focusing on ACL revision, ACL repair or multiligament reconstruction surgeries will be excluded. Two independent reviewers will conduct searches, determine study eligibility, extract data, assess methodological quality (Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research) and rate the overall confidence in findings (JBI ConQual). Ethics and dissemination: Findings will be published in a peer-reviewed journal, as well as presented at conferences and locally to physiotherapy teams. Ethical approval is not required for this systematic review.
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Estimating the cost and carbon output of musculoskeletal primary care management decisions : a retrospective analysis of electronic health recordsBackground: Healthcare accounts for up to 5% of worldwide carbon emissions and costs global economies an estimated $9 trillion annually. Primary care accounts for up to one-fifth of all NHS carbon emissions, with musculoskeletal (MSK) pain accounting for 14%-30% of all primary care consultations. Method: A cost-carbon calculator model was used to undertake a retrospective economic and environmental analysis of resource use for non-inflammatory MSK pain primary care consulters. Data used to populate the model was derived from Electronic Health Records and patient surveys collected during The Multi-level Integrated Data for Musculoskeletal Health Intelligence and ActionS GP Study. The model was utilised to estimate the mean (with 95%CI's) cost and carbon output per MSK consulter, while also examining variations at two levels: (a) the Primary Care Network (PCN), and (b) the consulter's index MSK pain site. Results: One thousand eight hundred seventy-five individuals from 30 NHS primary care practices across 13 PCNs were eligible for EHR and survey data analysis. The mean carbon and cost output per person (over 6 months) was 46.91 kg CO2e (95% CIs; 45.02, 48.81 kg CO2e) and £182.65 (95% CIs; £178.69, £190.62), respectively, with substantial variation observed across PCNs. The resource category with the highest carbon footprint was consistently pharmacological intervention across all PCNs. Individuals who consulted for multisite/widespread pain and back pain had the highest mean carbon and cost output respectively. Conclusion: This is the first study, we are aware of, that presents data on both the environmental and economic impact of the primary care of non-inflammatory MSK pain. Future work should focus on benchmarking the cost and carbon output of MSK care pathways and standardising methods that are implemented to influence sustainable practice and policy development.
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Are Allied Health Professionals (AHPs) research ready? A regional evaluation in England : the Research ABC project (AHPs Building Research Capacity Across the Black Country)Background: Research active organisations achieve better healthcare outcomes. The Research ABC Project (Allied Health Professions (AHPs) Building Research Capacity Across the Black Country), funded from 1/8/23-31/3/24 by a Clinical Research Network West Midlands Improvement and Innovation grant, was commissioned to facilitate the Black Country Integrated Care System to address the four domains of Health Education England's AHPs' Research and Innovation Strategy for England (capacity, capability, context and culture). This evaluation aimed to understand research-readiness, initiate research skills development through bespoke training, increase research capacity of the local AHP Community and inform the Integrated Care Board of future requirements. Methods: AHPs in six Black Country NHS Trusts, West Midlands, United Kingdom (n = 2396) were invited to participate in a cross-sectional survey via Microsoft forms (October-November 2023). Baseline levels of engagement in research activities, existing research skills, barriers to engagement, and training needs were explored. Descriptive analysis and thematic analysis for free text answers were undertaken. Project outputs included bespoke training, shared digital space, and Research Champions identification and support; success of the project was evaluated. Results: There were 440 eligible responses from 11 of 14 professions (response rate 18.4%) with over half qualified > 10 years. Qualifications ranged from diploma (5.9%), degree/BSc (40.2%), postgraduate credits (27.0%), and MSc (24.6%) to PhD (0.9%). Research outputs were limited: 85.9% had no publications, 83.8% no abstract submissions; only 6.8% had Chief/Principal Investigator experience. However, audit (83.6%), service evaluation (75.9%), and quality improvement (78.9%) activities were common. Main barriers to research engagement were work pressures (42%), commitments outside work (22%), deemed not applicable (14%), not supported (8%), and not interested (7%). Training needs and Research Champions (n = 93) were identified. Training sessions (n = 23) were attended by 169 AHPs and well-evaluated. The digital space facilitated networking (285 AHPs signed-up). Conclusions: The Research ABC project identified baseline research levels for AHPs across the Black Country, and delivered training, with potential to develop research capability and capacity. Research Champions enable research, creating a supportive environment (context) and changing culture, addressing the AHP Research Strategy vision. The Research ABC model and GO-RESEARCH recommendations (developed from the project findings) could be adopted more widely to help drive AHP research forward; appropriate infrastructure and raising the importance of research is essential to achieve this in the future.
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Patient-reported outcomes as early warning signs of flare following drug cessation in rheumatoid arthritisObjectives: Drug withdrawal in rheumatoid arthritis (RA) in remission can reduce toxicity, but with the risk of flare which requires close monitoring. We explored the potential of patient-reported outcomes (PROs) for flare detection among RA patients in sustained remission after conventional synthetic disease-modifying antirheumatic drug (csDMARD) cessation. Methods: Four PROs (Factors that Limit sustAined Remission in rhEumatoid arthritis (FLARE-RA), EuroQol-5 Dimensions (EQ5D), Routine Assessment of Patient Index Data-3 (RAPID-3) and RA Flare Questionnaire (RA-FQ)) were captured at baseline and at sequential visits until time-of-flare or end of 6-month follow-up as part of the BIO-FLARE prospective cohort study. Flare was defined as any of (i) Disease Activity Score 28 (DAS28)-C reactive protein (CRP) ≥3.2 at any visit, (ii) DAS28-CRP≥2.4 on two visits within 2 weeks or (iii) resuming DMARD and/or steroid therapy despite DAS28-CRP<2.4. Cox regression models with time-varying covariates were fitted to evaluate associations between PRO changes and likelihood of flare. Receiver-operating characteristic (ROC) curves enabled discriminatory changes in each PRO to be compared as a means of identifying flare. Results: 58/121 (47.9%) participants (70.1% females, mean age 64.8 years) experienced a flare. A 1-point change in each PRO score was strongly associated with flare development in the multivariate Cox regression model (p<0.001 in each case). ROC curve analysis confirmed that monitoring adverse changes in PROs from baseline offered robust discriminatory utility for identifying flare occurrence. This was most evident for RA-FQ and FLARE-RA (both areas under the curves 0.90, 95% CI 0.84 to 0.96; p=0.001); for example, an RA-FQ increment of ≥5.5 from baseline identified objective flare with positive and negative predictive values of 80% and 91%, respectively. Conclusions: Our data support the potential value of remote PRO monitoring of RA patients in drug-free remission to identify flare occurrence.
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Vamorolone : a novel metabolism resistant steroid that suppresses joint destruction in chronic polyarthritis with reduced systemic side effectsObjectives: Vamorolone, a dissociated steroidal compound with reduced side effects, offers a promising alternative to traditional glucocorticoids for inflammatory diseases. Unlike conventional glucocorticoids, vamorolone lacks the hydroxyl or ketone groups required for metabolism by 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), a key enzyme that modulates glucocorticoid activity. This study investigates vamorolone's resistance to 11β-HSD1 metabolism and assesses its therapeutic efficacy in the murine tumour necros factor-alpha-overexpressing (TNFtg) model of polyarthritis. Methods: 11β-HSD1 metabolism and action were examined in Hs68 and primary leucocyte culture. Vamorolone 20 mg/kg/day, prednisolone (standard of care) or vehicle were administered by gavage to TNFtg or TNFtg 11β-HSD1 knock-out (TNFtg11BKOKO) animals. Body weight and disease severity were scored daily, and markers of inflammation, joint destruction and side effects assessed at day 56 of age. Results: Vamorolone was entirely resistant to 11β-HSD1 metabolism in vitro. Vamorolone demonstrated comparable anti-inflammatory actions in TNFtg mice, with a comparable reduction in joint inflammation, serum interleukin-6 (IL-6) and synovitis relative to prednisolone. However, vamorolone-treated mice did not experience typical glucocorticoid side effects, including adrenal atrophy, body weight reduction, muscle wasting or inhibition of anabolic bone metabolism. These benefits persisted in 11β-HSD1 knockout mice, indicating that the efficacy of vamorolone is largely independent of 11β-HSD1 metabolism. Conclusion: The findings suggest that at the effective anti-inflammatory dose examined in this study, vamorolone possesses a reduced profile of deleterious systemic effects relative to prednisolone. Whilst highlighting its potential for broader clinical application in inflammatory conditions, it remains unclear whether these side effects would remain mild at markedly higher doses.
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Clinical predictors of flare and drug-free remission in rheumatoid arthritis : preliminary results from the prospective BIO-FLARE experimental medicine studyObjectives: Huge advances in rheumatoid arthritis (RA) treatment mean an increasing number of patients now achieve disease remission. However, long-term treatments can carry side effects and associated financial costs. In addition, some patients still experience painful and debilitating disease flares, the mechanisms of which are poorly understood. High rates of flare and a lack of effective prediction tools can limit attempts at treatment withdrawal. The BIOlogical Factors that Limit sustAined Remission in rhEumatoid arthritis (BIO-FLARE) experimental medicine study was designed to study flare and remission immunobiology. Here, we present the clinical outcomes and predictors of drug-free remission and flare, and develop a prediction model to estimate flare risk. Design, setting and participants: BIO-FLARE was a multicentre, prospective, single-arm, open-label experimental medicine study conducted across seven National Health Service Trusts in the UK. Participants had established RA in clinical remission (disease activity score in 28 joints with C reactive protein (DAS28-CRP)<2.4) and were receiving methotrexate, sulfasalazine or hydroxychloroquine (monotherapy or combination). Interventions: The intervention was disease-modifying anti-rheumatic drug cessation, followed by observation for 24 weeks or until flare, with clinical and immune monitoring. Outcome measures: The primary outcome measure was the proportion of participants experiencing a confirmed flare, defined as DAS28-CRP≥3.2 or DAS28-CRP≥2.4 twice within 2 weeks, and time to flare. Exploratory predictive modelling was also performed using multivariable Cox regression to understand risk factors for flare. Results: 121 participants were recruited between September 2018 and December 2020. Flare rate by week 24 was 52.3% (95% CI 43.0 to 61.7), with a median (IQR) time to flare of 63 (41-96) days. Female sex, baseline methotrexate use, anti-citrullinated peptide antibody level and rheumatoid factor level were associated with flare. An exploratory prediction model incorporating these variables allowed estimation of flare risk, with acceptable classification (C index 0.709) and good calibration performance. Conclusion: The rate of flare was approximately 50%. Several baseline clinical parameters were associated with flare. The BIO-FLARE study design provides a robust experimental medicine model for studying flare and remission immunobiology. Trial registration number: ISRCTN registry 16371380.
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Laser hair depilation therapy for pilonidal sinus disease : a 5-year, retrospective experience in a university teaching hospital in the UK, 2017-2023Background: Pilonidal sinus disease (PSD) is a chronic debilitating condition predominantly affecting young men. Laser hair depilation is an established adjunct to surgical treatment for PSD and can lead to reduced rates of recurrence, and post-surgical interventions.This study aimed to assess the outcome of laser hair depilation therapy on disease progression in pilonidal sinus disease patients at the Birmingham Skin Regional Laser Centre. Methods: Patient demographics, PSD clinical stage, laser type, number of laser sessions, surgical intervention, and treatment outcomes were extracted from electronic medical records of patients (n=97) referred for laser hair depilation between 2017 and 2023. Statistics were performed using Microsoft Excel and R. Treatment outcomes were categorised as improvement (healed, improved) or no improvement of underlying PSG. Disease severity was classified using Guner et al.'s method. Results: Most patients affected were males (77.3%). Median age was 22 (IQR, 20 - 28). Median LHR sessions were 8 (IGR, 5.5, 10). The number of LHR sessions provided was the only predictive factor for symptom resolution (p = 1.28e-06). Neither undergoing surgical intervention nor the type of surgery (incision, excision, modified flap, or endoscopic surgical intervention) performed showed a significant association with improvement in PSD (p = 0.474, p = 0.6504). In the subgroup of patients who did not undertake surgery (n = 32, 33.0%), 25 (79.1%) patients had improvement or healing in their PSD. There was no statistically significant association between age, type of laser, disease severity, and benefit from LHR. No complications were reported and there was only one case of recurrence. Conclusion: Laser hair depilation is a safe and effective post-operative adjunct treatment for treating sacrococcygeal PSD. For early stage disease it may offer curative treatment.
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Meeting report : The Systemic Lupus International Collaborating Clinics (SLICC) world Lupus seminar on AfricaThe Systemic Lupus International Collaborating Clinics (SLICC) is an international research group dedicated to promoting collaboration among scientific investigators in the study of systemic lupus erythematosus (SLE). Currently, most SLICC members are based in North America and Europe, with limited representation from other regions. SLICC recognises the importance of expanding its global collaborations and representation to ensure that its research accurately reflects the global burden of SLE and provides equal benefit to all patients with SLE worldwide. Given that SLICC currently lacks representation from the African continent, an opportunity was identified to convene a meeting bringing together lupus physicians with experience providing clinical care and conducting lupus research in Africa, along with members of the SLICC group. The purpose of the meeting was to share information regarding SLE in Africa, to discuss recent innovations and current challenges in the region and to explore future collaborations between SLICC members and colleagues in Africa in the areas of SLE clinical care, research and education. This meeting report highlights information presented during the seminar as well as a discussion of next steps moving forward.
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Exploring barriers and facilitators to self-management for patients with persistent musculoskeletal conditions following NHS-led hydrotherapy : a service evaluationIntroduction: Persistent musculoskeletal (MSK) disorders are one of the leading reasons for years lived with disability within the UK. Guidelines encourage integrating self-management support. Hydrotherapy supports patients with persistent MSK conditions; however, self-management following NHS-led hydrotherapy has been inconsistent. Aim: To identify outcomes of hydrotherapy alongside the barriers, facilitators, and contributory factors affecting self-management in the local persistent MSK pain population. Methods: Between April 2023 and May 2023, a service evaluation was undertaken exploring factors affecting self-management in the local persistent MSK pain population following NHS-led hydrotherapy. Demographics, clinical factors, functional status (MSK-HQ) and patient-reported experiences, including barriers and facilitators to self-management, were recorded. Data was analysed using descriptive statistics alongside exploration of themes. Results: Ninety patients completed hydrotherapy. White British (n = 24) and Indian British (n = 23) were the most common groups to attend. Multiple joint (n = 27) and spinal conditions (n = 26) were the most common MSK conditions. Mean pre- and post-MSK-HQ scores were 20.8 and 26.1, respectively. Among the contactable patients (n = 69), 49 patients did not maintain independent water-based self-management reporting barriers such as ongoing support, access and financial concerns. Patients supported the establishment of a support group (n = 56) to help maintain water-based exercises. Conclusions: The local persistent MSK pain population lacks self-efficacy for independent water-based self-management. A supportive and collaborative approach is proposed to address this via a patient-led hydrotherapy support group.
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A review on the epidemiology of rheumatoid arthritis : an update and trends from current literatureRheumatoid arthritis (RA) is a systemic, chronic autoimmune disease affecting mainly the joints, often with extra articular manifestations. This review provides an update on RA epidemiological trends and management. PubMed and EMBASE were searched from 2014 to 2024 using rheumatoid arthritis as keyword, combined with incidence, prevalence, diagnosis, classification, and management. Emphasis was on papers published in the past 5 years. Globally, the age-standardised prevalence and incidence rate (ASPR and ASIR) of RA increased with varying figures. The ASPR increased by 0.37%, 14.1%, and 6.4% from 1990 to 2019, 2020 and 2017 respectively; and 9% from 1980 to 2019. The ASIR increased by 0.3% and 8.2% from 1990 to 2019 and 2017 respectively; the disability-adjusted life years (DALY) figures increased 0.12% and decreased 0.36% in the same period from different authors. Reduction in ASIR were reported while ASPR varies. Disease modifying anti-rheumatic drugs (DMARDs) remain the cornerstone of treatment.
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Long-term improvements in glycemia and user-reported outcomes associated with open-source automated insulin delivery systems in adults with type 1 Diabetes in the United Kingdom : a real-world observational studyObjective: To evaluate real-world outcomes in adults with type 1 diabetes initiating open-source automated insulin delivery systems (OS-AID). Methods: Adults with type 1 diabetes who commenced OS-AID, between May 2016 and April 2021, across 12 centers in the United Kingdom were included. Anonymized clinical data, collected during routine clinical care between December 2019 and November 2023, were submitted to a secure web-based tool within the National Health Service network. Outcomes included change in hemoglobin A1c (HbA1c), sensor glucometrics, diabetes distress score, Gold score (hypoglycemia awareness), user opinion of OS-AID, and event rates (hospital admissions, paramedic callouts, severe hypoglycemia, and adverse events) between baseline and follow-up. Results: In total, 81 OS-AID users were included (51.9% male; 90.1% White British; mean age 41.4 years; median diabetes duration 25 years [IQR 17-32]). Over a mean follow-up of 1.7 years, HbA1c reduced by 0.8% (9 mmol/mol) (7.3 ± 1.1% vs. 6.5 ± 0.7%; P < 0.001), and the percentage of individuals achieving HbA1c ≤ 7.0% (53 mmol/mol) increased from 48.6% to 75.7% (P < 0.001). Diabetes-related distress score reduced by 0.9 (95% confidence interval [CI] -0.3, -1.5; P = 0.006), and Gold score reduced by 0.7 (95% CI -0.1, -1.3; P = 0.022). The percentage of individuals with impaired hypoglycemia awareness (Gold score ≥4) reduced (27.8% at baseline vs. 8.3% at follow-up; P = 0.039). Of those asked, all participants stated that OS-AID had a positive impact on quality of life. The number of hospital admissions was low. Conclusions: The use of OS-AID is associated with long-term improvements in HbA1c, hypoglycemia awareness, and diabetes-related distress in type 1 diabetes. These benefits were achieved without increased rates of hospital admissions, diabetic ketoacidosis, or severe hypoglycemia.
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EXamining the feasibility of exerCisE to manage symptoms of Lupus (EXCEL) : a protocol for a randomised controlled pilot studyIntroduction: SLE is a chronic autoimmune disease that results in sustained hyperactivation of innate and adaptive immune cells and widespread inflammatory damage. Regular exercise reduces SLE symptoms including fatigue and joint pain and improves patient quality of life. However, most individuals with SLE are not sufficiently active to achieve these benefits, and guidance on the optimal approach to exercise is limited. EXCEL will examine the feasibility of conducting a large-scale randomised controlled trial comparing the effects of a remotely monitored, home-based, exercise programme with standard of care for individuals with SLE. Methods and analysis: 30 females with SLE will be recruited, and those randomised into Exercise (SLE-Ex) will codesign a progressive training plan with support from the research team. The aim of each 12-week plan will be to complete 150 min of moderate (60-70% heart rate max, HRmax) or 90 min of vigorous exercise (>70% HRmax) per week. SLE-Ex will be encouraged to exercise independently (without support) from weeks 13-18. Participants with SLE that are randomised into Control (SLE-Con) will maintain habitual activity without support for 18 weeks. Measures of feasibility and acceptability will be reported, and peripheral blood will be collected at weeks 0, 12 and 18 to explore whether the frequency, phenotype and metabolic profile of lymphocyte subsets has changed. Biomarkers of SLE activity, and self-reported measures of fatigue, sleep quality and health-related quality of life will also be monitored at these timepoints. Blood and self-reported measures will be compared with a healthy control (HC) group (n=15, age and body mass index matched) at baseline only. Ethics and dissemination: A favourable ethical opinion was given by South East Scotland Research Ethics Committee (22/SS/0082). Findings will be disseminated at conferences and published in peer-reviewed journals.
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Time below range and its influence on hypoglycemia awareness and severe hypoglycemia : insights from the Association of British Clinical Diabetologists studyObjective: This study aimed to explore the relationship between time below range (TBR), impaired awareness of hypoglycemia (IAH), and severe hypoglycemia (SH). Research design and methods: This cross-sectional study analyzed data from individuals with diabetes using continuous glucose monitors (CGMs) in the Association of British Clinical Diabetologists audit. Hypoglycemia awareness was assessed via the Gold score (≥4 denoting IAH), and SH was defined as hypoglycemia requiring third-party assistance. Logistic regression was used to determine the association between TBR percentage (<70 mg/dL; 3.9 mmol/L) at first follow-up and follow-up Gold score and SH incidence. The Youden J index identified optimal TBR percentage cutoffs for detecting IAH and SH. Results: The study included 15,777 participants, with follow-up TBR and SH data available for 5,029. The median TBR percentage was 4% (interquartile range 2-6.6%), with 42% meeting the recommended TBR of ≤4%. Adjusted for age, sex, and BMI, TBR was significantly associated with SH (P < 0.001) and IAH (P = 0.005). Optimal TBR cutoffs for identifying IAH and SH were 3.35% and 3.95%, yielding negative predictive value (NPV) values of 85% and 97%, respectively. Conclusions: Our findings support the international consensus recommending a TBR of <4% in type 1 diabetes, with high NPV values suggesting the utility of TBR in screening for SH.
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Acute generalised exanthematous pustulosis associated with upadacitinib treatmentAcute generalised exanthematous pustulosis (AGEP) is a rare drug-induced pustular eruption characterised by the rapid onset of superficial pinhead pustules. We discuss the case of a 27-year-old man who presented with a generalised pustular eruption on the neck, trunk and limbs. He commenced upadacitinib for the treatment of atopic dermatitis (AD) 6 months before developing the rash, and the dose was increased from 15 to 30 mg daily, 3 months prior. His only other medication was oral terbinafine, for suspected tinea corporis, which was initiated 1 month before developing the pustular eruption. Laboratory investigations showed a mildly raised CRP 25 mg/L, neutrophilia 8.22 10 × 9/L, and a mildly raised ALT 46 U/L. A skin biopsy showed subcorneal pustules and a few scattered keratinocytes. Upadacitinib and terbinafine were suspended and the pustular eruption resolved. Updacitinib was reintroduced 3 weeks later as the rash was thought to be due to terbinafine and the rash recurred. He was diagnosed with AGEP secondary to upadacitinib. Upadacitinib is a selective JAK inhibitor that is increasingly used for the management of AD and clinicians should be aware that AGEP is a rare but severe adverse effect.
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Optimising musculoskeletal patient flow through digital triage and supported self-management : a service evaluation set within community musculoskeletal careIntroduction: Musculoskeletal (MSK) conditions are one of the leading causes of years of living with disability in the UK, resulting in pressure on the health system and the UK economy. In response to the increasing levels of patients accessing NHS care with MSK conditions across Sandwell and West Birmingham (SWB), a digital triage and self-management tool was implemented in 2023. Aims: To optimise safety, efficiency, and choice within the community MSK service from the first contact through to specialist MSK care through digital triage and supported self-management. Methods: SWB's community MSK service implemented two digital tools in January 2023. Objectives included 1. Increase safety, through providing 24/7 access to rapid digital MSK triage; 2. Optimise workforce by releasing clinicians back to face-to-face care, increasing clinical capacity, 3. Increase patient choice by offering digitally supported self-management to appropriate low risk patients. Results: 4804 patients self-referred to the MSK service through the digital triage tool within the first 12 months. 378 of these patients were offered, accepted, and accessed self-management support using the digital self-management app. These innovations led to the release of 1240 clinical hours for face-to-face care, an average 8-week reduction in waiting times and high patient satisfaction (80% good/very good). Conclusion: Evaluation over the first 12 month showed that the digital innovations were safe, led to enhanced access to and choice of care pathways, optimised use of clinical staff, and received positive patient feedback. Research is needed in this newly emerging area of practice to support further adoption across the healthcare system.
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Clinical characteristics and variation in musculoskeletal complexity of different ethnic populations accessing Sandwell and West Birmingham Hospital's MSK Service : a service evaluationIntroduction: Health inequality is a global public health challenge, limited by insufficient high-quality data and analysis. Musculoskeletal (MSK) pain disorders are more prevalent among ethnic minority groups disproportionately affected by socioeconomic disparities and poor health outcomes. Ethnicity data collection enables NHS organisations and policymakers to understand specific healthcare needs and ensure equitable access and care provision. Objective: To understand the baseline clinical characteristics across ethnic population groups accessing MSK care at Sandwell and West Birmingham (SWB) NHS Trust. Methods: Retrospective analysis of routine data collected using patient self-report surveys (August 2020-February 2023). Core metrics included demographics, pain characteristics, and Patient Reported Outcome Measures (PROMs) including the Musculoskeletal Health Questionnaire (MSK-HQ) and Numeric Pain Rating Scale (NPRS). Descriptive statistics and statistical tests were undertaken, with means, percentage values and variation by ethnic groups across baseline MSK-HQ and pain scores reported. Results: Survey data were provided by 13,248 patients, with 7295 (55.06%) stating their ethnicity. Statistical differences were found between baseline MSK-HQ and NPRS scores between ethnic groups. The mean MSK-HQ score was 24.1 overall, lowest in the Asian group (22.3) and highest in the Mixed group (24.8). Mean baseline pain intensity was (7.8), highest in the Asian group (8.3). One or more comorbidities were present in 46% of patients, with the highest percentage in the White and Black groups sequentially. Conclusion: Baseline health inequalities exist among ethnic groups accessing the SWB MSK service. Disparities may be associated with patient or system barriers and require further exploration.
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Cutaneous vasculitis in systemic lupus erythematosus : epidemiology and risk factors over a 20-year follow-upObjectives: Cutaneous vasculitis (CV) is common in SLE, but the epidemiology and risk factors remain unclear. We aimed to identify the trends and risk factors for CV in patients with SLE over a period of 20 years. Methods: The Birmingham Lupus Cohort is an observational longitudinal cohort of SLE patients. Patients were enrolled within 3 years of meeting their fourth ACR criterion. Disease activity, laboratory test results and treatment records were collected. A multivariable shared frailty Cox proportional hazard model was used to identify clinical, laboratory, and treatment-related variables associated with the development of CV. Results: We included 392 patients: 92.5% were female. The median (IQR) duration of follow up was 9.2 (5.1-14.7) years. CV occurred in 27% of SLE patients, of whom 43.3% had two or more CV events. This study demonstrated a marked decline in the incidence rates of CV, decreasing from 34.4% (95% CI: 29.7, 39.3) during the first three years after enrolment to 2.1% (95% CI: 0.05, 11.5) after 18 years of follow-up. Development of CV was associated with Raynaud's phenomenon, constitutional, mucocutaneous, musculoskeletal, haematological, and cardiovascular involvement, anti-Sm antibodies, anti-dsDNA and hypocomplementemia. However, the use of azathioprine and antimalarials was inversely associated with the development of CV. Patients with CV were more likely to develop at least 1 item of organ damage. Conclusions: The incidence rates of CV in SLE decreased over the follow-up period and CV is associated with defined clinical, serological and treatment-related factors.
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Quality indicators for the primary and community care of musculoskeletal conditions : a systematic reviewObjectives: To identify, appraise, and synthesize common themes from quality indicator (QI) sets designed for the assessment, management, and rehabilitation of musculoskeletal (MSK) conditions in primary and community care contexts. Data sources: A systematic search was performed on six databases (MEDLINE, EMBASE, AMED, Web of Sciences Core Collection, The Cochrane Library, and The Health Management Information Consortium), public repositories, and the websites of organizations involved in the reporting of MSK QIs. Study selection: Potential QI sources were screened for relevance using an a priori criteria. After the screening of 1493 titles, abstracts, 71 articles were reviewed independently by two authors, of which 25 met our criteria and were therefore included within the review. Data extraction: The development of the QI sets was appraised using the AIRE instrument. Key characteristics of QI sets were extracted and tabulated. Nine out of 25 QI sets had "high" developmental methodology quality. A total of 410 QIs were identified from 25 QI sets. Data synthesis: A narrative synthesis was undertaken to identify common themes among QIs. Themes were mapped against improvement drivers mentioned in recent British primary/community MSK care policy directives. Finally, "Draft Indicators" were synthesized from common themes identified. Eleven overarching themes were synthesized: policy and governance; optimizing access and provision of care; staffing and spending; optimizing assessment and diagnosis; optimizing patient education and self-management; pharmacology and injection guideline adherence; optimizing personalized care; optimizing imaging, investigations, and referral; public health management relevant to MSK conditions; optimizing patient experience; and optimizing patient outcomes. Conclusions: This review has identified common themes among QIs that focus on optimizing assessment, investigations, and treatment decisions for the primary/community care of MSK conditions. This work represents a valuable resource to commissioners, service managers, and clinicians internationally who resource, monitor, manage, assess, and rehabilitate individuals with MSK conditions.