Quality standards for the care of people with giant cell arteritis in secondary care.

OBJECTIVE: GCA is the commonest primary systemic vasculitis in adults, with significant health economic costs and societal burden. There is wide variation in access to secondary care GCA services, with 34% of hospitals in England not having any formal clinical pathway. Quality standards provide levers for change to improve services. METHODS: The multidisciplinary steering committee were asked to anonymously put forward up to five aspects of service essential for best practice. Responses were qualitatively analysed to identify common themes, subsequently condensed into domain headings, and ranked in order of importance. Quality standards and metrics for each domain were drafted, requiring a minimum 75% agreement. RESULTS: 13 themes were identified from the initial suggestions. Nine quality standards with auditable metrics were developed from the top 10 themes. Patient Access, glucocorticoid use, pathways, ultrasonography, temporal artery biopsy, PET scan access, rheumatology/ophthalmology expertise, education, multidisciplinary working have all been covered in these quality standards. Access to care is a strand that has run through each of the developed standards. An audit tool was developed as part of this exercise. CONCLUSION: These are the first consensus auditable quality standards developed by clinicians from rheumatology and ophthalmology, nursing representatives and involvement of a patient charity. We hope that these standards will be adopted by commissioning bodies to provide levers for change from the improvement of patient care of individuals with GCA.

Systemic rheumatoid vasculitis in the era of modern immunosuppressive therapy.

OBJECTIVES: Systemic rheumatoid vasculitis (SRV) is a rare but potentially serious systemic disease manifestation of rheumatoid arthritis (RA) characterized by the development of necrotizing vasculitis. The incidence of SRV appears to be decreasing possibly reflecting progress in RA treatment. The aims of this study were to review the clinical manifestations of SRV in a stable well-defined population during 2001-10 and to compare with our previous cohort (1988-2000) and also a cohort from 1975 to 1981. METHODS: Using Norfolk Vasculitis Register, a prospective register of patients with systemic vasculitis since 1988, all patients with a diagnosis of SRV from 1 January 2001 until 31 December 2010 were identified. SRV was defined according to the Scott and Bacon criteria (1984). Clinical features were obtained by retrospective case note review. RESULTS: Eighteen patients with SRV were identified (10 male), median age at diagnosis was 72 years and average disease duration 15.6 years. The average annual incidence for 2001-10 was 3.9 per million. One-year mortality was 12% and 5-year mortality 60%. The clinical manifestations were similar apart from systemic and cutaneous features which were more common in the earlier cohorts. CONCLUSION: The incidence of SRV has declined significantly in the last 40 years; but the clinical manifestations remain similar. Systemic symptoms, and cutaneous manifestations such as infarcts and nodules, are slightly less common in the recent cohort. Despite modern immunosuppressive therapy the prognosis remains poor.

The informational needs of patients with ANCA-associated vasculitis-development of an informational needs questionnaire.

OBJECTIVE: The aim of the study was to compare the informational needs of patients with ANCA-associated vasculitis (AAV). METHODS: We developed a Vasculitis Informational Needs Questionnaire that was distributed to members of Vasculitis UK (VUK) by mail and registrants of the Vasculitis Clinical Research Consortium (VCRC) online registry with self-reported AAV. Patients were asked to use a 5-point scale (1 = not important, 5 = extremely important) to rank aspects of information in the following domains: disease, investigations, medication, disease management and psychosocial care. The source and preferred method of educational delivery were recorded. RESULTS: There were 314 VUK and 273 VCRC respondents. Respondents rated information on diagnosis, prognosis, investigations, treatment and side effects as extremely important. Information on patient support groups and psychosocial care was less important. There was no difference in the ratings of needs based on group, sex, age, disease duration, disease or method of questionnaire delivery. The most-preferred methods of providing information for both groups were by a doctor (with or without written material) or web based; educational courses and compact disc/digital video disc (CD/DVD) were the least-preferred methods. CONCLUSION: This study demonstrates that people with AAV seek specific information concerning their disease, treatment regimes and side effects and the results of investigations. Individuals preferred to receive this information from a doctor. Patients with AAV should be treated in a similar manner to patients with other chronic illnesses in which patient education is a fundamental part of care.

HEAL: a strategy for advanced practitioner assessment of reduced urine output in hospital inpatients.

AIMS AND OBJECTIVES: To produce a model for advanced nurse practitioners (ANPs) to follow in the assessment and management of patients with a reduced or low urine output. BACKGROUND: Reduced urine output can be caused by a multitude of factors, some of which signify serious disease or may lead to serious morbidity. Assessment of reduced urine output is essential to ensure that patient safety is maintained at all times. Advanced nurse practitioners can add to patient safety by undertaking assessments of these patients at appropriate times and managing appropriately. DESIGN: This paper presents a new model for immediate triage, assessment and treatment for reduced urine output, using history, early warning score, accuracy and laboratory results, or HEAL, with clear points for referral where appropriate. CONCLUSION: This model can be used by advanced nurse practitioners to guide assessments and ensure that patients are appropriately managed in response, with minimal additional training. RELEVANCE TO CLINICAL PRACTICE: This can aid advanced nurse practitioners in assessment, increasing patient safety and expatiating management. This shows how ANPs can be used to safely blur traditional professional boundaries with the aid of protocols.

The contrasting epidemiology of granulomatosis with polyangiitis (Wegener's) and microscopic polyangiitis.

OBJECTIVES: Granulomatosis with polyangiitis (Wegener's) (GPA) and microscopic polyangiitis (MPA) are uncommon and have unknown aetiology. The aim of the study was to investigate the epidemiology of GPA and MPA in a stable, well-defined population looking for differences in the pattern of occurrence, which might suggest a different aetiology. METHODS: Since 1988, we have maintained a prospective register of all patients with systemic vasculitis attending the Norfolk and Norwich University Hospital. Patients presenting with new-onset GPA and MPA as defined by the European Medicines Agency algorithm and registered with general practitioners in the former Norwich Health Authority area between 1988 and 2010 were identified. The population in 2008 was estimated to be 459 000 (221 000 males). RESULTS: One hundred and eleven GPA and 58 MPA incident cases were identified during 1988-2010. The overall annual incidence of GPA and MPA was 11.3/million and 5.9/million, respectively. There was evidence of a cyclical pattern of occurrence with a periodicity of 7.6 years for GPA with a peak incidence of 28.3/million in 2005 and the lowest in 2002 (2.2/million). Other lesser peaks occurred in 1990 and 1996. While the peak incidence of MPA was in 2008 (15.2/million), there was no convincing evidence of periodicity. The incidence of cANCA/PR3- or pANCA/MPO-positive vasculitis showed a similar pattern to GPA and MPA, respectively. CONCLUSION: This study lends support to the notion that the aetiology of GPA and MPA may be distinct conditions with different aetiologies. The cyclical incidence of GPA is possibly an indication for the influence of infection.

An evaluation of rheumatology practitioner outreach clinics: a qualitative study.

BACKGROUND: Services for Rheumatoid Arthritis (RA) have evolved with the development of independently led outreach Rheumatology Practitioner (RP) clinics in Primary Care (PC). Their clinical and cost effectiveness, compared with Secondary Care (SC) services, has not been assessed. The RECIPROCATE study aims to evaluate their clinical and cost effectiveness. This part of the study aimed to explore health professionals' opinions of rheumatology outreach service. METHODS: Using a qualitative design, semi-structured interviews were conducted with GPs, practice nurses, hospital doctors and RPs, from one hospital and seven PC practices in Norfolk, to elicit their opinions of the service. The interviews were analysed using thematic analysis. RESULTS: All participants agreed the service was supportive and valuable providing high quality personalised care, disease management, social, and educational support. Advantages identified included convenience, continuity of care and proximity of services to home. RPs helped bridge the communication gap between PC and SC. Some participants suggested having a doctor alongside RPs. The service was considered to be cost effective for patients but there was uncertainty about cost effectiveness for service providers. Few disadvantages were identified the most recurring being the lack of other onsite services when needed. It was noted that more services could be provided by RPs such as prescribing and joint injections as well as playing a more active role in knowledge transfer to PC. CONCLUSIONS: Professionals involved in the care of RA patients recognised the valuable role of the RP outreach clinics. This service can be further developed in rheumatology and the example can be replicated for other chronic conditions.

ANCA vasculitis: time for a change in treatment paradigm? Not yet.

The ANCA-associated vasculitides (AAVs) are conventionally treated with a strategy of remission induction followed by maintenance therapy using glucocorticoids combined with CYC during induction and AZA for maintenance. Recently, several randomized controlled trials have been published that question whether these drugs should remain those of choice. B-cell depletion using rituximab is at least as effective as CYC for remission induction in newly presenting patients, but long-term efficacy, safety and cost-effectiveness data are awaited, and thus rituximab should be reserved for patients at high risk of infertility. Rituximab seems to be effective at inducing remission in relapsing patients. Whether routine pre-emptive treatment with rituximab for remission maintenance is a better approach than waiting for relapse is unknown. MTX and LEF have similar efficacy to AZA, but are not significantly safer; while MMF is less effective. Thus, AZA remains the conventional maintenance drug of choice.

Homeostasis 6: nurses as external control agents in rheumatoid arthritis.

All disorders involve a disturbance of cellular and hence chemical function in the body. Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease that usually attacks synovial joints and surrounding ligaments, muscles and their tendons and blood vessels. This article applies the concept of health professionals operating as external agents of homeostatic control (Clancy and McVicar, 20011a; 2011b) to RA and to the care of affected patients, using a case scenario to illustrate attempts to minimize homeostatic imbalances. After reading the article, nurses should be able to understand: how the principles of homeostatic theory apply to skeletomuscular function, in particular to synovial joint function; the skeletomuscular homeostatic role in movement; and that homeostatic failure of reduced mobility, as in RA, is a result of nature-nurture interaction; that illness arises from a cellular, hence chemical, homeostatic imbalance(s) (Clancy and McVicar, 2011a; 2011b; 2011c; 2011d; 2011e). RA is considered a cellular (B-lymphocyte) hence chemical (autoantibody) imbalance that causes the homeostatic imbalances (inflammatory pain, reduced mobility, reduced activities of daily living) associated with the condition. Health professionals are able at act as external agents of homeostatic control to only a limited extent when caring for people with RA because, as with any progressive disorder, they will only be managing signs and symptoms to improve patients' quality of life.

The epidemiology of Takayasu arteritis in the UK.

OBJECTIVES: Takayasu arteritis (TAK) is a large-vessel vasculitis of unknown aetiology. The annual incidence in hospital-based studies is 1-2/million. The UK General Practice Research Database (UKGPRD) contains complete primary care records on 3.6 million people. There are no data on the incidence of TAK in the UK or from primary care anywhere in the world. The aim of this study was to determine the annual incidence of TAK in the UK using the UKGPRD and in a well-defined hospital population [Norfolk Vasculitis Register (NORVASC)]. METHODS: We identified all patients in the UKGPRD with a first diagnosis of TAK during 2000-05, using the Read code (G757); and in the NORVASC population. The annual incidence was calculated as the number of incident cases divided by total person-years. RESULTS: A total of 14 (13 females) subjects were identified with a first diagnosis of TAK during 2000-05 in the UKGPRD. The median age was 51.0 years (interquartile range 28-66). The overall annual incidence of TAK was 0.8/million (95% CI 0.4, 1.3). The incidence was stable throughout the study period. The mean prevalence of TAK was 4.7/million. There were six patients (five females) aged <40 years presenting in 2000-05 with TAK. The annual incidence in those aged <40 years was 0.3/million. In the NORVASC population, one case was identified (0.4/million/year) with three prevalent cases (7.1/million). CONCLUSION: This is the first population-based study of the epidemiology of TAK. The annual incidence and prevalence are consistent with previous studies.

Impact of caring for someone with a rare rheumatic condition, views from patients and informal carers-the need for cat-like vigilance.

OBJECTIVE: ANCA-associated vasculitis (AAV) is a rare multisystem disease. Modern therapeutic protocols have turned AAV from an acute, frequently fatal disease into a chronic disease requiring long-term immunosuppression. Patients must often manage substantial burdens related to chronic illness and treatment-related side effects, requiring help from informal carers. This study aimed to explore the experience of patients and of informal carers of patients with AAV about the impact of managing a rare rheumatic condition. METHODS: A qualitative approach using semi-structured interviews was used. Interviews were conducted with a purposeful sample of 18 pairs of patients with AAV and their informal carers. The interviews were used to explore the participants' experience and effects of caring. The interviews were recorded and transcribed as verbatim text and analysed using the framework technique. RESULTS: Eighteen patients (seven female; disease: 10 granulomatosis with polyangiitis; four microscopic polyangiitis; four eosinophilic granulomatosis with polyangiitis; age range 34-78 years; disease duration 1-20 years). Caregiver and patient perspectives were shared. The emerging themes were the physical and psychological impacts of the disease, the need for constant vigilance and fear of the future. CONCLUSION: Both patients and carers faced a range of challenges in managing a rare condition, including the seriousness of the illness, dealing with the emotional toll and knowing what to expect. This study offers insight into the experiences of patients and informal carers, and health-care professionals should address individuals' fears and expectations for recovery.

Validation of the EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis by disease content experts.

The European League Against Rheumatism recommendations for the management of antineutrophil cytoplasmic antibody-associated vasculitis have been recently published. Unique to recommendation development, they were also voted on by members of a learned society. This paper explores the wider validity of the recommendations among people who self-identify as clinicians caring for patients with vasculitis. In addition to the task force, a learned society (European Vasculitis Society-EUVAS) was invited, through online survey, to rate independently the strength of evidence of each recommendation to obtain an indication of the agreement among the final target audience and ultimate end-users of the recommendations. The survey took place in June 2015. Of the 158 EUVAS members surveyed, there were 88 responses (55.7%). There was a large degree of agreement in the voting patterns between EUVAS survey participants and task force members. Notable exceptions were lower grades for the recommendation of the use of rituximab for remission induction in patients with eosinophilic granulomatosis with polyangiitis and for methotrexate and mycophenolate mofetil as remission maintenance agents in patients with granulomatosis with polyangiitis/microscopic polyangiitis by EUVAS members. These results are encouraging and suggest that the voting patterns of the task force are representative of the wider vasculitis community. We recommend future recommendations adopt this approach for data/expert-based treatment guidelines, especially for multisystem diseases.

The outcome and cost-effectiveness of nurse-led care in the community for people with rheumatoid arthritis: a non-randomised pragmatic study.

OBJECTIVE: To determine the outcome and cost-effectiveness of nurse-led care in the community for people with rheumatoid arthritis (RA). DESIGN: Non-randomised pragmatic study. SETTING: Primary (7 primary care practices) and secondary care (single centre) in the UK. METHODS: In a single area, pragmatic non-randomised study, we assessed the outcome, cost-effectiveness of community-based nurse-led care (NLC) compared with rheumatologist-led outpatient care (RLC). Participants were 349 adults (70% female) with stable RA assessed at baseline, 6 and 12 months. In the community NLC arm there were 192 participants. Outcome was assessed using Stanford Health Assessment Questionnaire (HAQ). The economic evaluation (healthcare perspective) estimated cost relative to change in HAQ and quality-adjusted life years (QALY) derived from EQ-5D-3L. We report complete case and multiple imputation results from regression analyses. RESULTS: The demographics and baseline characteristics of patients in the community group were comparable to those under hospital care apart from use of biological disease-modifying antirheumatic drugs (DMARDS), which were adjusted for in the analysis. The mean incremental cost was estimated to be £224 less for RLC compared to the community NLC, with wide CIs (CI -£213 to £701, p=0.296). Levels of functional disability were not clinically significantly higher in the community NLC group: HAQ 0.096 (95% CI -0.026 to 0.206; p=0.169) and QALY 0.023 (95% CI -0.059 to 0.012; p=0.194). CONCLUSIONS: The results suggest that community care may be associated with non-significant higher costs with no significant differences in clinical outcomes, and this suggests a low probability that it is cost-effective.

Targeted therapies for patients with rheumatoid arthritis.

Rheumatoid arthritis is characterised by an auto-immune response that eventually leads to the destruction of affected joints. This has major implications for patients' lives, with many becoming debilitated within three years of diagnosis. This paper describes the body's auto-immune mechanism and outlines new therapies that seek to block the body's destructive response to itself.

'In one ear and out the other - it's a lot to take in': a qualitative study exploring the informational needs of patients with ANCA-associated vasculitis.

OBJECTIVES: To explore the informational needs of patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS: Three focus groups and eight one-to-one interviews were conducted with patients with AAV. A purposeful sample of 15 patients (ten female) [disease: three Churg-Strauss syndrome (CSS); nine granulomatosis with polyangiitis (GPA); one microscopic polyangiitis (MPA); two polyarteritis nodosa (PAN)] participated in the focus groups. Eight (five female) (disease: three CSS; four GPA; one MPA) participated in the one-to-one interviews. A semi-structured interview guide was used to explore patients' experiences of informational needs. The focus groups and interviews were audio-recorded and transcribed verbatim, and analysed using the framework technique. RESULTS: Emergent themes were: reaction to diagnosis, need for information on disease management and access to knowledgeable practitioners. When given the initial diagnosis, all patients described themselves as being too ill to take in information and that they later found it difficult to find information. Most information received at diagnosis was in the form of verbal information given by the hospital doctor. Patients wanted positive but truthful information in the form of a booklet. CONCLUSIONS: Receiving the diagnosis of a rare, potentially life-threatening disease and then dealing with its complex treatment causes anxiety and fear and can impede information retention and recall. Patients want information on diagnosis and treatment but this should be tailored to individual needs, including timing that is appropriate for them. All patients wanted the opportunity to discuss their illness and its management with a knowledgeable healthcare practitioner but also wanted printed forms of information to assimilate at their own pace.

A literature review regarding the management of varicella-zoster virus.

Chickenpox and shingles (varicella-zoster virus [VZV]) pose a threat to individuals who are immunosuppressed and/or have rheumatoid arthritis or another inflammatory musculoskeletal condition. In this paper we present a literature review of the condition, management and prevention.