Estimation of the burden of shielding among a cross-section of patients attending rheumatology clinics with SLE-data from the BSR audit of systemic lupus erythematosus.

OBJECTIVES: We aimed to estimate what proportion of people with SLE attending UK rheumatology clinics would be categorized as being at high risk from coronavirus disease 2019 (COVID-19) and therefore asked to shield, and explore what implications this has for rheumatology clinical practice. METHODS: We used data from the British Society for Rheumatology multicentre audit of SLE, which included a large, representative cross-sectional sample of patients attending UK Rheumatology clinics with SLE. We calculated who would receive shielding advice using the British Society for Rheumatology's risk stratification guidance and accompanying scoring grid, and assessed whether ethnicity and history of nephritis were over-represented in the shielding group. RESULTS: The audit included 1003 patients from 51 centres across all 4 nations of the UK. Overall 344 (34.3%) patients had a shielding score ≥3 and would have been advised to shield. People with previous or current LN were 2.6 (1.9-3.4) times more likely to be in the shielding group than people with no previous LN (P < 0.001). Ethnicity was not evenly distributed between the groups (chi-squared P < 0.001). Compared with White people, people of Black ethnicity were 1.9 (1.3-2.8) and Asian 1.9 (1.3-2.7) times more likely to be in the shielding group. Increased risk persisted after controlling for LN. CONCLUSION: Our study demonstrates the large number of people with SLE who are likely to be shielding. Implications for clinical practice include considering communication across language and cultural differences, and ways to conduct renal assessment including urinalysis, during telephone and video consultations for patients who are shielding.

BSR guideline on the management of adults with systemic lupus erythematosus (SLE) 2018: baseline multi-centre audit in the UK.

OBJECTIVES: To assess the baseline care provided to patients with SLE attending UK Rheumatology units, audited against standards derived from the recently published BSR guideline for the management of adults with SLE, the NICE technology appraisal for belimumab, and NHS England's clinical commissioning policy for rituximab. METHODS: SLE cases attending outpatient clinics during any 4-week period between February and June 2018 were retrospectively audited to assess care at the preceding visit. The effect of clinical environment (general vs dedicated CTD/vasculitis clinic and specialized vs non-specialized centre) were tested. Bonferroni's correction was applied to the significance level. RESULTS: Fifty-one units participated. We audited 1021 episodes of care in 1003 patients (median age 48 years, 74% diagnosed >5 years ago). Despite this disease duration, 286 (28.5%) patients had active disease. Overall in 497 (49%) clinic visits, it was recorded that the patient was receiving prednisolone, including in 28.5% of visits where disease was assessed as inactive. Low documented compliance (<60% clinic visits) was identified for audit standards relating to formal disease-activity assessment, reduction of drug-related toxicity and protection against comorbidities and damage. Compared with general clinics, dedicated clinics had higher compliance with standards for appropriate urine protein quantification (85.1% vs 78.1%, P ≤ 0.001). Specialized centres had higher compliance with BILAG Biologics Register recruitment (89.4% vs 44.4%, P ≤ 0.001) and blood pressure recording (95.3% vs 84.1%). CONCLUSIONS: This audit highlights significant unmet need for better disease control and reduction in corticosteroid toxicity and is an opportunity to improve compliance with national guidelines. Higher performance with nephritis screening in dedicated clinics supports wider adoption of this service-delivery model.

Glucocorticoid use and factors associated with variability in this use in the Systemic Lupus International Collaborating Clinics Inception Cohort.

Objectives: To describe glucocorticoid (GC) use in the SLICC inception cohort and to explore factors associated with GC use. In particular we aimed to assess temporal trends in GC use and to what extent physician-related factors may influence use. Methods: Patients were recruited within 15 months of diagnosis of SLE from 33 centres between 1999 and 2011 and continue to be reviewed annually. Descriptive statistics were used to detail oral and parenteral GC use. Cross sectional and longitudinal analyses were performed to explore factors associated with GC use at enrolment and over time. Results: We studied 1700 patients with a mean (s.d.) follow-up duration of 7.26 (3.82) years. Over the entire study period, 1365 (81.3%) patients received oral GCs and 447 (26.3%) received parenteral GCs at some point. GC use was strongly associated with treatment centre, age, race/ethnicity, sex, disease duration and disease activity. There was no change in the proportion of patients on GCs or the average doses of GC used over time according to year of diagnosis. Conclusion: GCs remain a cornerstone in SLE management and there have been no significant changes in their use over the past 10-15 years. While patient and disease factors contribute to the variation in GC use, between-centre differences suggest that physician-related factors also contribute. Evidence-based treatment algorithms are needed to inform a more standardized approach to GC use in SLE.

Clinical leadership fellow schemes for junior doctors: a brief overview of available schemes and how to apply.

Medical training in the UK provides limited exposure to formal training in leadership and management, and yet the role of a consultant or general practitioner requires such skills which deal with commissioning arrangements, service transformation, quality improvement, Care Quality Commission visits, complaints and supervision of junior colleagues. A number of clinical fellowships in leadership now exist to bridge this gap, and provide training in leadership and management, together with experiential learning in a complex organisation. Well-established leadership schemes suited to junior doctors include the National Medical Director's Clinical Fellow Scheme, the Royal College of Physicians' chief registrar scheme, the Darzi Fellowship scheme and local schemes run by Health Education England. Here we describe and compare our experience of these schemes, and outline what junior doctors should consider when applying for a clinical fellowship.

Whole finger iontophoresis of sodium nitroprusside to increase blood flow in patients with systemic sclerosis: Influence of concentration.

Iontophoresis of sodium nitroprusside increases finger blood flow in patients with systemic sclerosis, a multisystem connective tissue disease. Our aim was to examine the influence of dose, as a first step in exploring a possible new therapeutic approach. Ten patients with SSc and nine healthy controls were recruited. Blood flow in a single finger was assessed using laser Doppler imaging following iontophoresis of sodium nitroprusside at 'doses' of 2, 1, 0.5 and 0%. Graphs of perfusion over time (30 min) were produced for each dose and from these curves, summary measures of response were calculated (area under curve/baseline and maximum perfusion/baseline. These measures were subject to regression analysis to investigate the effect of dose on response and to consider whether response differed between patients and healthy controls. Individual responses to altering the dose of iontophoresed sodium nitroprusside were highly variable but there was evidence to suggest increased response at doses of 0.5 and 1% (but not at 2%) compared to 0% for both area under curve/baseline (p=0.028 and p=0.011 respectively) and maximum perfusion/baseline (p=0.001 and p=0.002 respectively). There was no evidence that responses differed between patients and controls. Therefore the optimal dose for sodium nitroprusside iontophoresis is likely to be around 1%.