Clinical Service Line 06 - Rheumatology, Diabetes & Endocrinology, Renal, Clinical Haematology, Medical Day Units

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    A case study experience of natrox wound oxygen therapy: Should this be part of regular conservative wound management in diabetic foot ulcer?
    (2023) Nijith, L.; Chan, S.; Currell, V.; Cronin, B.; Banerjee, R.
    A 46 year old gentleman, with history of type 2 diabetes, diagnosed 11 years ago, presented with new onset right 14645491, 2023, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/dme.15048 by Test, Wiley Online Library on [11/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | CLINICAL CARE AND OTHER CATEGORIES POSTERS: CASE REPORTS 101 of 185 foot ulcer with black discoloration of dorsum of foot, in volving the fourth toe and 4/5th web space. He was diag nosed with ascending cellulitis and superficial gangrene with non-viable right fourth toe. After he was seen by diabetes foot multidisciplinary team (MDT), the patient underwent surgical debridement of ulcer and fourth right toe amputation. CT angiogram right lower limb showed tight stenosis distally of the right pop liteal with multilevel disease and angioplasty was done. MDT suggested for trans-metatarsal amputation which he declined. He opted for conservative management. He had maggot therapy followed by Natrox wound oxygen therapy. He was discharged on vacuum assisted closure dressing. Follow up appointments showed significant im provement with wound healing. This case study showed a favourable outcome of diabetic foot ulcer where Natrox was used. This device delivers up to 98% of humidified oxygen directly to wound bed;stimu lating wound healing. Recent NICE guidance summarises Natrox therapy is beneficial as adjunct therapy in grade II/III diabetic foot ulcers. Our local centre has limited use of this. We propose increased usage of Natrox oxygen therapy as an adjunct to other conservative measures to augment wound healing. This will need further educa tion, funding and reports of its usage in multiple centres.
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    Il-17 Or Tnf Inhibitors - Real World Impact of Shared Decision Making in a Nurse Led Biologics Service
    (2023) Begum, J; Nissar, M
    Background: Since the availability of anti TNF biosimilars and the push from reimbursement panels to use them first line, real world data regarding therapeutic choice in biologic naive population is sparse. Objectives: Evaluate the reasons for nurse led service choosing IL17 antago nists in biologic naïve SpA patients, in a shared decision making model, despite the availability of cheaper anti TNF biosimilar. Methods: We conducted a retrospective analysis of our electronic register for people with PsA and AS from 1994 up to and including April 2022 at our univer sity teaching hospital. We had access to full patient records including details on co-morbidities, drugs and disease management. All patients were evaluated in biologics service led by clinical specialist nurses. Results: PsA. 90 patients were prescribed Secukinumab since its availability in the UK. Mean age was 51 yrs (24-80) and 56 (62%) were women. All were pre scribed since the adoption of Adalimumab biosimilar. Median duration of therapy was 551 days (62-1284). Mean TJC and SJC were 8.14 (1-64) and 3.15 (1-57) at initiation which improved at six months to 6.28 (1-46) and 2.77 (1-18) respectively. 24 (27%) were biologic naïve; 18 had it for better efficacy (six had axial disease, four with enthesitis and eight with concomitant moderate to severe psoriasis) and six for relative anti TNF contraindications including three with treated solid organ neoplasms, one with BMI>35 and two for concurrent chronic infections including HIV. AS. 47 patients were prescribed Secukinumab. Mean age was 54 (27-79) and half were women. Median duration of therapy was 679 days (51-1154). Mean BASDAI was 3.3 (0-9.2) at initiation which improved to 2.1 (0-7.5). 11 (23%) were biologic naïve; five had it for better efficacy and six for relative anti TNF contraindications including three with treated cancers, two with latent TB and one for MS. Conclusion: To our knowledge this is the first dedicated retrospective review of a large real world spondyloarthritis cohort evaluating reasons for biologic choice. Nearly a quarter of patients were prescribed Secukinumab prior to cheaper adalimumab biosimilar despite it being commissioned first choice agent in the region. Clinicians including nurse specialists chose it for better efficacy in various SpA domains. Relative contraindication to anti TNF drugs, which would not have been considered significant in the past, was the second reason. Efficacy and safety outcomes were comparable to other biologics. This confirms that shared decision making process demands flexibility and limiting choice goes against clinical acumen and patient preference. Opting only for lower drug acquisition tariff is unlikely to be cost effective as the disease progresses whilst patients struggle with inappropriate prescription and thus delay biologics which are more likely to be efficacious and retained longer. Hence there is an urgent need to review prescribing guidelines to allow earlier employment of appropriate advanced therapies in the treatment paradigm with significant benefits to both patients and the health economy
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    Clinical Trajectories of Multifactorial Hand Function Deterioration in Systemic Sclerosis
    (2023) Di Donato, S.; Wilson, M.; Barnes, T.; Saleem, B.; Herrick, A.; Nisar, M.; Morley, C.; Douglas, K.; Denton, C.P.; Derret-Smith, E.; Heliwell, P.; Green, L.; Alcacer-Pitarch, B.; Del Galdo, F.
    Background Hand function deterioration is a major multifactorial driver of disability in Systemic Sclerosis (SSc) whose rate has been poorly described. Objectives The aim of this study is to describe incidence and risk factors of hand functional worsening in a longitudinal, multicenter, observational SSc cohort. Methods Hand involvement and disability were evaluated in consecutively enrolled patients for 24 months. Patient-reported hand impairment was captured with Cochin Hand Disability Score (CHFS) and the corresponding minimal clinical important differences (MCID) and patient acceptable symptom state (PASS). Clinical association with CHFS change over time and clinically meaningful worsening (MCID-Worsening) were investigated. Results Three-hundred-ninety-six patients from 10 centres were evaluated and 201 SSc (age 55.7±12.2 years, male 13.4%) were included in the final analysis. Median (IQR) disease duration was 5 (2-11) years while the proportion of patients with diffuse cutaneous variant was the 29.9%. Fifty-six (27.8%) patients had a CHFS ≥PASS at baseline. CHFS increased over time 35.8% of patients reaching CHFS≥PASS (p<0.001), and 52.2% of patients reporting MCID-Worsening at 24 months. A LASSO model simultaneously exploring the effects of multiple baseline clinical variables showed that MCID-Worsening was associated with male gender, LeRoy diffuse variant, late capillaroscopy pattern, shorter disease duration, absence of digital ulcers, presence of tenosynovitis, pain, Raynaud’s phenomenon, and global and hand disability severity, together with treatment with immunosuppressants, vasoactive medications, and second-line analgesics. Conclusion Hand function tends to deteriorate over time in one SSc patient in two despite available therapies and clinical assessment support risk stratification. These results pave the way to inform design of intervention studies aimed at improving the outcome of this major driver of disability in SSc.
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    Il-17 Or Tnf Inhibitors - Real World Impact of Shared Decision Making in a Nurse Led Biologics Service
    (2023) Begum, Julie; Nisar, Muhammad
    Background Since the availability of anti TNF biosimilars and the push from reimbursement panels to use them first line, real world data regarding therapeutic choice in biologic naive population is sparse. Objectives Evaluate the reasons for nurse led service choosing IL17 antagonists in biologic naïve SpA patients, in a shared decision making model, despite the availability of cheaper anti TNF biosimilar. Methods We conducted a retrospective analysis of our electronic register for people with PsA and AS from 1994 up to and including April 2022 at our university teaching hospital. We had access to full patient records including details on co-morbidities, drugs and disease management. All patients were evaluated in biologics service led by clinical specialist nurses. Results PsA. 90 patients were prescribed Secukinumab since its availability in the UK. Mean age was 51 yrs (24-80) and 56 (62%) were women. All were prescribed since the adoption of Adalimumab biosimilar. Median duration of therapy was 551 days (62-1284). Mean TJC and SJC were 8.14 (1-64) and 3.15 (1-57) at initiation which improved at six months to 6.28 (1-46) and 2.77 (1-18) respectively. 24 (27%) were biologic naïve; 18 had it for better efficacy (six had axial disease, four with enthesitis and eight with concomitant moderate to severe psoriasis) and six for relative anti TNF contraindications including three with treated solid organ neoplasms, one with BMI>35 and two for concurrent chronic infections including HIV. AS. 47 patients were prescribed Secukinumab. Mean age was 54 (27-79) and half were women. Median duration of therapy was 679 days (51-1154). Mean BASDAI was 3.3 (0-9.2) at initiation which improved to 2.1 (0-7.5). 11 (23%) were biologic naïve; five had it for better efficacy and six for relative anti TNF contraindications including three with treated cancers, two with latent TB and one for MS. Conclusion To our knowledge this is the first dedicated retrospective review of a large real world spondyloarthritis cohort evaluating reasons for biologic choice. Nearly a quarter of patients were prescribed Secukinumab prior to cheaper adalimumab biosimilar despite it being commissioned first choice agent in the region. Clinicians including nurse specialists chose it for better efficacy in various SpA domains. Relative contraindication to anti TNF drugs, which would not have been considered significant in the past, was the second reason. Efficacy and safety outcomes were comparable to other biologics. This confirms that shared decision making process demands flexibility and limiting choice goes against clinical acumen and patient preference. Opting only for lower drug acquisition tariff is unlikely to be cost effective as the disease progresses whilst patients struggle with inappropriate prescription and thus delay biologics which are more likely to be efficacious and retained longer. Hence there is an urgent need to review prescribing guidelines to allow earlier employment of appropriate advanced therapies in the treatment paradigm with significant benefits to both patients and the health economy.