Infection with SARS-CoV-2 causes flares in patients with juvenile idiopathic arthritis in remission or inactive disease on medication

Background Flares of juvenile idiopathic arthritis (JIA) have been described in the context of various infections. Flares of rheumatic diseases in adults have been described following infection with SARS-CoV-2 in several cohorts. So far, the effect of infection with SARS-CoV-2 on the course of JIA is unknown. Methods The database of the German Center for Pediatric and Adolescent Rheumatology was searched for patients with confirmed infection with SARS-CoV-2 and subsequent disease flare, admitted from July 2020 until June 2021. cJADAS-27, ESR and C-reactive protein, as well as uveitis activity, medication at the time of flare and treatment of flare was extracted. Patient cases were described individually. Results Out of 988 patients admitted, five patients with remission off medication (n = 2) or inactive disease on medication (n = 3) were identified, with flare symptoms up to four weeks after infection with SARS-CoV-2. Conclusions Flares can occur after infection with SARS-CoV-2 in patients with JIA in remission or inactive disease on medication. Treating physicians need to be aware of this fact, especially when counseling patients with rheumatic diseases about the respective dangers of COVID-19 and vaccination against SARS-CoV-2.

Infection with SARS-CoV-2 Causes Flares in Patients with Juvenile Idiopathic Arthritis in Remission or Inactive Disease on Medication

Background Flares of juvenile idiopathic arthritis (JIA) have been described in the context of various infections. So far, the effect of infection with SARS-CoV-2 on the course of JIA is unknown. Findings: The database of the German Center for Pediatric and Adolescent Rheumatology was searched for patients with confirmed infection with SARS-CoV-2 and subsequent disease flare. Five patients with remission or inactive disease were identified, with flare symptoms up to four weeks after infection with SARS-CoV-2. Conclusions Flares can occur after infection with SARS-CoV-2 in patients with JIA in remission or inactive disease on medication. Treating physicians need to be aware of this fact, especially when counseling patients with rheumatic diseases about the respective dangers of COVID-19 disease and vaccination against SARS-CoV-2.

POS1490-HPR “WHERE DOES IT HURT?”: IDENTIFYING PAIN CONTENT AND ITS CONTEXT WITHIN PAEDIATRIC AND ADOLESCENT RHEUMATOLOGY TRAINING

Background:Complex pain symptoms present across a wide spectrum of long-term musculoskeletal conditions in paediatric rheumatology. Pain training should therefore be part of a core curriculum for the professionals working in this speciality, but it is unclear to what extent this is the case currently.Objectives:To identify the extent of pain-specific content included in the training of healthcare professionals in paediatric and adolescent rheumatology in the UK.Methods:A systematic search of documental data using key internet search engines was conducted using combinations of the following terms: ‘training’, ‘curriculum’, ‘competency’, ‘paediatric’, ‘adolescent’ and ‘rheumatology’. A targeted search of online content from the main professional organisations followed; doctors (Royal College of Paediatric and Child Health [RCPCH]), nurses (Royal College of Nursing [RCN]), physiotherapists (Chartered Society of Physiotherapy), occupational therapists (Royal College of Occupational Therapists) and psychologists (British Psychological Society). Documents from professional learned societies such as The British Society of Paediatric and Adolescent Rheumatology (BSPAR) and The Scottish Paediatric and Adolescent Rheumatology Network (SPARN) were also included. Document search strategies were designed by the authors in partnership with healthcare professionals. Data were extracted and analysed following a summative content analysis. Pain-related terms were quantified. Latent content was interpreted qualitatively to explore the context in which pain-related phrases were presented.Results:Nine documents were identified. Pain-related terms represented 0.17% of all words across texts (used 55 times in total). Most pain terms were found in documents aimed at doctors (n=40, 72.7%). Of the pain terms used, most were used in the context of referring to specific pain syndromes such as chronic regional pain, generalized idiopathic pain and pain amplification. Content around the assessment and management of pain was vague and no detail was given as to how health professionals should perform these tasks. There was no reference to pain intensity, location or emotion. There were several problematic conceptual issues in the way pain was presented, with pain mostly portrayed either in the context of inflammatory or non-inflammatory pain and rarely in the context of both. Musculoskeletal pain was also positioned as a ‘somatic’ symptom, potentially conveying an interpretation of pain as being psychologically mediated.Conclusion:Training for healthcare professionals in paediatric rheumatology would benefit from updates informed by contemporary pain theories and evidence-based practices. This is key to ensuring that children and young people with chronic pain receive effective pain care from tertiary care services focused on treating musculoskeletal disease.Table 1.Documents and pain terms identifiedProfessionTitleOrganisations, year.% of document covered by pain termsDoctorsGeneric syllabus level 1.RCPCH, 2018.0.14%DoctorsGeneric syllabus level 2.RCPCH, 2018.0.14%DoctorsGeneric syllabus level 3.RCPCH, 2018.0.06%DoctorsPaediatric rheumatology level 3.RCPCH, 2018.0.48%DoctorsCompetencies for the special interest module in paediatric rheumatologyRCPCH, 2014.0.43%NursesCompetencies for rheumatology nurses.RCN, 2020.0.05%NursesCompetencies for clinical nurse specialists/advanced nurse practitioners.BSPAR, 2014.0.29%NursesRole of the paediatric rheumatology nurse.SPARN, 2016.0%Allied Health Professionals (AHPs)Competencies for AHPsBSPAR, 2019.0.73%Disclosure of Interests:None declared

P60 Rituximab use within the Scottish paediatric and adolescent rheumatology network: a review of five years’ experience

Background Rituximab is an anti-CD20 chimeric monoclonal antibody that depletes pre-plasma B cells. It is used in paediatric rheumatology for conditions including juvenile systemic lupus erythematosus (jSLE), juvenile dermatomyositis (JDM), vasculitides and refractory juvenile idiopathic arthritis (JIA). We aim to describe the cohort of patients treated with rituximab in the Scottish Paediatric and Adolescent Rheumatology Network (SPARN) in a 5-year period, and assess the need for a network guideline. Methods A review of paper and electronic case records. Patients seen within the SPARN network who received Rituximab between 2014 and 2018 were included. Results Vasculitis Rituximab was given to 16 patients in 5 different SPARN centres between 2014 and 2018. Male: Female ratio was 1:4.3. Mean age at first dose of rituximab was 12.75 years. Mean disease duration pre rituximab was 1 year. 8 (50%) patients had jSLE, 7 multisystem and 1 isolated lupus nephritis. 3 had ANCA-positive vasculitis and 5 had other conditions. (1 had RF+ve JIA; 1 severe panuveitis; 1 had an unspecified autoinflammatory condition; 1 had COPA syndrome with severe interstitial lung disease and 1 had autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). Documentation of pre-rituximab checks was poor. Baseline bloods were done in all 16 patients. 11 patients had lymphocyte subsets and 13 immunoglobulins documented. Disease-specific antibodies were measured in all patients in whom applicable (11). 11 had a chest x-ray prior to rituximab. In 9 cases a pre-rituximab pregnancy test was indicated: none were documented. In only 3 patients was a pre-rituximab history of recent infections documented. In 8 patients a discussion regarding treatment risks and benefits was documented. Post-infusion lymphocyte subset monitoring was variable but documented in 15. 1 patient was never B cell deplete. 9 never fully reconstituted. RTX dose information was available for 14. All received doses of 750mg/m2 with 6 having the dose capped at 1g. Dose frequency information was available for all. The majority (9) received 2 doses. Of the rest, 1 patient received a single dose. 3 received 3 doses, 2 had 4 and 1 had 5. All patients in whom information was available, received pre-medication with paracetamol, chlorphenamine and methylprednisolone (n = 14). 4 patients had side effects noted (rash/itch in 1, anaphylaxis in 1, facial flushing in 1 and post-infusion infection in 1). Clinical response was clearly documented in 8 patients, 7 of whom showed clinical improvement (2 had systemic jSLE, 2 had ANCA +ve vasculitis, 1 had isolated lupus nephritis, 1 had COPA syndrome and 1 had RF+ JIA). Conclusion Rituximab is used for a range of conditions and in a number of centres within SPARN. This review highlights variation in and poor documentation of pre-rituximab discussions and investigations, prescribing, monitoring and response. A SPARN rituximab protocol is being developed to address this. Conflicts of Interest The authors declare no conflicts of interest.

P01 Incidence of juvenile idiopathic arthritis in the United Kingdom: estimates from a national primary care dataset

Poster presentation Tuesday 8 October Background Juvenile idiopathic arthritis (JIA) is the most common childhood onset inflammatory arthritis. The last estimates of incidence of JIA in the UK are from nearly 30 years ago, prior to international classification consensus and the emergence of paediatric and adolescent rheumatology as a specialty. The aim of this study was to estimate incidence of JIA from primary care records in the UK since 2000. Methods The study used data from the Clinical Practice Research Datalink (CPRD), a database of UK primary care records broadly representative of the UK in terms of age, gender and ethnicity. A pre-defined list of JIA Read codes were used to identify incident cases annually from 2000-2018. Incidence rates (IR) with 95% confidence intervals(CI) were calculated and stratified by age and gender. The denominator was the population of CPRD <16 years old on the 31st December each year. Direct standardisation, applying Office for National Statistics population data, was used to estimate the UK IR. IRs in 5-year groupings were calculated 2000-2015 to identify change over time. Results Between 2000-2018, there were 1927 incident cases of JIA, from a total of 23,328,676 children <16 years old in CPRD. The total IR (95% CI) was 8.26 (7.90-8.64) per 100,000 population; for females and males respectively it was 9.83 (9.27-10.43) and 6.78 (6.33-7.27) per 100,000. Age-adjusted direct standardisation to the UK population estimated a total IR of 9.66 per 100,000 person-years. By age group, there appeared to be a lower incidence in middle childhood compared to early childhood and adolescents, as well as infancy where lower rates may be due to difficulties recognising the disease (Table 1). IRs over time did not appear to change. P01 Table 1: Incidence rates by age group Age (years) Denominator Cases IR (95% CI) Per 100,000 0-2 1739417 113 6.5 (5.40-7.81) >2-6 5763003 534 9.27 (8.51 – 10.08) >6-12 9464988 693 7.32 (6.80-7.90) >12-15 6361268 587 9.22 (8.51-10.01) Conclusion This is the first study to provide contemporary UK estimates of the incidence of JIA for nearly 30 years. JIA was more common in females compared to males, and in early childhood and adolescence compared to other age groups. Incidence appeared to be stable over fifteen years. These data provide important information for patients, their families and healthcare providers; in addition, they are vital for appropriate resource planning and service provision in paediatric and adolescent rheumatology. Conflicts of Interest The authors declare no conflicts of interest.