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Background The safety and immunogenicity profile of COVID-19 vaccines when administered concomitantly with seasonal influenza vaccines have not yet been reported. We therefore aimed to report the results of a substudy within a phase 3 UK trial, by evaluating the safety, immunogenicity, and efficacy of NVX-CoV2373 when co-administered with licensed seasonal influenza vaccines. Methods We did a planned exploratory substudy as part of the randomised, observer-blinded, placebo-controlled, phase 3 trial of the safety and efficacy of the COVID-19 vaccine (NVX-CoV2373) by co-administrating the influenza vaccine at four study hospitals in the UK. Approximately, the first 400 participants meeting the main study entry criteria—with no contraindications to influenza vaccination—were invited to join the substudy. Participants of the main study were randomly assigned (1:1) to receive two intramuscular injections of either NVX-CoV2373 (5 μg) or placebo (normal saline) 21 days apart; participants enrolled into the substudy were co-vaccinated with a single (0·5 mL) intramuscular, age-appropriate (quadrivalent influenza cell-based vaccine [Flucelvax Quadrivalent; Seqirus UK, Maidenhead] for those aged 18–64 years and adjuvanted trivalent influenza vaccine [Fluad; Seqirus UK, Maidenhead] for those ≥65 years), licensed, influenza vaccine on the opposite deltoid to that of the first study vaccine dose or placebo. The influenza vaccine was administered in an open-label manner and at the same time as the first study injection. Reactogenicity was evaluated via an electronic diary for 7 days after vaccination in addition to monitoring for unsolicited adverse events, medically attended adverse events, and serious adverse events. Immunogenicity was assessed with influenza haemagglutination inhibition and SARS-CoV-2 anti-spike protein IgG assays. Vaccine efficacy against PCR-confirmed, symptomatic COVID-19 was assessed in participants who were seronegative at baseline, received both doses of study vaccine or placebo, had no major protocol deviations affecting the primary endpoint, and had no confirmed cases of symptomatic COVID-19 from the first dose until 6 days after the second dose (per-protocol efficacy population). Immunogenicity was assessed in participants who received scheduled two doses of study vaccine, had a baseline sample and at least one post-vaccination sample, and had no major protocol violations before unmasking (per-protocol immunogenicity population). Reactogenicity was analysed in all participants who received at least one dose of NVX-CoV2373 or placebo and had data collected for reactogenicity events. Safety was analysed in all participants who received at least one dose of NVX-CoV2373 or placebo. Comparisons were made between participants of the substudy and the main study (who were not co-vaccinated for influenza). This study is registered with ClinicalTrials.gov, number NCT04583995. Findings Between Sept 28, 2020, and Nov 28, 2020, a total of 15 187 participants were randomised into the main phase 3 trial, of whom 15 139 received treatment (7569 received dose one of NVX-CoV2373 and 7570 received dose one of placebo). 431 participants were co-vaccinated with a seasonal influenza vaccine in the substudy (217 received NVX-CoV2373 plus the influenza vaccine and 214 received placebo plus the influenza vaccine). In general, the substudy participants were younger, more racially diverse, and had fewer comorbid conditions than those in the main study. Reactogenicity events were more common in the co-administration group than in the NVX-CoV2373 alone group: tenderness (113 [64·9%] of 174 vs 592 [53·3%] of 1111) or pain (69 [39·7%] vs 325 [29·3%]) at injection site, fatigue (48 [27·7%] vs 215 [19·4%]), and muscle pain (49 [28·3%] vs 237 [21·4%]). Incidences of unsolicited adverse events, treatment-related medically attended adverse events, and serious adverse events were low and balanced between the co-administration group and the NVX-CoV2373 alone group. No episodes of anaphylaxis or deaths were reported within the substudy. Co-administration resulted in no change to influenza vaccine immune response although a reduction in antibody responses to the NVX-CoV2373 vaccine was noted. NVX-CoV2373 vaccine efficacy in the substudy (ie, participants aged 18 to

Evidence from the Global Burden of Disease studies suggests that osteoarthritis (OA) is a significant cause of disability globally; however, it is less clear how much of this burden exists in low-income and lower middle-income countries. This study aims to determine the prevalence of OA in people living in low-income and lower middle-income countries. Four electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched from inception to October 2018 for population-based studies. We included studies reporting the prevalence of OA among people aged 15 years and over in low-income and lower middle-income countries. The prevalence estimates were pooled across studies using random effects meta-analysis. Our study was registered with PROSPERO, number CRD42018112870.The search identified 7414 articles, of which 356 articles were selected for full text assessment. 34 studies were eligible and included in the systematic review and meta-analysis. The pooled prevalence of OA was 16·05% (95% confidence interval (CI) 12·55–19·89), with studies demonstrating a substantial degree of heterogeneity (I2 = 99·50%). The pooled prevalence of OA was 16.4% (CI 11·60–21.78%) in South Asia, 15.7% (CI 5·31–30·25%) in East Asia and Pacific, and 14.2% (CI 7·95–21·89%) in Sub Saharan Africa. The meta-regression analysis showed that publication year, study sample size, risk of bias score and country-income categories were significantly associated with the variations in the prevalence estimates. The prevalence of OA is high in low-income and lower middle-income countries, with almost one in six of the study participants reported to have OA. With the changing population demographics and the shift to the emergence of non-communicable diseases, targeted public health strategies are urgently needed to address this growing epidemic in the aging population. Supplementary Information The online version contains supplementary material available at 10.1007/s00296-021-04838-y.

Objective To determine whether a diagnosis of polymyalgia rheumatica (PMR) is associated with premature mortality. Methods We extracted anonymised electronic medical records of patients over the age of 40 years, who were eligible for linkage with the Office for National Statistics (ONS) Death Registration dataset, from the Clinical Practice Research Datalink from 1990-2016. Patients with PMR were individually matched by age, sex and registered General Practice with up to 5 controls without PMR. The total number and proportion of deaths and mortality rates were calculated. The mortality rate ratio (MRR), with 95% confidence interval (CI), adjusted for age, sex, region, smoking status, body mass index (BMI), and alcohol consumption, was calculated using Poisson regression. The twenty most common causes of death were tabulated. Results 18,943 patients with PMR were matched to 87,801 controls. Mean (standard deviation) follow-up after date of diagnosis was 8.0 (4.4) years in patients with PMR, and 7.9 (4.6) in controls. PMR was not associated with an increase in the risk of death (adjusted MRR 1.00 [95% CI 0.97, 1.03]) compared to matched controls. Causes of death were broadly similar between patients with PMR and controls, although patients with PMR were slightly more likely to have a vascular cause of death recorded (24% vs 23%). Conclusions A diagnosis with PMR does not appear to increase the risk of premature death. Minor variations in cause of death were observed, but overall this study is reassuring for patients with PMR and clinicians.

Objectives: To determine the burden of comorbidities, including glucocorticoid (GC) related adverse effects, in patients with polymyalgia rheumatica (PMR) before and after diagnosis.\ud \ud Methods: We extracted anonymised electronic medical records of patients over the age of 40 years from the Clinical Practice Research Datalink from 1990-2016. Patients with PMR were individually matched on age, sex and registered General Practice to between three and five controls. The prevalence, cumulative probability and likelihood of a range of comorbidities was estimated. Odds ratios (ORs) and hazard ratios (HRs) were calculated using conditional logistic regression and Cox proportional hazards regression respectively, adjusted for a wide range of covariates.\ud \ud Results: 31,984 patients with PMR were matched to 149,436 controls. PMR was prospectively associated with vascular disease (adjusted HR 1.23 [95% confidence interval (CI) 1.19, 1.28]), as well as respiratory (HR 1.25 [1.18, 1.32]), renal (HR 1.34 [1.30, 1.39]), and autoimmune diseases (HR 4.68 [4.35, 5.03]). Conversely, before PMR diagnosis, the risk of cancer (adjusted OR [OR] 0.89 [0.86, 0.93]) and neurological disease (OR 0.36 [0.33, 0.40]) was significantly lower. Patients with PMR had an increased risk of comorbidities associated with glucocorticoid (GC) use.\ud \ud Conclusions\ud Patients with PMR have a high comorbidity burden, both before and after diagnosis. Whilst further work is needed to more fully understand these associations, clinicians should be aware of the high prevalence of comorbid conditions in this group and the impact that treatment with glucocorticoids may have on comorbidity.

Background Obesity predisposes to a pro-inflammatory state. Studies have reported worse clinical outcomes in patients with inflammatory arthritis who are obese. The relationship between obesity and outcomes in patients with polymyalgia rheumatica (PMR), another common inflammatory rheumatic condition, has not been assessed. We examined this in a cohort study of primary care-recruited patients with PMR. Methods The PMR Cohort Study is an inception cohort of patients with incident PMR, recruited from 382 general practices. Self-completed questionnaires at 0, 12, and 24-months captured: (a) PMR-related pain (0-10 numeric rating scale [NRS]); (b) PMR-related stiffness (0-10 NRS); (c) anxiety (GAD7); (d) depression (PHQ8); (e) fatigue (FACIT-Fatigue); (f) function (mHAQ); (g) quality of life (EQ-5D-3L). Height was self-reported at baseline, and weight at baseline, 12 and 24 months. Patients were categorised as underweight (BMI Results 652 patients were included (62% female). At baseline, mean age was 72 years, median BMI 26.6 (IQR 24.0-30.2), 34% were normal/under-weight, 40% overweight, and 26% obese. Compared to normal/underweight patients, obese patients had the following significantly poorer outcomes (P Conclusion Obesity is associated with poorer outcomes in patients with PMR. Consideration should be given to providing weight management support to patients with PMR and obesity. Further research should examine the impacts of weight-based steroid dosing on outcomes. Disclosures I.C. Scott None. R. Bajpai None. S.L. Hider None. T. Helliwell None. S. Muller None. C.D. Mallen None.

Background Giant cell arteritis (GCA) is the most common form of medium and large vessel vasculitis. Diagnosis remains difficult since there are a multitude of symptoms experienced by patients with GCA and if not promptly identified or treated, patients with GCA are at risk of irreversible visual loss. Therefore, a clear understanding of recent trends in incidence is important for clinicians, researchers and policy-holders to better understand and address future healthcare resource needs. Our objective was to estimate the annual UK incidence of GCA and assess whether this is changing over time. Methods We used the Clinical Practice Research Datalink (CPRD), a database of routinely recorded primary care records from across the UK. CPRD is representative of the UK population and contains patient information from approximately 15% of the UK population. For each year from 1992-2017, the number of patients with a first Read coded record of GCA in that year, and aged 40 years or older at the time of diagnosis, was determined. The annual denominator population included the registered practice population without a prior record of GCA, aged 40 years or older. Annual incidence per 10,000 person-years (P-Y) at risk was derived overall and stratified by age, gender and region of the UK. Trends over time were modelled using Joinpoint regression. To be confident of the primary care diagnosis of GCA, a sensitivity analysis was undertaken which included a prescription of corticosteroids alongside the GCA Read code. Results There was a decrease in annual incidence of GCA in the UK between 1992 and 2017. Incidence was highest in 1994 (2.29/10,000 P-Y; 95% CI: 1.96, 2.67). This decreased to 1.51/10,000 P-Y in 2006, after which the incidence rates stabilised. Incidence rates for women were higher than men, irrespective of year. Incidence peaked between 70 and 89 years of age, with females aged 70-79 having the highest overall incidence rate of 5.20/10,000 P-Y (95% CI: 5.00, 5.40). The region of the UK with the highest incidence rate of GCA from 2015-2017 was Yorkshire & the Humber with 2.63/10,000 P-Y. The regions with the lowest incidence of 1.13/10,000 P-Y were the North East and West Midlands. Sensitivity analysis gave similar patterns. Conclusion The incidence of GCA in the UK has decreased slightly in recent years, which may reflect developments in more definitive early GCA diagnosis through fast-track clinics and improvements in imaging. However, further research into the presenting features of GCA in primary care is required. A set of early clinical features and comorbidities that are positively associated and predictive of a subsequent diagnosis of GCA would improve diagnosis and avert significant complications associated with delayed treatment. Disclosures L.A. Barnett None. T. Helliwell None. K. Jordan None. J. Prior None.

Background The diagnosis of giant cell arteritis (GCA) remains challenging due to the varied number and type of clinical features (symptoms and comorbidities) that patients with GCA can present with. Prompt diagnosis is important, as if left undiagnosed and untreated, some patients may experience irreversible sight loss. Given the rarity of GCA and that many of the presenting clinical features may pertain to other, more prevalent illnesses in the typical age range for GCA, diagnostic delay is common. Such delay may increase the risk of GCA related complications. The aim of this study was to quantify the association between a diagnosis of GCA and the clinical features observed prior to diagnosis. Methods Patients with a coded record of GCA and aged 40 years or older at the time of diagnosis, were identified from the Clinical Practice Research Datalink (CPRD) between 1990 and 2017. CPRD is a large, national UK database of primary care records. Every GCA case was matched to 5 controls with no GCA diagnosis, by year of birth, gender and practice. Clinical features linked to GCA in previous research studies were identified in the patient’s primary care records at any time prior to GCA diagnosis. Conditional logistic regression was used to determine associations between clinical features and a subsequent diagnosis of GCA, adjusting for Body Mass Index, smoking status, and alcohol consumption. Results 9,205 patients with GCA were included, the majority of which were female (70.9%). 15 clinical features were examined. For example, 53.3% of GCA cases had a recorded consultation for headache prior to diagnosis (38.4% within six months prior to diagnosis), compared to 9.9% of controls; 3.2% of cases had recorded jaw pain (0.3% within six months prior to diagnosis) compared to 0.5% of controls; 39.4% of cases had a diagnosis for hypertension prior to their diagnosis of GCA. GCA cases were more likely than controls to have recorded consultations for headache (adjusted OR 10.57; 95% CI: 9.93, 11.25), jaw pain (5.37; 4.47, 6.44) and hypertension (1.33; 1.26, 1.40). Other clinical features that were statistically significantly associated with GCA included fever, anxiety/depression, and PMR. Cancer was the only clinical feature not associated with GCA. Conclusion Symptoms such as headache, jaw pain and hypertension are highly prevalent in GCA, but are also common symptoms in the usual age group affected by GCA and common features of many conditions. In isolation and considering the rarity of GCA in the UK population, these symptoms may not be immediately attributed to GCA by the diagnosing GP. It is therefore necessary to conduct further research where clinical features are not treated independently, but as groups or clusters, which together may more accurately help clinicians to diagnose GCA early. Disclosures L.A. Barnett None. T. Helliwell None. K.P. Jordan None. J.A. Prior None.

The aim of this study was to systematically consider the evidence for polymyalgia rheumatica (PMR) as a paraneoplastic disease. A systematic review of Medline and Embase was conducted from their inception to February 2017. Risk of bias was assessed using the Newcastle-Ottawa tool. Data were extracted regarding the PMR-cancer association, the types of cancer associated with PMR and the presentation of PMR patients subsequently diagnosed with cancer. Twenty-three full text articles were reviewed from the 1174 unique references identified in the search. Nine articles were included in the final review. There was some evidence of an association between PMR and cancer in the short-term (first 6 to 12 months after diagnosis), but no evidence of an association after this time. Limited evidence suggests that lymphoma, prostate and haematological cancers may be those cancers more commonly diagnosed in those with PMR. There was little evidence to suggest what presenting features may be associated with the development of cancer. There is little evidence of PMR as a true paraneoplastic disease. However, there is reason to be cautious when making the diagnosis of PMR. Clinicians should be aware of this potential association both prior to making a diagnosis and throughout the course of the condition.

Objectives To examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014. Methods All AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD. Results Of 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography—0.87; 0.84 to 0.91; PCI—0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication. Conclusion In a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.

Objectives To investigate potential subgroups of primary care–diagnosed patients with PMR based on self-reported pain and stiffness severity over time. Methods A total of 652 people with an incident PMR diagnosis were recruited from English general practices and completed a baseline postal questionnaire. They were followed up with a further six questionnaires over a 2 year period. A total of 446 people completed the 2 year follow-up. Pain and stiffness were reported on a 0–10 numerical rating scale. Latent class growth analysis was used to estimate the joint trajectories of pain and stiffness over time. A combination of statistical and clinical considerations was used to choose the number of clusters. Characteristics of the classes were described. Results Five clusters were identified. One cluster represented the profile of ‘classical’ PMR symptoms and one represented sustained symptoms that may not be PMR. The other three clusters displayed a partial recovery, a recovery followed by worsening and a slow, but sustained recovery. Those displaying classical PMR symptoms were in better overall health at diagnosis than the other groups. Conclusion PMR is a heterogeneous condition, with a number of phenotypes. The spectrum of presentation, as well as varying responses to treatment, may be related to underlying health status at diagnosis. Future research should seek to stratify patients at diagnosis to identify those likely to have a poor recovery and in need of an alternative treatment pathway. Clinicians should be aware of the different experiences of patients and monitor symptoms closely, even where there is initial improvement.

Permanent vision loss is one of the most serious complications of giant cell arteritis (GCA) and therefore prompt diagnosis is paramount. However, diagnosis of GCA remains challenging due to its frequently non-specific presentation. Our aim was to identify differences in the characteristics of GCA patients with, and without, current visual symptoms. A cross-sectional survey was mailed to patients with a GCA Read code entered in their GP electronic medical record. Responders were categorised as those currently reporting a visual symptom or not. We compared general and GCA-specific characteristics in these two groups. The association of diagnostic delay with subsequent experience of visual symptoms was examined using unadjusted and adjusted linear regression analysis. 318 GCA patients responded to the survey (59.6%). Responders were predominantly female (69.8%), with a mean age of 73.7 years (SD 8.2). 28% reported current visual symptoms. There was no statistically significant difference in the general characteristics between those with and without visual symptoms. Of GCA-specific characteristics, pre-GCA diagnosis of diplopia (p = 0.018), temporary (p ≤ 0.001) or permanent visual problems (p = 0.001) and hoarseness (p = 0.004) were more common among those reporting current visual symptoms. There was no association between the extent of diagnostic delay and reporting of current visual symptoms. Though we found few characteristics to distinguish between GCA patients with or without current visual symptoms, diagnostic delay was not associated with current visual symptoms. Our findings highlighted the continued difficulty for clinicians to identify GCA patients at the highest risk of visual complications.

Background Antibiotic-induced disturbances of the human microbiota have been implicated in the development of chronic autoimmune conditions. This study aimed to assess whether antibiotic use is associated with the onset of rheumatoid arthritis (RA). Methods A nested case-control study was conducted utilising data from the primary care Clinical Practice Research Datalink (CPRD). Patients with an incident diagnosis of RA were identified (1995–2017). Each case was matched on age, gender, and general practice to ≥ 5 controls without RA. Conditional logistic regression was used to examine previous antibiotic prescriptions and RA onset after controlling for confounding factors. Results We identified 22,677 cases of RA, matched to 90,013 controls, with a median follow-up of 10 years before RA diagnosis. The odds of developing RA were 60% higher in those exposed to antibiotics than in those not exposed (OR 1.60; 95% CI 1.51–1.68). A dose- or frequency-dependent association was observed between the number of previous antibiotic prescriptions and RA. All classes of antibiotics were associated with higher odds of RA, with bactericidal antibiotics carrying higher risk than bacteriostatic (45% vs. 31%). Those with antibiotic-treated upper respiratory tract (URT) infections were more likely to be RA cases. However, this was not observed for URT infections not treated with antibiotics. Antifungal (OR = 1.27; 95% CI 1.20–1.35) and antiviral (OR = 1.19; 95% CI 1.14–1.24) prescriptions were also associated with increased odds of RA. Conclusion Antibiotic prescriptions are associated with a higher risk of RA. This may be due to microbiota disturbances or underlying infections driving risk. Further research is needed to explore these mechanisms. Electronic supplementary material The online version of this article (10.1186/s12916-019-1394-6) contains supplementary material, which is available to authorized users.

Primary care is key to the early diagnosis and ongoing care of people with inflammatory rheumatic diseases. Primary care is usually the first point of call for health problems and is the setting wh...

We aimed to examine the association between pain, stiffness and fatigue in newly diagnosed polymyalgia rheumatica (PMR) patients using baseline data from a prospective cohort study. Fatigue is a known, but often ignored symptom of PMR. Newly diagnosed PMR patients were recruited from general practice and mailed a baseline questionnaire. This included a numerical rating scale for pain and stiffness severity, manikins identifying locations of pain and stiffness and the FACIT-Fatigue questionnaire. A total of 652 PMR patients responded (88.5%). The mean age of responders was 72.6 years (SD 9.0) and the majority were female (62.0%). Manikin data demonstrated that bilateral shoulder and hip pain and stiffness were common. The mean fatigue score (FACIT) was 33.9 (SD 12.4). Adjusted regression analysis demonstrated that a higher number of pain sites (23–44 sites) and higher pain and stiffness severity were associated with greater levels of fatigue. In newly diagnosed PMR patients, fatigue was associated with PMR symptom severity.

Background and aim Comorbidities are known to exist in many rheumatological conditions. Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition affecting older people which, prior to effective treatment, causes severe disability. Our understanding of associated comorbidities in PMR is based only on case reports or series and small cohort studies. The objective of this study is to review systematically the existing literature on the comorbidities associated with PMR. Methods MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched for original observational research from inception to November 2016. Papers containing the words ‘Polymyalgia Rheumatica’ OR ‘Giant Cell Arteritis’ OR the terms ‘PMR’ OR ‘GCA’ were included. Article titles were reviewed based on pre-defined criteria by two reviewers. Following selection for inclusion, studies were quality assessed using the Newcastle–Ottawa tool and data were extracted. Results A total of 17,329 papers were reviewed and 41 were incorporated in this review, including three published after the search took place. Wide variations were found in study design, comorbidities reported and populations studied. Positive associations were found between PMR diagnosis and stroke, cardiovascular disease, peripheral arterial disease, diverticular disease and hypothyroidism. Two studies reported a positive association between PMR and overall malignancy rate. Seven studies reported an association between PMR and specific types of cancer, such as leukaemia, lymphoma, myeloproliferative disease and specified solid tumours, although nine studies found either no or negative association between cancer and PMR. Conclusion Quantification of the prevalence of comorbidities in PMR is important to accurately plan service provision and enable identification of cases of PMR which may be more difficult to treat. This review highlights that research into comorbidities in PMR is, overall, methodologically inadequate and does not comprehensively cover all comorbidities. Future studies should consider a range of comorbidities in patients with a validated diagnosis of PMR in representative populations. Electronic supplementary material The online version of this article (10.1186/s13075-018-1757-y) contains supplementary material, which is available to authorized users.

AimThe aim of this study was to assess the provision of information to, and seeking of information by, patients newly diagnosed with polymyalgia rheumatica (PMR) in primary care.BackgroundPMR is an inflammatory rheumatological condition of older people that can be treated with long-term oral glucocorticoids. Management usually requires the patient to understand the potential complications of treatment and the disease, as well as involvement in reducing treatment dose. This may be complex for patients to understand.MethodData are taken from the baseline phase of the PMR Cohort study, which recruited newly diagnosed patients with PMR from UK primary care. Participants provided information on their PMR symptoms, general health and sociodemographics. They also completed items regarding information provision by their doctor at diagnosis, its usefulness and their own search for information.FindingsA total of 652 people responded to the baseline survey. In all, 399 (62.7%) had received written information from their doctor; 237 (98%) found it useful; 265 (42.9%) would have liked more information; and 311 (48.4%) sought out more information. Those who were not given information and did not seek it out tended to be older and have poorer internet access.Information provided at diagnosis to patients with PMR is useful, but more than a third did not receive any. This is concerning when PMR requires self-management and vigilance for red flags. Doctors should make use of the resources already available to them to support patients and should specifically ensure that these are available to more elderly patients and those without internet access.

ObjectivePolymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in older people. Contemporary estimates of the incidence and prevalence are lacking, and no previous study has assessed treatment patterns at a population level. This study aims to address this.MethodsWe extracted anonymised electronic medical records of patients over the age of 40 years from the Clinical Practice Research Datalink in the period 1990–2016. The absolute rate of PMR per 100 000 person-years was calculated and stratified by age, gender and calendar year. Incidence rate ratios were calculated using a Poisson regression model. Among persons with PMR, continuous and total duration of treatment with glucocorticoids (GC) were assessed.Results5 364 005 patients were included who contributed 44 million person-years of follow-up. 42 125 people had an incident diagnosis of PMR during the period. The overall incidence rate of PMR was 95.9 per 100 000 (95% CI 94.9 to 96.8). The incidence of PMR was highest in women, older age groups and those living in the South of England. Incidence appears stable over time. The prevalence of PMR in 2015 was 0.85 %. The median (IQR) continuous GC treatment duration was 15.8 (7.9–31.2) months. However, around 25% of patients received more than 4 years in total of GC therapy.ConclusionsThe incidence rates of PMR have stabilised. This is the first population-based study to confirm that a significant number of patients with PMR receive prolonged treatment with GC, which can carry significant risks. The early identification of these patients should be a priority in future research.

BACKGROUND: Previous studies that quantified the risk of fracture among patients with gout and assessed the potential effect of urate-lowering therapy have provided conflicting results. Our study aims to provide better estimates of risk by minimizing the effect of selection bias and confounding on the observed association. METHODS: We used data from the Clinical Practice Research Datalink, which records primary care consultations of patients from across the United Kingdom. We identified patients with incident gout from 1990 to 2004 and followed them up until 2015. Each patient with gout was individually matched to 4 controls on age, sex and general practice. We calculated absolute rate of fracture and hazard ratios (HRs) using Cox regression models. Among patients with gout, we assessed the impact of urate-lowering therapy on fracture, and used landmark analysis and propensity score matching to account for immortal time bias and confounding by indication. RESULTS: We identified 31 781 patients with incident gout matched to 122 961 controls. The absolute rate of fracture was similar in both cases and controls (absolute rate = 53 and 55 per 10 000 person-years, respectively) corresponding to an HR of 0.97 (95% confidence interval 0.92–1.02). Our finding remained unchanged when we stratified our analysis by age and sex. We did not observe statistically significant differences in the risk of fracture among those prescribed urate-lowering therapy within 1 and 3 years after gout diagnosis. INTERPRETATION: Overall, gout was not associated with an increased risk of fracture. Urate-lowering drugs prescribed early during the course of disease had neither adverse nor beneficial effect on the long-term risk of fracture.

Objective.The Outcome Measures in Rheumatology (OMERACT) polymyalgia rheumatica (PMR) working group aims to develop a core set of outcome measures to be used in clinical trials for PMR. Previous reports from OMERACT 11 included a qualitative study of the patient experience and a preliminary literature review.Methods.A 3-round Delphi survey of clinicians and patients with PMR was undertaken to identify a candidate core domain set for PMR research. Additionally, a literature review of outcome measures and their respective measurement instruments was undertaken. Meetings of patient research partners and clinicians were convened to review face validity of the provisional core domain set, which was subsequently presented and discussed at the OMERACT 12 congress.Results.Of the 60 clinicians taking part in round 1, 55 took part in round 2 and 51 in round 3. Of the 55 patients who took part in round 1, 46 and 35 took part in subsequent rounds. In total, 91% of participants in round 3 deemed the resulting draft core domain set reasonable. The literature review identified 28 studies for full review. Measurement instruments for each proposed domain were identified. Clinicians are highly aware of glucocorticoid-related adverse effects, but there is relatively little evidence about their true prevalence and severity, especially in PMR.Conclusion.A provisional core domain set, presented for clinical trials in PMR, comprises acute phase markers, physical function, death, glucocorticoid-related adverse events, and development of giant cell arteritis. Measurement instruments are suggested that may cover each domain, but these require formal validation for clinical trials in PMR.

This study aimed to examine fracture risk in patients with late-onset psoriasis. A cohort study was conducted using primary care records from the Clinical Practice Research Datalink. Psoriasis patients had a 10% increased risk of fracture compared to matched controls (hazard ratio (HR) = 1.10; 95% confidence interval (CI) 1.04, 1.16). This study aimed to examine fracture risk in patients with late-onset psoriasis and investigate the effect of methotrexate on fracture risk. A cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident (new onset) diagnoses of psoriasis, were identified from 1990 to 2004 and followed up until 2015. For each exposed individual, up to four age-, gender-, and practice-matched controls were randomly selected. Incidence rates of fragility fracture (hip, vertebral, spine, radius or unspecified site) per 10,000 person-years were calculated and hazard rates were compared to the unexposed using Cox regression models. The risk of fracture was also estimated, within the exposed group for patients receiving/not receiving methotrexate. Twenty-four thousand two hundred nineteen patients with psoriasis and 94,820 controls were identified. The absolute rate of fracture in psoriasis patients was 58 per 10,000 person-years (95% CI 55, 61) and 53 per 10,000 person-years in the matched controls (CI 52, 54). Psoriasis patients had a 10% increased risk of fracture compared to their matched controls (HR = 1.10; 95% CI 1.04, 1.16). Methotrexate use was not associated with increased risk (HR = 0.91; 95% CI 0.72, 1.15). Identifying additional clinical factors associated with increased fracture risk is important in improving fracture risk stratification. Further work is needed to determine the relationship between age of onset of psoriasis and fracture risk, explore causative explanations, and identify if existing fracture risk stratification tools underestimate fracture risk in patients with psoriasis.

BackgroundPolymyalgia rheumatica (PMR) is one of the most common inflammatory arthritic disorders seen in older individuals. Most patients with PMR are diagnosed and managed exclusively in general practice, yet primary care-focused research is lacking.AimTo identify and explore the challenges of diagnosis and management of PMR in general practice.Design and settingA multi-methods study in UK primary care.MethodThe multi-methods study comprised two complementary studies: a national questionnaire survey of 5000 randomly selected GPs from across the UK; and a qualitative semi-structured telephone interview study of UK GPs. Simple descriptive statistics were used to analyse questionnaire data. A thematic approach was used to analyse verbatim transcripts of the GP interviews.ResultsIn total, 1249 (25%) GPs responded to the questionnaire survey. From this total, 24 GPs were interviewed for the qualitative study. Features used by GPs to identify PMR were largely in line with current guidance. Diagnosis was found to be challenging, with GPs relying heavily on response to treatment with glucocorticoids. Investigations advised by current British PMR guidance to attempt to rule out other causes for symptoms were not routinely requested. Concerns surrounding ongoing treatment with glucocorticoids were widespread in relation to both potential adverse effects and ongoing monitoring.ConclusionFocused strategies to investigate and therefore exclude non-PMR differential diagnoses are required for patients with new-onset suspected PMR symptoms. Additionally, ongoing active review for alternative causes for symptoms as well as vigilance for treatment complications needs to be implemented.

Background To examine the frequency of possible giant cell arteritis (GCA) symptoms (including headache, temporal/scalp tenderness, jaw claudication and visual symptoms) in newly diagnosed polymyalgia rheumatica (PMR) patients in UK primary care. Methods The PMR Cohort Study is a primary care inception cohort of 652 adults with newly diagnosed polymyalgia rheumatica (PMR). At baseline, participants were asked to report (yes/no) on the presence of seven potential GCA symptoms: sudden headache, tender scalp, disturbed/double vision, jaw claudication, fever, appetite loss and unintentional weight loss. Results Of the 652 patients, 405 (62%) were female, with a mean (SD) age of 72.5 (8.9) years. Sudden headache was the commonest symptom in 161 patients (24.7%). The least commonly reported symptom was jaw claudication in 66 (10.1%) patients. Females had a higher prevalence of headache, tender scalp and jaw pain. Sudden onset headache and fever were commoner in younger patients, (OR (95% CI) per 10 year age band increase: headache 0.76 (0.62–0.92), fever 0.63 (0.49, 0.79)). In those reporting sudden headache (n = 161), 19.9% (n = 32) also reported double/disturbed vision and a tender scalp, whilst 11.8% (n = 19) reported double/disturbed vision and jaw pain. Conclusion The data suggests possible GCA symptoms are common in PMR patients, particularly sudden headache, appetite loss and weight loss. These symptomatic PMR patients warrant careful monitoring and consideration for early referral to specialist services. Electronic supplementary material The online version of this article (10.1186/s41927-017-0007-2) contains supplementary material, which is available to authorized users.

ObjectivesClinical management of giant cell arteritis (GCA) involves balancing the risks and burdens arising from the disease with those arising from treatment, but there is little research on the nature of those burdens. We aimed to explore the impact of giant cell arteritis (GCA) and its treatment on patients’ lives.MethodsUK patients with GCA participated in semi-structured telephone interviews. Inductive thematic analysis was employed.Results24 participants were recruited (age: 65–92 years, time since diagnosis: 2 months to >6 years). The overarching themes from analysis were: ongoing symptoms of the disease and its treatment; and ‘life-changing’ impacts. The overall impact of GCA on patients’ lives arose from a changing combination of symptoms, side effects, adaptations to everyday life and impacts on sense of normality. Important factors contributing to loss of normality were glucocorticoid-related treatment burdens and fear about possible future loss of vision.ConclusionsThe impact of GCA in patients’ everyday lives can be substantial, multifaceted and ongoing despite apparent control of disease activity. The findings of this study will help doctors better understand patient priorities, legitimise patients’ experiences of GCA and work with patients to set realistic treatment goals and plan adaptations to their everyday lives.

Background Glucocorticoids are associated with increased fracture risk and are the mainstay of treatment in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). However, fracture risk in these conditions has not been previously quantified. The aim of this study was to quantify the risk of fracture among patients with PMR and GCA. Methods A retrospective cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident diagnoses of PMR or GCA were separately identified from 1990–2004 and followed up until 2015. For each exposed individual, four age-, sex- and practice-matched controls were randomly selected. Incidence rates of fracture per 10,000 person-years were calculated for each disease group and hazard rates were compared to the unexposed using Cox regression models. Results Overall, 12,136 and 2673 cases of PMR and GCA, respectively, were identified. The incidence rate of fracture was 148.05 (95% CI 141.16–155.28) in PMR and 147.15 (132.91–162.91) in GCA per 10,000 person-years. Risk of fracture was increased by 63% in PMR (adjusted hazard ratio 1.63, 95% CI 1.54–1.73) and 67% in GCA (1.67, 1.49–1.88) compared to the control populations. Fewer than 13% of glucocorticoid-treated cases were prescribed bisphosphonates. Conclusions This study reports, for the first time, a similar increase in fracture risk for patients with PMR and GCA. More needs to be done to improve adherence to guidelines to co-prescribe bisphosphonates. Further research needs to identify whether lower glucocorticoid starting doses and/or aggressive dose reduction reduces fracture risk. Electronic supplementary material The online version of this article (doi:10.1186/s12916-017-0987-1) contains supplementary material, which is available to authorized users.

This paper aims to examine the relationship between different characteristics of pain and stiffness and the functional status of patients with newly diagnosed polymyalgia rheumatica (PMR). Baseline analysis of an inception cohort study was conducted. Patients aged ≥18 years, with a new diagnosis of PMR were recruited from 382 English general practices. Participants were mailed a baseline questionnaire, including separate pain and stiffness manikins and numerical rating scales (NRS), a question on their ability to raise their arms above their head and the modified Health Assessment Questionnaire (mHAQ) to examine participants’ functional status. Linear regression analysis, reported as regression co-efficients (95% confidence intervals (95% CI)), was used to assess the association of pain and stiffness with function, initially unadjusted and then adjusted for age, gender, deprivation status, smoking status, BMI, anxiety and depression. Six hundred fifty two patients responded to the baseline survey (88.5%). The majority (88.2%) reported no, or mild impairment in their functional status. Adjusted linear regression analysis demonstrated that high (NRS ≥8) pain (0.20 (95% CI 0.10–0.28)) or stiffness (0.18 (0.09–0.26)) ratings, an increasing number of sites of pain (0.18 (0.06–0.29)) or stiffness (0.19 (0.08–0.31)) and shoulder pain (0.18 (0.05–0.31)), stiffness (0.10 (0.01–0.20)) and difficulty raising arms above one’s head (0.19 (0.10–0.28)) were all associated with increased functional impairment. The majority of newly diagnosed PMR patients reported no or minimal functional difficulty. However, those who experience severe or widespread pain or stiffness often have significant functional limitation in performing their daily activities and may be a subset worthy of additional focus in primary care.

Background Gout is the most common type of inflammatory arthritis, affecting 2.4% of adults in the UK and is associated with a number of co-morbidities. Our understanding of the association between gout and fracture risk is limited with previous studies offering conflicting results. Objectives To determine the risk of fracture among gout patients and assess the potential impact of urate-lowering therapy (ULT) on fracture risk. Methods Utilising primary care records from Clinical Practice Research Datalink we identified patients with gout between 1990 and 2004 who were followed up until 2015. Each gout patient was individually matched to 5 individuals without gout based on age, sex, and registered practice. Absolute rate (AR) of fracture and hazard ratios (HR) were calculated using Cox regression models. We further stratified our analysis by age, gender and ULT prescription. Results We matched 35,857 patients with incident gout to 148,407 controls. Overall, we found no increased risk of fracture among gout patients compared to controls. However, men with no evidence of ULT had higher absolute risk of fracture compared to controls (AR=39 versus 26 per 10,000 person-years) corresponding to a 23% (HR=1.23; 95% CI 1.12–1.36) increased risk. The risk was particularly high for vertebral (HR=1.50; 95% CI 1.20–1.87) and wrist fracture (HR=1.45; 95% CI 1.21–1.74). Those treated with ULT had a 12% (HR=0.88; 95% CI 0.79–0.98) lower risk of fracture. Similar findings were not observed for women. Conclusions We found higher risk of vertebral and wrist fractures among men with gout not prescribed ULT. Those prescribed ULT had lower risk of fracture compared to the general population. Further research is needed to understand the role of ULT in fracture prevention. Acknowledgements CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice. TH is funded by a NIHR Clinical Lectureship in General Practice and AAS is funded by NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health Disclosure of Interest None declared

Background Psoriasis is a common inflammatory skin disease affecting 2–4% of the population and of these a subset will develop an associated inflammatory arthritis (psoriatic arthritis - PsA). An increased risk of osteoporosis has previously been reported in psoriasis patients but the risk of fracture in patients with both psoriasis and PsA has not been established. Objectives To estimate the effect of psoriasis, and PsA, on the risk of fracture using a large electronic primary health care database. Methods A matched cohort study was conducted utilizing data from the Clinical Practice Research Datalink, a large UK database of primary care medical records. The exposed population was defined as psoriasis patients aged over 40 years with an incident diagnosis between 1990–2004, who were followed up until 2015. Four unexposed patients were matched to each exposed based on age, sex and general practice. The incidence rate of fracture were calculated as the number of incident diagnoses per 10,000 person-years, stratified by sex. Hazard ratios (HR) and 95% confidence intervals were estimated using a Cox proportional hazards model to compare the hazard rate between the exposed and unexposed, adjusting for BMI, alcohol consumption, smoking status, Charlson comorbidity index and steroid use. Fracture risk was estimated for patients with both psoriasis and PsA, identified as patients with an incident diagnosis of psoriasis and a diagnosis of PsA between 1990–2004. Results 24,219 patients with psoriasis and 94,820 controls were included in the study. The mean age was 59 years at study entry and just over half (51%) of the patients were male. The incidence rate of fracture was 58.4 (95% CI:55.6–61.3) and 53.1 (51.7–54.5) per 10,000 person-years for the exposed and unexposed, respectively. After adjusting for confounding factors, patients with psoriasis had 12% increased risk of fracture (HR: 1.12; 95% CI: 1.06–1.19) compared to the matched unexposed group. The risk was slightly higher in males (1.22 (1.09–1.36)) than females (1.09 (1.03–1.17)). Among those with psoriasis, 4.1% were also diagnosed with PsA. An increased risk of 45% was found in those exposed to both psoriasis and PsA compared to the unexposed group (1.45 (1.09–1.94)). Conclusions This study reports for the first time, an increase in fracture risk in patients with psoriasis. A higher risk was found in males than females and the risk was further increased if the patient also had PsA. These findings suggest that fracture risk assessment needs to be considered for individuals with psoriasis and PsA. Acknowledgements This study was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). TH is funded by an NIHR Clinical Lectureship in General Practice. AAS is funded by an NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Disclosure of Interest None declared

Background Early, accurate diagnosis of RA is critical to improving outcomes. Patients with RA may develop a variety of symptoms including joint pain, swelling and stiffness. The Symptoms in Persons at Risk of Rheumatoid Arthritis (SPARRA) questionnaire was derived to assess the presence, severity and impact of common symptoms in patients at risk of RA (1). However, to date there is little data available on how common these symptoms are in primary care consulters. Objectives To describe the prevalence of self-reported inflammatory joint symptoms in primary care patients consulting for both musculoskeletal and non-musculoskeletal complaints. Methods Questionnaires were sent to 10161 individuals, of whom 5050 had consulted primary care for musculoskeletal problems. The remainder were matched to this sample by age, gender and general practice and had consulted for any non-musculoskeletal indication. Respondents provided data on presence of common symptoms such as joint pain, stiffness and swelling. The prevalence of these symptoms, their severity and impact was compared between musculoskeletal and non-musculoskeletal consulters. Results 4549 people responded to the survey (adjusted response 45.8%) of whom 52.3% were in the musculoskeletal consultation group. The mean (SD) age was 61.6 (14.8) years and 58.9% were female. Symptoms commonly associated with inflammatory arthritis were common in both groups. 89.1% of musculoskeletal consulters reported current joint pain, compared with 74.9% in the non-MSK consulter group, 48.7% of MSK consulters reported joint swelling compared to 37.3% of non-MSK consulters and 77.9% of MSK consulters reported joint stiffness (64.3% in non-MSK group). A similar proportion in each group reported fatigue (59.5% vs 55%). Joint symptoms remained common symptoms in both groups even when severity and impact of symptoms was considered. Conclusions Although symptoms such as joint pain, swelling, and stiffness are predictive of inflammatory arthritis, a large proportion of those consulting primary care for non-musculoskeletal reasons routinely report these symptoms when prompted. This compounds the challenges of diagnosing inflammatory arthritis in a non-specialist setting where new approaches are needed to ensure accurate, early diagnosis, facilitating a treat to target approach. References van Tuyl, et al. Musculoskeletal Care 2016;14:169–73. Acknowledgements This study represents independent research funded by the National Institute for Health Research (NIHR). TH is funded by a NIHR Clinical Lectureship in General Practice. CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). The views expressed are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health. Disclosure of Interest None declared

Background Polymyalgia rheumatica (PMR) is a common rheumatological disorder of older patients. The majority of UK patients are diagnosed and managed exclusively in general practice. In primary care, it has been shown that there is wide variation in practice, and established diagnostic criteria are infrequently used. Aim This study aims to investigate the diagnostic processes, management, and monitoring of patients with PMR in UK primary care. Design and setting This is a retrospective cohort study set in primary care. Method Data were extracted from two interlinked primary care databases from north Staffordshire. Patients with PMR were identified using Read Codes and the relevant investigation, prescription, and consultation data were extracted and reviewed. Results Three hundred and four patients’ records were analysed. Documentation of symptoms leading to a diagnosis of PMR was found in 248 records (81.6%). A documented process of exclusion of relevant differential diagnoses was demonstrated in 68 (22.4%) patients. The mean initial dose of prednisolone was 21.5 mg. Referral to specialist care was made for 135 (44.4%) patients. Gastric prophylaxis was prescribed in 85 (28.0%) cases. Osteoporosis prophylaxis was prescribed to 183 patients (60.2%); 12 patients (3.9%) developed osteoporosis and 56 (18.4%) developed gastric symptoms that led to GP consultation. Conclusion The management of PMR in general practice could be optimised. Identified areas for improvement include clear documentation of a process of exclusion of other diagnoses, and prophylaxis for potential treatment complications, including osteoporosis and gastric symptoms.

The authors describe the causes, diagnosis and recommended management of polymyalgia rheumatica, the commonest rheumatological disorder in the elderly.

BACKGROUND: The aim was to characterise the sociodemographic, general health and polymyalgia rheumatica (PMR)-specific features of participants in a large inception cohort of patients with PMR diagnosed in UK primary care. METHODS: Patients (n = 739) with a new diagnosis of PMR were referred into the study and mailed a questionnaire detailing their general health and sociodemographic characteristics in addition to the symptoms of and treatment for PMR. Characteristics of responders and non-responders were compared and descriptive statistics were used to characterise the health of the cohort. RESULTS: A total of 654 individuals responded to the questionnaire (adjusted response 90.1 %). Responders and non-responders were similar in age, gender and deprivation (based on postcode). The mean (standard deviation) age of the recruited cohort was 72.4 (9.3) years; 62.2 % were female. The sample reported high levels of pain and stiffness (8 out of 10 on numerical rating scales) and reported stiffness that lasted throughout the day. High levels of functional impairment, fatigue, insomnia and polypharmacy were also reported. Overall, women reported worse general and PMR-specific health than did men. CONCLUSIONS: This first primary care cohort of patients with incident PMR is similar in demographic terms to cohorts recruited in secondary care. However, the extent of symptoms, particularly reported stiffness, is higher than has been described previously. Given the majority of patients with PMR are exclusively managed in primary care, this cohort provides important information on the course of PMR in the community that will help clinicians managing this painful and disabling condition.

Background: Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events. Methods: We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica. Results: A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.3–12.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.4–2.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis. Interpretation: Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk.

Musculoskeletal disorders such as back pain, neck pain, osteoarthritis, and rarer conditions like gout and inflammatory arthritis are the most common limiting long-term conditions in the UK.1 They represent a huge and growing burden on population health, accounting for 30% of all years lived with disability, and 7.5 million days lost from work each year. The challenge was recognised by the Chief Medical Officer and confirmed in the recent Global Burden of Disease report: ‘Although health-care cost and activity data confirm that these conditions consume massive UK health system resources, concerted public health and high-quality integrated medical care strategies are not implemented systematically. Interventions are available for musculoskeletal disorders, but to what extent the health system is delivering is unclear. Musculoskeletal disorders will only increase in importance in view of present trends and require more urgent policy attention.’ 1 General practice and primary care more generally have a critical role in meeting these challenges. Of the 300 million general practice consultations that occur in England every year, approximately one in six are for arthritis and musculoskeletal problems. An important feature of primary care is its capacity to address the needs of patients with long-term conditions such as musculoskeletal complaints; this includes responsibility for anticipatory and preventive care across the life-course, supporting patients to self-manage their condition, and delivery of evidence-based clinical treatment. Effective primary health care can improve the health and wellbeing of individual patients and their families, and reduce the health and economic impact of musculoskeletal disorders on the population as a whole. The Research Institute for Primary Care and Health Sciences at Keele University is a multidisciplinary collaboration between academics from general practice, clinical rheumatology, epidemiology, physiotherapy, psychology, and health services research, and clinical partners across the West Midlands and Cheshire. …

Objective To investigate the incidence of new cancer diagnoses in a community sample of patients with polymyalgia rheumatica (PMR). Methods All incident cases of PMR in the UK General Practice Research Database (GPRD) (1987–99), without pre-existing cancer or vascular disease and treated with corticosteroids (n=2877) were matched with up to five age, sex and GP practice patients without PMR (n=9942). Participants were followed up until first cancer diagnosis, death, transfer out of the database or end of available records. Results The mean age of the sample was 71.6 years (SD 9.0), 73% were female. Median follow-up time was 7.8 years (IQR 3.4, 12.3). 667 (23.2%) people with a PMR diagnosis developed cancer compared with 1938 (19.5%) of those without PMR. There was an interaction between PMR status and time. In the first 6 months after diagnosis, those with a PMR diagnosis were significantly more likely to receive a cancer diagnosis (adjusted HR (95% CI): 1.69 (1.18 to 2.42)). The number of events was small, but occurrences of prostate, blood, lymph nodes, female reproductive and nervous system cancers may be more common in those with PMR in the first 6 months after PMR diagnosis. Conclusions An increase in the rate of cancer diagnoses was noted in the first 6 months of observation, but we were unable to determine whether the cancer incidence in PMR was different from controls, beyond this time point. Clinicians should ensure they fully exclude cancer as a cause of PMR-like symptoms and monitor patients for possible malignancies.

Polymyalgia rheumatic (PMR) is the most common inflammatory arthritis managed in primary care settings. The majority of clinical care is typically provided by General Practitioners (GPs) with evidence suggesting that current management is suboptimal. This talk will highlight some of the key challenges faced by GPs highlighting areas where the diagnosis, monitoring and long term care can be improved. Disclosure of Interest None declared

Background Polymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition. Methods Patients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers. Discussion This will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.

Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disorder affecting older people.1 Patients typically present with bilateral shoulder pain, morning stiffness, raised inflammatory markers, and have a rapid response to low-dose corticosteroids. There is no gold standard diagnostic test and despite being first described in 1888, controversies still exist as to its defining characteristics. PMR carries a lifetime risk of 2.4% for females and 1.7% for males.2 The incidence in the UK has been shown to be 8.42 per 10 000 person years.3 In the UK, the majority of patients are managed exclusively in primary care4 with an average full-time GP seeing five new cases of PMR per year.5 Accurate diagnosis can be challenging even for specialists, but is essential as many serious illnesses can mimic PMR. Guidelines for the diagnosis and management of PMR have recently been published by the British Society of Rheumatologists (BSR) and British Health Professionals in Rheumatology (BHPR).6 Consider PMR in patients over the age of 50 years with: Subsequent clinical assessment and investigations should …

Background Giant Cell Arteritis (GCA) is the commonest large vessel vasculitis yet a full time UK general practitioner (GP) can expect to see just 1 case every 1-2 years [Barraclough]. GCA may be difficult to identify, particularly in atypical cases. For example headache has been shown to be absent in just under a quarter of GCA patients which may falsely reassure clinicians resulting in delayed diagnosis and potential visual loss [Ezeonyeji]. Objectives The aim of this study was to investigate how GPs identify GCA. Methods A postal questionnaire survey of 5000 randomly selected UK general practitioners was undertaken. Questions included experience of managing patients with GCA, presenting symptoms used to identify GCA and the referral pathways used. Results 1249 questionnaires were returned. The mean age of responder was 43 years and they had been qualified as a GP for a mean of 14 years (SD 9.03). Respondents were more likely to be from larger practices. 879 responders (70.4%) indicated that they had diagnosed and managed a patient with GCA. [Figure 1][1] illustrates the combinations of the main symptoms that GPs use to identify GCA with headache being the predominant feature (n=1071 (86%)). Other commonly reported features were visual disturbances (n=671 (53.9%)), jaw symptoms (n=420 (33.7%)) and temporal artery/scalp tenderness (n=468 (37.6%)). 21.86% (n=273) indicated that they only use headache as a symptom for identifying GCA. ![Figure 1.][2] Figure 1. Venn diagram of symptoms used to identify GCA. Conclusions General practitioners in the UK rely overly on headache when diagnosing GCA. Educating clinicians about other presenting symptoms and atypical presentations is essential to optimise diagnosis and reduce the potential for visual loss for this patient group and to reduce potentially serious long term complications. References 1. Barraclough K et al. Br J Gen Pract. 2012 Jun;62(599):329-3 2. Ezeonyeji A et al. Clin Rheumatol. 2011;30(2):259-262 Acknowledgements Administration and support staff at Keele University Department of Primary Care and Health Sciences. IT Staff Zoe Mason and Ashley Ford. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4634 [1]: #F1 [2]: pending:yes

Background Giant cell arteritis (GCA) although the commonest large vessel vasculitis, is relatively uncommon in primary care. However, given the potentially serious complications of GCA including visual loss, general practitioners (GPs) need to recognise suspected GCA early and instigate appropriate management. UK BSR guidelines advocate early referral for specialist review and the initiation of treatment with high dose corticosteroids to minimise the likelihood of visual loss [1] Objectives The aim of this study was to investigate steroid management and referral patterns for GCA amongst UK GPs. Methods A postal questionnaire survey of 5000 randomly selected UK GPs was undertaken. Questions included experience of managing patients with GCA, initial steroid doses used and the referral pathways of suspected GCA. Results 1249 GPs responded (corrected response rate of 25.1%). Responders had a mean age of 44 years (SD 9.2) and had been qualified as a GP for a mean of 14 (SD 9.03) years. Respondents were more likely to be from larger practices. 879 responders (70.4%) indicated that they had diagnosed and managed a patient with GCA. The most common initiating dose of prednisolone was 60mg, although this varied widely (figure 1). Once GPs had suspected the diagnosis, 478 respondents (38.3%) indicated that they refer to rheumatology, 366 (29.3%) would refer to ophthalmology, 144 (11.5%) would refer to general medicine and 35 (2.8%) would refer to accident and emergency. Table 1 illustrates the action taken by respondents when GCA is suspected. Conclusions These results show that there appears to be wide variation amongst responders in how suspected GCA is managed in general practice. This is likely to be due to variation in the availability of relevant services. However, it may also reflect GPs training and previous experience. Referral pathways that allow urgent specialist review for diagnostic confirmation are essential to avoid the serious complications of GCA, but also inappropriate over treatment of patients who do not have the disorder. References Dasgupta B et al. Rheumatology (Oxford). 2010 Aug;49(8):1594-7. Acknowledgements Administration and support staff at Keele University Department of Primary Care and Health Sciences. IT Staff Zoe Mason and Ashley Ford Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4756

Background The initial diagnosis of polymyalgia rheumatica (PMR) is often made in primary care. Given the non-specific nature of PMR symptoms, diagnosis can be challenging especially as many disorders can mimic the symptoms of PMR. Although guidelines are available1, studies suggest guidelines are rarely followed2 and that diagnostic accuracy is poor3. However, previous studies have relied upon data from retrospective case review or data from referral letters. Objectives The aim of this study was to describe how general practitioners (GPs) in the UK, report that they diagnose PMR based on symptoms, investigations and exclusion of other disorders. Methods 5000 randomly selected GPs in the UK were mailed a questionnaire on PMR. As part of the survey GPs were asked, in their routine practice, which clinical features were most important in diagnosing PMR and, what investigations they performed. They were also asked, what they would do if the inflammatory markers were normal and which disorders they would routinely try to exclude before making a formal diagnosis of PMR. Results 1249 (25.1%) GPs responded. Responders were generally from practices with larger list sizes and more GP principals than non-responders. GPs rated bilateral shoulder pain, raised inflammatory markers and response to corticosteroids as the most important clinical features for diagnosing PMR. Most respondents performed full blood count and ESR or CRP. Other recommended blood tests were performed less frequently (figure 1 ). 25% (n=315) of GPs reported that they would exclude PMR in patients with normal inflammatory markers, whilst 31% (n=392) would refer their patients to secondary care for specialist review. 80% (n=1001) of GPs sought to exclude giant cell arteritis (GCA). 61% (n=759) routinely excluded other rheumatological disorders, but just 55% (n=682) considered excluding relevant malignancies. Image/graph Conclusions This large GP survey suggests that despite using recommended clinical features to diagnose PMR and seeking to exclude GCA, many GPs do not routinely exclude other diagnoses as a cause of symptoms. This has significant implications for diagnostic accuracy which could result in prolonged, inappropriate treatment with corticosteroids or a missed opportunity for timely more appropriate intervention in disorders such as malignancy or rheumatoid arthritis. Further work is needed to investigate the accuracy of the diagnosis of PMR in primary care. References Rheumatology, 49(1), pp. 186-90. Family Practice, 25(5), pp. 328-333. Clinical rheumatology, 19(4), pp. 278-280. Disclosure of Interest None Declared

It is potentially dangerous to suggest that normal inflammatory markers can be used to rule out illnesses such as giant cell arteritis and polymyalgia rheumatica.1 Although patients with polymyalgia rheumatica will …

BackgroundIn the UK, general practitioners (GPs) are usually the first medical contact for patients with suspected giant cell arteritis (GCA). While rare, it is critical not to miss, as delayed treatment can lead to significant complications including permanent visual loss. To date, little is known about the approach and challenges to diagnosis and management of GCA by GPs.ObjectiveTo investigate the diagnosis and management of patients with suspected GCA in UK general practice.Design and participantsA multimethods approach was taken, comprising a postal survey of 5000 randomly selected UK GPs and semistructured telephone interviews of 24 GPs from across the UK.SettingUK general practice.Results1249 questionnaires were returned. 879 responders (70%) indicated that they had diagnosed and managed a patient with GCA. A variety of clinical features were used to identify GCA. 21.9% suggested that they would exclude GCA as a diagnosis if headache was absent and around one-third do not routinely initiate glucocorticoid treatment prior to referral. Significant regional variations in referral pathways were reported. Thematic analysis of interview transcripts highlighted fears relating to a missed diagnosis of GCA and the non-specific nature of early GCA presentation. Accessing specialist care was highlighted as challenging by many GPs and that a national standard fast-track pathway is lacking to support this patient group. Additionally there were significant concerns regarding potential adverse effects relating to long-term treatment with glucocorticoids.ConclusionGPs appear to over-rely on headache to identify GCA and marked geographical differences in management, with conflicting referral pathways and difficulties in accessing appropriate services exist in the UK. A national standard for fast-tracking patients with suspected GCA to relevant specialists would be beneficial to improve care and outcomes for patients with GCA.