Interstitial lung disease (ILD) is a significant complication of many systemic autoimmune rheumatic diseases (SARDs), although the clinical presentation, severity and outlook may vary widely between individuals. Despite the prevalence, there are no specific guidelines addressing the issue of screening, diagnosis and management of ILD across this diverse group. Guidelines from the ACR and EULAR are expected, but there is a need for UK-specific guidelines that consider the framework of the UK National Health Service, local licensing and funding strategies. This article outlines the intended scope for the British Society for Rheumatology guideline on the diagnosis and management of SARD-ILD developed by the guideline working group. It specifically identifies the SARDs for consideration, alongside the overarching principles for which systematic review will be conducted. Expert consensus will be produced based on the most up-to-date available evidence for inclusion within the final guideline. Key issues to be addressed include recommendations for screening of ILD, identifying the methodology and frequency of monitoring and pharmacological and non-pharmacological management. The guideline will be developed according to methods and processes outlined in Creating Clinical Guidelines: British Society for Rheumatology Protocol version 5.1.

Background: Patients with autoimmune rheumatic diseases (ARDs) taking JAK inhibitors may have an increased risk of cardiovascular events, especially if they have other health conditions. Identifying high-risk patients can inform targeted preventive care. This study assessed the value of age and deprivation decile in predicting cardiovascular events in patients on JAK inhibitors for ARDs. Objective: To assess the predictive value of age and deprivation decile in identifying patients at risk of cardiovascular events while on JAK inhibitor therapy for ARDs. Methods: This cross-sectional cohort study enrolled 309 patients with ARDs (mean age 59.3 years, 77% female) treated with JAK inhibitors at a UK teaching hospital. Baseline characteristics, including age, gender, ethnicity, and comorbidities, were collected. Cardiovascular events (myocardial infarctions, strokes, and cardiovascular-related deaths) that occurred while on JAK inhibitor therapy were identified retrospectively. Deprivation indices were calculated using socioeconomic factors. Results: Multivariate logistic regression analysis, adjusting for potential confounders, showed that a model combining age and deprivation decile was statistically significant (p = 0.031) in predicting cardiovascular events. Neither age nor deprivation decile alone was statistically significant. Older patients had an odds ratio of 1.06 (95% CI: 1.00-1.13) for increased risk of cardiovascular events. The logistic regression model as a whole was statistically significant (Chi2(14) = 24.04, p = 0.031, n = 309). The AUC of the ROC curve was 0.837. Conclusion: Age and deprivation decile can effectively predict cardiovascular events in patients on JAK inhibitor therapy for ARDs. Incorporating these predictive tools into routine clinical practice can help identify patients who warrant intensified cardiovascular risk management.

With all the challenges facing the NHS at the current time, specialist nurses are fundamental and an important part of an ever-expanding NHS workforce. Furthermore, specialist nurses now possess more diversity and a wide range of advanced skills. In the field of rheumatology in most NHS hospitals, specialist nurses play a key role in biologic services to ensure that patients are promptly started on biological therapy to control their disease. An important element of this workup is the ability to comment on an unreported chest radiograph to facilitate a biological prescription. Some studies have shown that there is limited expertise among non-doctors with the required skills to review unreported chest X-rays confidently. The authors of this paper sought to explore whether this is the case among specialist nurses involved in the biologic prescription service among other clinicians in the same service. An online questionnaire was designed by the authors, which included seven questions and responses collected on a 5-point Likert scale. Trainee doctors, non-trainee grade doctors, and specialist nurses who were involved in the biologic prescribing team from Rheumatology, Dermatology, and Gastroenterology were invited. A total of 56 responses were obtained and analyzed. Descriptive and inferential statistics were obtained from the data. To determine if there was a statistical difference between the responses of trainee doctors and specialist nurses, the Kruskal-Wallis statistical test was used, and a post hoc test using the Dunn-Bonferroni test was used to analyze any statistically significant results. Regarding chest X-ray interpretation prior to starting biological treatment, only 8% of specialist nurses reported being confident, whereas 63% of trainees reported being confident. The Kruskal-Wallis test revealed a significant difference between specialist nurses' and doctors' confidence in interpreting unreported chest radiographs. The P-value is 0.001; thus, with available data, the null hypothesis is rejected. A Dunn-Bonferroni test (post hoc test) showed that, based on the available data, it can be assumed that the two groups had different levels of confidence between Specialist Nurses and trainee doctors. Chest X-ray interpretation skills are vital for specialist nurses in the context of biological therapy prescriptions. Therefore, we recommend access to resources, ongoing formal training, and educational sessions to help specialist nurses maintain their advanced skill sets and broaden their scope of practice to those without the required expertise.

Objectives: The National Health Service in England funds 12 months of weekly subcutaneous tocilizumab (qwTCZ) for patients with relapsing or refractory giant cell arteritis (GCA). During the COVID-19 pandemic, some patients were allowed longer treatment. We sought to describe what happened to patients after cessation of qwTCZ. Methods: Multicentre service evaluation of relapse after stopping qwTCZ for GCA. The log-rank test was used to identify significant differences in time to relapse. Results: 336 GCA patients were analysed from 40 centres, treated with qwTCZ for a median (interquartile range, IQR) of 12 (12-17) months. At time of stopping qwTCZ, median (IQR) prednisolone dose was 2 (0-5) mg/day. By 6, 12 and 24 months after stopping qwTCZ, 21.4%, 35.4% and 48.6% respectively had relapsed, requiring an increase in prednisolone dose to a median (IQR) of 20 (10-40) mg/day. 33.6% of relapsers had a major relapse as defined by EULAR. Time to relapse was shorter in those that had previously also relapsed during qwTCZ treatment (P = 0.0017); in those not in remission at qwTCZ cessation (P = 0.0036); and in those with large vessel involvement on imaging (P = 0.0296). Age ≥65, gender, GCA-related sight loss, qwTCZ treatment duration, TCZ taper, prednisolone dosing, and conventional synthetic DMARD use were not associated with time to relapse. Conclusion: Up to half our patients with GCA relapsed after stopping qwTCZ, often requiring a substantial increase in prednisolone dose. One third of relapsers had a major relapse. Extended use of TCZ or repeat treatment for relapse should be considered for these patients.

Objective: Development and test of a culturally sensitive intervention for rheumatology healthcare professionals (HCPs). Methods: Using a before and after study design, fifteen HCPs were recruited to undertake the bespoke intervention from four NHS sites across England, in areas serving a diverse population. The intervention was evaluated using the validated outcomes: [1] Patient Reported Physician Cultural Competency (PRPCC); and [2] Patient Enablement Instrument (PEI), measuring patients' perceptions of their overall healthcare delivery. Additionally, HCPs completed the Capability COM-B questionnaire (C), Opportunity (O) and Motivation (M) to perform Behaviour (B), measuring behaviour change. Results: 200 patients were recruited before HCPs undertook the intervention (cohort 1), and 200 were recruited after (cohort 2) from fifteen HCPs, after exclusions 178 patients remained in cohort 1 and 186 in cohort 2. Patients identifying as White in both recruited cohorts were 60% compared with 29% and 33% of patients (cohorts 1 and 2 respectively) who identified as of South Asian origin. After the intervention, the COM-B scores indicated HCPs felt more skilled and equipped for consultations. No significant differences were noted in the average overall cultural competency score between the two cohorts in White patients (57.3 vs 56.8, p= 0.8), however, in the South Asian cohort, there was a statistically significant improvement in mean scores (64.1 vs 56.7, p= 0.014). Overall, the enablement score also showed a statistically significant improvement following intervention (7.3 vs 4.3, p< 0.001) in the White patients; and in the South Asian patients (8.0 vs 2.2, p< 0.001). Conclusion: This novel study provides evidence for improving cultural competency and patient enablement in rheumatology settings.

Objectives: Cannabinoids have gained popularity recently with special emphasis on their use for chronic pain. Although NICE guidelines advise against their usage for management of chronic pain, almost all rheumatologists encounter a few patients in their daily practice who either use them or are curious about them. We reviewed the mechanism of action of cannabinoids, current knowledge about their role in rheumatology and potential drug interactions with common drugs used in Rheumatology. We attempted to answer the question "If cannabinoids are friend, foe or just a mere bystander?" Methods: We adhered to a search strategy for writing narrative reviews as per available guidelines. We searched PubMed with the search terms "Cannabinoids", "Rheumatology" and "Chronic pain" for published articles and retrieved 613 articles. The abstracts and titles of these articles were screened to identify relevant studies focusing on mechanism of actions, adverse effects and drug interactions. We also availed the services of a musculoskeletal librarian. Results: Despite the NHS guidelines against the usage of cannabinoids and associated significant stigma, cannabinoids are increasingly used for the management of pain in rheumatology without prescription. Cannabinoids act through two major receptors CB1 and CB2, which are important modulators of the stress response with potential analgesic effects. Their role in various rheumatological diseases including Rheumatoid arthritis, Osteoarthritis and Fibromyalgia have been explored with some benefits. However, in addition to the adverse effects, cannabinoids also have some potential interactions with common drugs used in rheumatology, which many users are unaware of. Conclusion: While the current studies and patient reported outcomes suggest cannabinoids to be a "friend" of rheumatology, their adverse events and drug interactions prove to be a "Foe". We were unable to arrive at a definite answer for our question posed, however on the balance of probabilities we can conclude cannabinoids to be a "foe". Under these circumstances, a disease and drug focussed research is need of the hour to answer the unresolved question.

Toxic epidermal necrosis (TEN)-like lupus is a rare condition characterized by epidermal loss and mucosal ulceration occurring in patients with acute severe flares of systemic lupus erythematosus. The clinical picture may mimic drug-induced Stevens-Johnson syndrome/TEN; however, the absence of a suitable culprit drug, and the context of acute lupus point to the correct diagnosis. In a case series of three patients, further discriminating features included a slower onset of epidermal loss, more limited mucosal ulceration and a lack of ocular involvement when compared with drug-induced TEN. Histology may show similar features, including basal layer vacuolation, apoptosis and full-thickness epidermal necrosis. Patients with TEN-like lupus may have additional features of lupus, and a lupus band on direct immunofluorescence. It is important to identify this condition correctly, so that these patients can be appropriately managed with early input from Rheumatologists and prompt treatment with high-dose combined immunosuppressant therapy.