bluuebunny/crossref_metadata_2025 huggingface dataset:
P216 Promoting physical activity using mobile health technology in people living with rheumatoid arthritis: MOTIVATE RA
Authors: Bannell Daniel J , Cocks Matthew , Goodson Nicola , Taylor Chloe , Peçanha Tiago , Jones Helen , Low David A , Sprung Victoria S
Published: April 2022

Background/Aims

People with rheumatoid arthritis (RA) commonly experience pain and stiffness which reduces engagement in physical activity (PA). The range of health benefits associated with PA are now well established, and include improvements in cardiovascular health and symptoms associated with RA. However, people with RA are more inactive than the general population and face unique barriers to becoming more active. Mobile health (mHealth) technology (i.e. fitness watches and apps) may provide an effective and economical solution to promoting PA in this population. Therefore, the aim of the current study is to assess the effectiveness of mHealth technology to increase PA levels and reduce disease activity in people living with RA.

Methods

Following ethical approval, 13 females diagnosed with RA were randomised to either an mHealth (n=7, age 47 ± 14 years; BMI 30 ± 5 kg/m2) or a conventional care (CC) intervention group (n=6, age 50 ± 11 years; BMI 25 ± 3 kg/m2). The CC group were provided with online educational material to increase PA whereas the mHealth group were provided with a personalised, progressive walking programme delivered via mHealth technology with ongoing support throughout the 12-week intervention. Prior to (week 0) and following (week 12) the intervention, participants conducted assessments remotely, with guidance from the research team. At each time point all participants wore a GT9X ActiGraph PA monitor for 7 days to quantify PA and completed a RADAI-5 questionnaire to monitor disease activity Change data between weeks 0 and 12 were analysed using independent t-tests and reported as mean difference (95% confidence intervals).

Results

Intervention groups were well matched in terms of age [3 years (95% CI= -12, 19); P=0.66] but differed for BMI [-5 kg/m2 (95% CI= -10, -0.1); P=0.05]. Preliminary analyses reveal no significant difference in steps per day between the mHealth vs. CC groups [323 steps/day (95% CI= -2273, 1632; P=0.72]. Similarly, no difference in RADAI-5 score was observed between the mHealth and CC groups [0.09 (95% CI= -0.28, 4.6); P=0.61].

Conclusion

These preliminary data identify the potential effectiveness of a PA programme to increase PA levels in people with RA delivered via mHealth, though positive changes in mHealth are very small at this early stage. These data, in full, will be important in identifying whether this technology could be used as a cost effective, non-pharmacological management strategy for RA.

Disclosure

D.J. Bannell: None. M. Cocks: None. N. Goodson: None. C. Taylor: None. T. Peçanha: None. H. Jones: None. D.A. Low: None. V.S. Sprung: None.
P221 Autoantibodies are common in patients with idiopathic interstitial lung disease, suggesting a high prevalence of undiagnosed autoimmune connective tissue disease
Authors: Tansley Sarah , Cotton Caroline , McMorrow Fionnuala K , Lu Hui , New Robert P , Spencer Lisa G , McHugh Neil J , Cooper Robert G ,   UK-BILD Collaboration
Published: April 2022

Background/Aims

In some patients, interstitial lung disease (ILD) may be the dominant or even sole manifestation of an otherwise unrecognised autoimmune connective tissue disease (CTD). Accurate diagnosis can be challenging given considerable overlap of the clinical, radiological and histological disease features. Distinguishing CTD related ILD (CTD-ILD) from idiopathic ILD, enables appropriate immunosuppressive treatment, informs prognosis and facilitates monitoring for other CTD associated complications. Occasionally a lung biopsy may be necessary to ensure accurate diagnosis. Autoantibodies are a hallmark feature of CTD, are highly disease specific and their presence is strongly suggestive of covert CTD-ILD. We investigated patients with idiopathic ILD for the presence of autoantibodies that may suggest misdiagnosis.

Methods

The serum from three subgroups of patients recruited to UK Biomarkers of Interstitial Lung Disease (BILD) were analysed: 171 with a diagnosis of idiopathic ILD and non-specific organising pneumonia on HRCT and 27 with a diagnosis of idiopathic ILD and cryptogenic organising pneumonia on HRCT. Autoantibody status was determined by radio-immunoprecipitation.

Results

Results are summarised in Table 1. Overall CTD-autoantibodies were identified in 15.6% of patients with idiopathic ILD, and were more common in those with NSIP, see table. Autoantibodies identified included those readily detectable e.g. anti-Jo1, in addition to rarer antibodies not included in standard assays e.g. anti-EIF3. Nearly half of all autoantibodies detected were anti-synthetase autoantibodies.

Conclusion

Covert-CTD is likely to be common amongst patients diagnosed with idiopathic ILD, particularly idiopathic NSIP. More specific guidance on autoantibody testing could improve diagnosis and ensure patients receive appropriate immunosuppressive treatment.

Disclosure

S. Tansley: None. C. Cotton: None. F.K. McMorrow: None. H. Lu: None. R.P. New: None. L.G. Spencer: None. N.J. McHugh: None. R.G. Cooper: None.
P234 The effect of calcitriol on the expression of interferon signature genes in dendritic cells and macrophages in systemic lupus erythematosus
Authors: Magro Rosalie , Seria Elisa , Grech Godfrey , Borg Andrew A , Scerri Christian
Published: April 2022

Background/Aims

A number of studies have demonstrated the inverse association between vitamin D and (i) disease activity and (ii) interferon (IFN) signature gene expression in systemic lupus erythematosus (SLE). The aim of the study was to establish the effect of calcitriol supplementation to cultured macrophages and dendritic cells (DC) from a SLE patient and control, on the expression of 12 IFN signature genes, interferon regulatory factor (IRF)7 and IRF8.

Methods

Blood samples were collected from a 41-year-old female SLE patient who fulfilled the SLICC classification criteria for SLE and from a 36-year-old healthy female control after obtaining informed consent. Both patients had a serum 25-hydroxyvitamin D level of 25ng/ml. Peripheral blood mononuclear cells (PBMC) were isolated by using histopaque®-1077. CD83 and CD14 expression was measured by flow cytometry and cell count and viability were assessed. The PBMC suspension was cultured in 6-well plates using: (i) ImmunoCultTM DC culture kit (following kit protocol) for DC differentiation, (ii) culture medium for macrophage differentiation containing RPMI 1640 Medium, DMEM, fetal bovine serum and LPS. Following 7 days of incubation, differentiation of cells was confirmed using microscopy and flow cytometry to measure CD83 and CD14 expression. Calcitriol at a concentration of 20nM was added to half of the wells of each sample category. Following 24 and 48 hours, RNA extraction was carried out on treated and untreated samples. QuantiGene Plex technology was used to measure the expression of 12 IFN signature genes, IRF7, IRF8 and four housekeeping genes in the extracted RNA. The normalised median florescence intensity for the 12 IFN signature genes was used to calculate the IFN score.

Results

A significantly lower IFN score was noted at 24 hours in SLE patient dendritic cell and macrophage cell cultures and in control macrophage cell cultures treated with calcitriol when compared with respective untreated samples (p = 0.014, p = 0.034, p = 0.031 respectively). On comparing IRF8 expression in treated and untreated cell cultures, a significantly lower IRF8 expression was noted in treated macrophage cell cultures obtained from both SLE patient and control (p = 0.034, p = 0.041). No difference in IRF7 expression was noted in treated and untreated cultures for all samples.

Conclusion

The suppression of the interferon signature genes in dendritic cell and macrophage cell cultures with vitamin D was confirmed in the in vitro experiment carried out. In this experiment a decrease in the expression of IRF8 (known to have a VDR binding site) was also observed in macrophage cultures from both SLE patient and control.

Disclosure

R. Magro: None. E. Seria: None. G. Grech: None. A.A. Borg: None. C. Scerri: None.
P238 Pre-pregnancy switching from mycophenolate to azathioprine in patients with lupus nephritis: a retrospective outcome analysis
Authors: Ali Saadia S , Sangle Shirish , D'Cruz David
Published: April 2022

Background/Aims

Mycophenolate mofetil is not recommended in pregnancy due to teratogenic effects. A previous small prospective study found that switching from MMF to AZA rarely led to renal flares. Our aim was to assess the impact of switching from MMF to AZA on renal flares and pregnancy outcomes in a lupus nephritis cohort.

Methods

A retrospective analysis of the records of patients attending the renal and antenatal clinics at St Thomas’s Hospital in London who underwent pre-pregnancy counselling and switched from MMF to AZA was undertaken between January 2019 and December 2020. Inclusion criteria included a diagnosis of SLE based on the 2019 EULAR/ACR classification criteria for SLE and lupus nephritis assessed by a biopsy and classified according to the International Society of Nephrology/Renal Pathology Society 2003 classification. A flare was defined as rising urine PCR, decreasing serum albumin, decreasing serum complement and rising dsDNA antibodies and/or an increase in serum creatinine. Analyses included descriptive statistics [mean (standard deviation) and median (interquartile ranges) for continuous variables and frequency (percent) for categorical values].

Results

Twenty-seven patients were included in this study. 55% were of Afro-Caribbean or Asian background and remaining were Caucasian. The median age at SLE diagnosis was 22 (18-26) years. The average disease duration prior to treatment switch was 8 years. The median time between biopsy and switching was 32 months (17-69). 25.9% of patients had a diagnosis of APS. 48% were Ro positive, while 85.2% were positive for dsDNA antibodies. The median serum creatinine was 69 umol/L (58-84), median serum albumin was 42g/L (38-47) and median PCR was 26.5mg/mol (12-61) prior to switching. Our study showed that nine patients (33.3%) flared after switching. five patients (18.5%) flared during pregnancy. 10 (37%) patients went onto have successful pregnancies, two (7.4%) had miscarriages, three (11.1%) patients developed preeclampsia. 46% of patients with class III/IV Nephritis on biopsy developed complications in pregnancy. 36% of patients with dsDNA had poor pregnancy outcomes compared to 25% who were dsDNA negative. 42.2% of patients of Afro-Caribbean/Asian background flared during pregnancy compared to 25% of their Caucasian counterparts.

Conclusion

Although azathioprine is an option in patients with lupus nephritis who are planning pregnancy, there is a need to identify patients at risk of a disease flare on switching from MMF. This study showed that patients with low serum albumin, creatinine >65, urine PCR >50 and positive dsDNA antibodies at the time of the switch were more likely to flare after switching and in pregnancy.

Disclosure

S.S. Ali: None. S. Sangle: None. D. D'Cruz: None.
P249 Analysis of the performance of a newly developed axial spondyloarthritis clinic at a district general hospital
Authors: Newdick Lisa A , Sykes Mark P
Published: April 2022

Background/Aims

Traditionally, patients with ankylosing spondylitis (AS) and axial spondyloarthritis (axSpA) have been managed in general rheumatology clinics at district general hospitals, which can potentially lead to delays in diagnosis or treatment. In order to improve the service, a fortnightly axSpA clinic was set up at West Suffolk Hospital, with appointments with either a consultant or nurse specialist.

Methods

A retrospective case note review was performed for patients diagnosed with axSpA prior to the establishment of the axSpA clinic in April 2019 (comparator group), who were subsequently followed-up in the axSpA clinic. The ‘active group’ comprised patients referred to the clinic with suspected axSpA from May 2019 to December 2020. The performance analysis looked at time from GP referral to outpatient appointment (OPA), time from OPA to MRI examination, time from MRI scan to follow-up appointment and time to biologic disease-modifying anti-rheumatic drug (bDMARD) therapy. Statistical analysis was performed using unpaired t-tests.

Results

From December 2013 to April 2019, 31 patients were identified with an axSpA diagnosis (comparator group), and 65 patients were identified post-audit (active group). The mean time from referral to initial OPA was unchanged between the two groups, at 37 days. While the time from OPA to MRI scan was significantly shorter prior to set-up of the axSpA clinic (34.9 vs. 76.7 days; p = 0.0014), at least nine patients had delayed MRI owing to COVID-19. Excluding these patients from the analysis, the mean wait time from MRI scan in the active group reduced to 35.2 days, which was not statistically different from the comparator group (p = 0.9600). Time from MRI to follow-up OPA and time from a patient meeting the criteria for bDMARD therapy to first prescription of bDMARD reduced following set-up of the axSpA clinic, although differences were not significant (93.1 vs. 50.0 days; p = 0.1400 and 35.3 vs. 21.0 days; p = 0.0510, respectively). Time from first OPA to bDMARD therapy prescription reduced significantly (288.4 vs. 116.7 days; p < 0.0500).

Conclusion

The set-up of the axSpA clinic did not make any difference to the early part of the axSpA pathway (the diagnostic phase); however, there was a notable difference for follow-up times and starting treatment after the diagnosis had been made, which most likely reflects the importance of the role of a nurse specialist in the clinic.

Disclosure

L.A. Newdick: None. M.P. Sykes: None.
P251 A rare case of cauda equina syndrome complicating axial spondyloarthropathy
Authors: Byravan Swetha , Javaid Farhan , Neame Rebecca
Published: April 2022

Background/Aims

Cauda equina syndrome is a rare but disabling neurological complication of axial spondyloarthropathy (axSpA) that occurs many years after disease onset, and often in the absence of inflammatory symptoms. Its insidious onset in long-standing axSpA means that this is a condition that can easily be missed, and this case report describes such an instance.

Methods: Case report

An 82-year-old man diagnosed with HLA-B27 positive axSpA in 1972 developed symptoms of lumbar pain and thigh pain in 2012. He had nerve conduction studies which demonstrated an axonal sensory and motor peripheral neuropathy thought to be multifactorial in cause. He was unable to have a spinal MRI scan due to back pain. Over the years he had ongoing lumbar and sacral pain with increased lower limb weakness, and he became wheelchair bound. In 2014 he started adalimumab, then switched to golimumab. He felt some improvement in pain but never mobility. Over the next few years, he started to experience gastro-urological symptoms including diarrhoea, tenesmus, incontinence, and urinary retention. In March 2021 he presented to hospital with shortness of breath. He was found to have a pleural effusion and enlarged mediastinal lymph nodes consistent with lymphoma and/or lung malignancy. It was also noted that a spinal MRI scan had been requested a few months ago by his GP for ongoing sciatic pain, constipation, and tenesmus. This scan had showed an ankylosed spine, but also abnormal tissue occupying the thecal sac between S1 and S2 and the presence of arachnoiditis. It then came to light that the patient had also undergone a spinal MRI scan in 2014 after being admitted due to a fall. This scan had shown chronic distal cauda equina distortion and even then, had presence of an enlarged thecal sac at S1/2 and chronic arachnoiditis. These results had been overlooked.

Results

Cauda equina syndrome complicating long-standing axSpA was first reported in 1961. The pathophysiology in axSpA is not well understood but seems to occur in longstanding disease suggesting chronic progressive dural stiffening causes a damaging rise in CSF pressure that is transmitted to the sacral nerve roots. It is not considered to be due to active inflammation, and anti-TNF treatment can be non-beneficial. MRI imaging may show nerve clumping and distortion of the thecal sac. Management for this condition is not well established and surgical intervention may not be successful. The resulting neurological deficit can be severe and irreversible and high index of suspicion is needed to investigate and diagnose it.

Conclusion

Neurological symptoms should not be overlooked by the rheumatology team or attributed to a joint issue. Safety netting should be in place for following up the results of imaging investigations.

Disclosure

S. Byravan: None. F. Javaid: None. R. Neame: None.
P252 Physiotherapy services in axial spondyloarthritis in the North West of England. An ASSIGNw benchmarking survey
Authors: Gregory William J , Brazendale Jane , Greenall Carol , McCall Gary
Published: April 2022

Background/Aims

The physiotherapist's role in the assessment and management of axial spondyloarthritis (axSpA) is evolving. The axSpA Specialist Interest Group North-West (ASSIGNw) surveyed practices of its members in 2016. This abstract reports on a 5-year follow-up survey, exploring how our North-West physiotherapy axSpA services are running following the impact of the COVID-19 pandemic. The aim is to benchmark practice of physiotherapists working with axSpA, identifying discrepancies between services and recommending ways forward.

Methods

In June 2021, members of ASSIGNw identified areas of practice to benchmark; questions were formulated to elucidate these, creating a SmartSurveyTM sent to ASSIGNw members August-September 2021.

Results

Sixteen Trusts replied, two more than the 2016 survey. Ratios of physiotherapy:medical staffing range from 1:1 to 1:8. All centres intended to offer virtual appointments as a long-term option. The majority of centres (60%) offered yearly follow up; 40% offered 6-monthly follow up. The median appointment duration had reduced from 45 minutes in 2016 to 30 minutes in 2021. The number of centres offering 60 minute slots reduced from 36% in 2016 to 20% in 2021. The vast majority of consults were undertaken independently by the physiotherapist (86%), a small number offering combined appointments with medical colleagues (7.1%). Half of centres surveyed had no access to onsite hydrotherapy, most of these actively signpost to local pools for self-led water-based exercise (62.5%). A dedicated flare/emergency access service was not offered by 60% of centres. Most centres undertake patient education on a one-to-one basis (94%); formal axSpA education programmes are only offered in one centre surveyed.

Conclusion

This survey, as in 2016, has highlighted a large inter-trust variation in physiotherapy:medic staffing ratio. A broad collection of outcome measures was collected and there is an unchanged general consensus that the BASMI and BASDAI are essential. The average and maximum appointment durations have both reduced. Urgent/flare and hydrotherapy access remains limited. Formal patient education is yet to be adopted, one-to-one education remains the prevalent model. Further work on standardising axSpA physiotherapy-led services is warranted. As we drive forwards best-care, the enhanced use of the full rheumatology multi-disciplinary team and standardisation of staffing levels is recommended.

Disclosure

W.J. Gregory: Honoraria; WG has received honoraria from Abbvie, Novartis, Pfizer and UCB. J. Brazendale: None. C. Greenall: None. G. McCall: None.
P283 Hydrotherapy and aquatic therapy provision in a post-COVID NHS
Authors: Hamilton Jill , Jeffries Claire , Whalley Simon , Webb Dale
Published: April 2022

Background/Aims

Hydrotherapy remains an important part of treatment for a range of rheumatological, musculoskeletal and other conditions. As there is little robust clinical evidence, hydrotherapy is scarcely included in national guidelines, with the exception of the National Institute for Health and Care Excellence (NICE) Guidance for Spondyloarthritis which recommends hydrotherapy as an adjunct therapy. In recent years, hydrotherapy services have often been targeted in cost-saving exercises by commissioners and providers. There was a concern that this would be further exacerbated by the pandemic with pools closing to become storage space and remaining closed beyond this.

Methods

Via the All Party Parliamentary Group (APPG) for axial spondyloarthritis (axial SpA), we submitted a Freedom of Information Request (FOI) to establish the status of hydrotherapy pools pre- and post-pandemic. The FOI was sent to all NHS trusts in England asking them about the status of their pool before and after COVID, future plans and reasons for any delay in re-opening.

Results

90 trusts (69%) responded. 72% of those had an onsite hydrotherapy pool prior to the pandemic, 90% of which were open. 27% of pools had already re-opened and there were plans to re-open 49%. 2% were due to remain permanently shut with 21% unsure of the future of their pool. The most common reasons for delays in pools re-opening were linked to infection prevention control restrictions, including changing area capacity (23%), social distancing and ventilation (38%). The most common reasons for the uncertainty of when they would re-open were changing area capacity (46%), staff to clean (23%), access to pool i.e., still being used for other purposes (30%), social distancing and ventilation (23%). Of those pools that were already open or due to re-open, 93% had a reduced capacity with an average capacity of 37%. This was largely due to changing area capacity (54%), staff to clean (44%), access to the pool (28%), social distancing and ventilation (55%). Of the pools that were open prior to the pandemic, the condition areas which used them included MSK (92%), neurology (74%), physical disability (77%) and children (77%). 8% of users had axial SpA.

Conclusion

There is a very real threat to NHS hydrotherapy facilities in England. A lack of robust clinical evidence often leaves therapists and patients in limbo, with anecdotal testimony as to the benefits often not being enough to convince of its value. A co-ordinated cross-condition alliance is needed to ensure: clear local pathways are established into hydrotherapy; pools are considered in new build and refurbishments; robust clinical evidence is produced; hydrotherapy is included in national guidelines; tools are available at local level to audit and promote hydrotherapy; local services can become self-funding via community and patient groups.

Disclosure

J. Hamilton: None. C. Jeffries: None. S. Whalley: None. D. Webb: None.
P291 Long-term use of glucocorticoids for polymyalgia rheumatica: follow-up of the PMR cohort study
Authors: Muller Sara , Hider Samantha L , Sokhal Balamrit Singh , Lawton Sarah A , Helliwell Toby , Mallen Christian D
Published: April 2022

Background/Aims

Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition in older adults, characterised by pain and stiffness in the shoulder and hip girdles. The mainstay of treatment is oral glucocorticoids (GCs). Classically, treatment is tapered to a stop over two years, but there is growing evidence this does not happen in practice. International guidelines recommend early referral to specialist services for patients at risk of prolonged treatment. However, they do not specify who these patients are. This study considers the factors at, and shortly after, diagnosis that might be associated with prolonged glucocorticoid treatment, and therefore who may benefit from early specialist review.

Methods

652 people with incident PMR were recruited from English general practice between 2012 and 2014. They completed up to seven questionnaires over two years and a further long-term follow-up questionnaire (LTFUQ) 4.5-6.5 years after diagnosis. The first seven questionnaires have previously been used to allocate people to pain-stiffness trajectory classes. In the LTFUQ, participants reported current symptoms and other general health and lifestyle characteristics, as well as whether they were still taking GCs and whether they self-managed their GC use. Characteristics of those having successfully stopped GCs were compared to those still taking them.

Results

A median 5.16 years after diagnosis, 179 people responded to the LTFUQ. Of these, 67 (40.1%) were still on GCs with a mean daily dose of 5mg (1.5, 9). Those still taking GCs were more likely to be older (72.5 vs 70.2 years, p = 0.035), to live alone (31.8% v 15.0%, p = 0.01), and to report having self-managed their GCs (39.1% versus 11.0%, p < 0.0001). They were also more likely to have reported sustained pain-stiffness symptoms in the first two years, as defined by their trajectory class in earlier work (trajectory class [n{%} still treated]; partial recovery, sustained moderate symptoms [23 {34.3%}]; recovery before worsening [17 {25.4%}]; rapid and sustained recovery [15 {22.4%}]; Slow and continuous recovery [11 {16.34%}]).

Conclusion

PMR is not always the typically-described, time-limited condition. There are few patient characteristics that are associated with prolonged treatment early in the disease course, but those who are older and have sustained or recurrent pain and stiffness over two years appear to be at greater risk of remaining on GCs. Whilst accurate prediction of long-term treatment need is not possible from our data, people with sustained symptoms may benefit from specialist review to ensure diagnostic accuracy and consider need for additional therapies to reduce their GC burden.

Disclosure

S. Muller: None. S.L. Hider: None. B. Singh Sokhal: None. S.A. Lawton: None. T. Helliwell: None. C.D. Mallen: None.
P292 Follow up of giant cell arteritis patients with ultrasound: can cranial giant cell arteritis phenotype evolve towards large vessel vasculitis?
Authors: Ciechomska Anna , Melville Andrew R
Published: April 2022

Background/Aims

Ultrasound (US) is well-established in diagnosis of giant cell arteritis (GCA) but its value in follow-up is not yet adequately defined. The large vessel vasculitis (LVV) phenotype of GCA has less favourable outcomes and more often requires steroid-sparing treatment compared to the cranial phenotype. Evolution towards LVV might account for first-line treatment failure and impact on further therapeutic decisions. Here we review follow-up data from the NHS Lanarkshire GCA service and describe several relevant cases.

Methods

We performed a retrospective review of routine clinical and ad hoc US data from the NHS Lanarkshire GCA service between November 2018 and October 2021. Patients with cranial GCA at baseline and no involvement of large vessels were identified; demographic and clinical data of those who later developed US signs of LVV were reviewed. US positivity was defined by temporal artery intima media thickness (IMT) ≥0.5mm or LV IMT >1.0mm.

Results

53 patients were diagnosed with GCA during the study period. At initial visit, 35 had cranial GCA on US, 12 had LVV, 6 were US negative. Five patients with cranial GCA developed US signs of LVV during follow-up. One of these was in remission clinically and had borderline IMT of 1.0mm. The other four had clinical relapse with mean LV IMT of 1.8mm (range 1.6-2.2); relapses occurred at mean 40 weeks (range 29-53), on prednisolone doses 0-15mg; all were subsequently commenced on steroid-sparing treatment (Table).

Conclusion

Cranial and LVV phenotypes of GCA may represent different stages of disease. US can be used to confirm evolution to LVV; identification of LVV US signs may explain clinical relapse and support the introduction of steroid sparing treatment.

Disclosure

A. Ciechomska: Other; Speaker, travel and registration fee sponsorship from Novartis, Abbvie, Chugai Pharma, Colgene, Roche and Lilly. A.R. Melville: Other; Dr Melville is a Medical Research Council (MRC) and GlaxoSmithKline (GSK) Experimental Medicine Initiative to Explore New Therapies clinical training fellow.
P294 Improved relapse-free survival with the Norwich prednisolone regimen for giant cell arteritis
Authors: Ducker Georgina , Mills Karen , Yong Cee , Jones Colin , Mukhtyar Chetan
Published: April 2022

Background/Aims

Glucocorticoid therapy is the mainstay treatment for giant cell arteritis (GCA). There is no consensus on the dose of prednisolone to be used. Prednisolone regimens used in clinical trials have reported relapse rates of 66-92%. The long-term follow-up of tocilizumab and prednisolone for one year showed a relapse rate of 74% at two years. The Norwich Regimen is a bespoke prednisolone plan with an initial dose of 1mg/kg of lean body mass. It delivers 164.64 mg/kg of lean body mass in a logarithmic taper over 100 weeks. It was devised to reduce the risk of relapse and allow patients to be in control of their prednisolone reduction.

Methods

All patients were diagnosed by biopsy, ultrasonography or PET scan and provided with a printed prednisolone plan at diagnosis. All individuals were assessed at approximately 3-6 monthly intervals in addition to suspected relapse, toxicity or other need for course correction. Relapses were confirmed objectively using a modification of the Kerr criteria. Relapse free survival was recorded at 100 weeks. Patients were given an open invite to contact us in the event of a suspected relapse after coming off prednisolone. A notes review was done to record events at 150 weeks.

Results

150 consecutive people with objectively diagnosed GCA (mean age 74) since 10/01/2012 have completed 150 weeks since starting prednisolone. Drug-free, relapse-free survival at 100 weeks was met by 133/150 (89%). Seven individuals died and 20 relapsed. A further five died and 15 relapsed by week 150; 103/150 (69%) survivors were in prednisolone-free remission. Of the 12 deaths, six died of cancer, one subdural haemorrhage, one ischaemic bowel, one septicaemia, and one general decline (aged 93). The cause of death was not available for two individuals who died in the community. The median time to relapse for the 35 individuals was 80 weeks (IQR 64,109).

Conclusion

We report the first results of a bespoke prednisolone taper to be used in real life. The Norwich Regimen for the treatment of GCA results in drug-free relapse-free survival of 89% at 100 weeks and 69% at 150 weeks, which is superior to all other reports published so far.

Disclosure

G. Ducker: None. K. Mills: None. C. Yong: None. C. Jones: None. C. Mukhtyar: None.
P303 Development of a Behçet’s disease specific patient concerns inventory
Authors: Mukhtar Saman , Moots Robert
Published: April 2022

Background/Aims

Behçet’s Disease (BD) is a rare multi-system variable vessel vasculitis. It is characterised by oral ulcers, genital ulcers and ocular involvement; however, expression can vary, with patients experiencing a range of symptoms affecting several body systems. This creates the need for an individual and holistic approach to management in order to optimise patient care. A patient concerns inventory (PCI) is a validated tool used to encourage patient-led reviews by exploring areas of concern and unmet needs, and has shown to increase patient satisfaction in oncology and rheumatology consultations. The aim of this study was to develop a novel BD-specific PCI and to assess the impact of this tool in clinic following ethical approval.

Methods

Phase I: Literature search conducted to identify concerns and areas of unmet need in BD patients to create an initial PCI across four separate domains, including physical and functional well-being, psychological and emotional well-being, social care and social well-being, and treatment related side effects. Phase II: PCI presented to the BD multi-disciplinary team for feedback and refinement. Members were asked to rate each item based on how frequently that issue was discussed in consultations, from ‘never’, to ‘sometimes’, ‘most of the times’ or ‘every time’. Phase III: Updated version of PCI presented to patient groups in association with Behçet’s Society UK. Patients were asked to rate on an identical scale. Collective feedback allowed for a final version of the PCI to be created. Phase IV: Pilot study to test the effectiveness of the PCI in BD clinics. Pre- and post-PCI groups will be created. The mean differences in consultation time, number of concerns and patient satisfaction will be compared.

Results

Phase I: Following the application of an inclusion and exclusion criteria, 35 papers yielded a total of 54 items for the initial PCI. Phase II: 12 responses were received, which led to the exclusion of 9 items based on 60% of the respondents reporting this issue was ‘never’ discussed in clinic. A total of 2 items were added, which led to a 47-item PCI. Phase III: 239 responses received from BD patients. 3 items eliminated and 4 added on. Final 48-version PCI created. Phase IV: Pilot study will commence following ethical approval.

Conclusion

A PCI is a holistic tool used to improve communication and encourage patient-led consultations. Phases I to III have led to the creation of a 48-item BD-specific PCI which will be tested in clinic as a pilot following ethical approval. We hope to demonstrate an increase in patient satisfaction following the introduction of a PCI in BD clinics.

Disclosure

S. Mukhtar: None. R. Moots: None.
Professional Social Work and Public Libraries in the United States: A Scoping Review
Authors: Lee Sunwoo , Bae Junghee , Sharkey Caroline N , Bakare Olaoluwa H , Embrey Jenna , Ager Mary
Published: April 2022

This study aims to investigate how professional social work is practiced in U.S. public libraries using a scoping review method. Following Arksey and O’Malley’s framework for conducting a scoping review, the research team undertook a scoping review of academic literature, such as peer-reviewed studies, academic conference presentations, and dissertations/theses, as well as so-called gray literature, including news articles and web search results. After every author’s review, a total of 53 materials were included in the review. The findings from this study provide evidence that collaborations between social work and libraries are documented in the academic and gray literatures, and the collaborations have been rapidly increasing since 2015. The findings also show that these collaborations tend to operate in three main ways: (1) professional social workers and social work interns directly working with library patrons, (2) professional social workers providing consultation with or training to library staff, and (3) social workers providing linkages between library staff and community-based social services agencies.
Persistent Pelvic Pain in Patients With Endometriosis
Authors: Green Isabel C. , Burnett Tatnai , Famuyide Abimbola
Published: April 2022

As our understanding of chronic pain conditions, including endometriosis-related pain and chronic pelvic pain evolves, the evaluation and management of patients should reflect our increasing appreciation of the role of central sensitization, comorbid conditions and biopsychosocial factors on the pain experience and treatment outcomes. This review provides a systematic approach to persistent pain in patients with endometriosis. Expanding the evaluation and treatment of endometriosis-related pain by all health care providers could limit unnecessary surgical interventions and best meet our patient’s needs.
Hyperspectral and Laser Speckle Contrast Imaging for Monitoring the Effect of Epinephrine in Local Anesthetics in Oculoplastic Surgery
Authors: Bunke Josefine , Merdasa Aboma , Stridh Magne , Rosenquist Pernilla , Berggren Johanna , Hernandez-Palacios Julio E. , Dahlstrand Ulf , Reistad Nina , Sheikh Rafi , Malmsjö Malin
Published: April 2022

Purpose:

Epinephrine is used in local anesthetics to induce vasoconstriction and thus reduce bleeding and prolong the anesthetic effect. Finding the optimal delay between the administration of the anesthetic and skin incision to ensure vasoconstriction and minimize bleeding is important and has recently become the subject of debate. This is the first study to assess blood perfusion and oxygen saturation (sO2) simultaneously in response to a local anesthetic containing epinephrine in human oculoplastic surgery.

Methods:

A local anesthetic consisting of lidocaine and epinephrine (20 mg/ml + 12.5 μg/ml) was injected in the eyelids of 9 subjects undergoing blepharoplasty. The perfusion and sO2 of the eyelids were monitored using laser speckle contrast imaging and hyperspectral imaging, respectively.

Results:

Laser speckle contrast imaging monitoring showed a decrease in perfusion over time centrally at the site of injection. Half-maximum effect was reached after 34 seconds, and full effect after 115 seconds, determined by exponential fitting. The drop in perfusion decreased gradually further away from the injection site and hypoperfusion was less prominent 4 mm from the injection site, with a spatially dependent half-maximum effect of 231 seconds. Hyperspectral imaging showed only a slight decrease in sO2 of 11 % at the injection site.

Conclusions:

The optimal time delay for skin incision in oculoplastic surgery is approximately 2 minutes after the injection of lidocaine with epinephrine. Longer delay does not lead to a further decrease in perfusion. As sO2 was only slightly reduced after injection, the results indicate that the use of epinephrine is safe in the periocular region.
Histopathological Evidence of Canalicular Agenesis in Patients With Punctal Agenesis: Punctum Update Study 2
Authors: Bothra Nandini , Ali Mohammad Javed
Published: April 2022

Purpose:

The purpose of this study was to histologically assess the presence and extent of the canalicular tissue in cases of punctal agenesis.

Methods:

A prospective, interventional study was performed on 10 consecutive cases of punctal agenesis over a study period of 6 months. Exclusion criteria included cases with punctal dysgenesis or incomplete punctal canalization, secondary/acquired cases of punctal effacement, or any prior interventions. Following the exploration, the entire specimen of the tissue (length = 8 mm and depth = 3 mm) was sent for histopathological analysis to ascertain the presence and extent of the canalicular tissue.

Results:

The mean age of the patients at the time of exploration was 7.5 years (range 6–10 years). Histopathological analysis showed tissue surfaces lined with stratified squamous epithelium with occasional interspersed goblets cells (conjunctival epithelium), a few chronic inflammatory cells, and muscle fragments. Epithelium suggestive of proximal lacrimal drainage system was absent. Canalicular tissues were found to be absent in all cases of punctal agenesis.

Conclusion:

The present series did not find any histologic evidence of canalicular tissues in cases of punctal agenesis. The findings of this study do not support retrograde approaches in cases of punctal agenesis.
Microbial Metagenomics of the Extubated Lacrimal Stents Following Dacryocystorhinostomy: The Lacriome Paper 4
Authors: Ali Mohammad Javed
Published: April 2022

Purpose:

To study the metagenome of the microbes present on the extubated lacrimal stents following a dacryocystorhinostomy.

Methods:

A prospective study was performed on 10 consecutive extubated lacrimal stents obtained for the metagenomic analysis from the patients following an endoscopic dacryocystorhinostomy. The stents were extubated at 4 weeks postoperatively under endoscopic guidance and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform. The downstream processing and bioinformatics of the samples were performed using multiple software packaged in SqueezeMeta pipeline or MG-RAST pipeline.

Results:

The taxonomic hit distribution across the stent samples showed that bacteria were the most common isolates (mean, 69.70%), followed by viruses (mean, 0.02%) and archaea (0.003%). The 3 major phyla identified were Firmicutes, Actinobacteria, and Proteobacteria. The prevalent organisms include Pseudomonas aeruginosa, Staphylococcus aureus, Corynebacterium accolens, Dolosigranulum pigrum, Citrobacter koserii, Staphylococcus epidermidis, E. coli, and Hemophilus influenza. The functional subsystem profiling demonstrated microbial genes associated with metabolism, cellular, and information processing. The functional subsystem categories were metabolism involving carbohydrates, amino acids, DNA and RNA, cell wall or cell capsule biogenesis, membrane transport, virulence, and defense mechanisms.

Conclusions:

The present study is the first whole metagenome sequencing of the microbes isolated from the extubated lacrimal stents. The stents harbor diverse microbial communities with distinct ecosystem dynamics. Further studies on microbes-host interactions in the early postoperative period would provide valuable insights.
Somatic Changes Perceived by Patients With Heart Failure During Acute Exacerbation
Authors: Okada Akiko , Tsuchihashi-Makaya Miyuki , Nagao Noriko , Ochiai Ryota
Published: April 2022

Background

Patients with heart failure (HF) often inadequately perceive their symptoms. This may be because the medical terms do not match the somatic changes experienced by patients. To improve symptom perception, healthcare professionals must understand the somatic changes as perceived by patients.

Objective

This study aims to analyze patients' narratives about somatic changes in patients with HF by text mining and to clarify the overall description of somatic changes using patients' expressions.

Methods

Semistructured interviews were conducted on 21 patients hospitalized for acute exacerbation of HF. Qualitative data obtained from the interviews were analyzed by content analysis through text mining.

Results

Among the 21 patients, 76.2% were men. The mean (SD) age was 71.3 (13.7) years. The most frequently used terms were “breath,” “distressed,” “feet,” and “ha-ha (gasping sound)” (46, 40, 29, and 28 times, respectively). The somatic changes noticed by patients could be categorized into medical jargon such as “dyspnea on exertion,” “exercise intolerance,” “fatigue,” “paroxysmal nocturnal dyspnea,” “frequent urination,” “increased sputum,” “weight gain,” “feet and face edema,” “abdominal edema,” and “ankle edema.” However, the expressions of somatic changes used by the patients were diverse.

Conclusions

The findings of patient-specific expressions of symptoms suggest that there is a need to assess symptoms not only using medical jargon but also by focusing on patient-specific expressions.
Perceived Facilitators and Barriers to Treatment Fidelity in Computerized Cognitive Training Interventions
Authors: Algashgari Elham Y. , Jung Miyeon , Von Ah Diane , Stewart Jesse C. , Pressler Susan J.
Published: April 2022

Background

Computerized cognitive training (CCT) interventions may have an important role in improving cognition among patients with heart failure. Ensuring treatment fidelity of CCT interventions is an essential part of testing their efficacy.

Objective

The aim of this study was to describe facilitators of and barriers to treatment fidelity perceived by CCT intervenors while delivering the interventions to patients with heart failure.

Methods and Results

A qualitative descriptive study was completed with 7 intervenors who delivered CCT interventions in 3 studies. Directed content analysis revealed 4 main themes of perceived facilitators: (1) training for intervention delivery, (2) supportive work environment, (3) prespecified implementation guide, and (4) confidence and awareness. Three main themes were identified as perceived barriers: (1) technical issues, (2) logistic barriers, and (3) sample characteristics.

Conclusion

This study is novel because it was one of the few studies focused on the intervenors' perceptions rather than the patients' perception of using CCT interventions. Beyond the treatment fidelity recommendations, this study found new components that might help the future investigators in designing and implementing CCT interventions with high treatment fidelity.
Palliative Care for Older Adults Hospitalized for Stroke From the Informal Caregivers' Perspectives
Authors: Su Jing Jing , Lin Rose S. Y. , Paguio Jenniffer , Leung Angela Y. M. , Molassiotis Alex
Published: April 2022

Background

International guidelines have promoted palliative care (PC) for stroke survivors, but definition and implementation have been less than ideal. This practice gap is more prominent in China, where discussion of death remains taboo.

Aim

The aim of this study was to explore the perspectives of PC among caregivers of hospitalized patients with stroke.

Design and Setting

A descriptive qualitative study design was used. Seventeen in-depth interviews with bedside caregivers in a first-rank tertiary hospital (general hospital with bed capacity exceeding 500) in China were analyzed thematically.

Results

“Promoting comfort” stands at the core of PC and was operationalized by “meeting physical care needs,” “ensuring communication,” “providing psychoemotional care,” “providing cognitive stimulation,” and “avoiding discussion on death and dying.” Caregivers who took care of older adults for a long time have described the use of “cognitive stimulation” to promote patients' positive emotional and cognitive reactions. All interviewees avoided mentioning “death” to protect patients' feelings, because they believed discussion of death was hurtful.

Conclusions

The high care demand for patients with stroke is a defining feature of stroke PC and should be recognized in addition to its prognosis estimation to promote this concept. The healthcare system should integrate PC as part of the regular service for patients with severe stroke to shift the focus of care from survival to promotion of comfort. A discussion of the dying process requires sensitivity and should be approached in a discussion of advanced PC planning, which views death as a meaningful transition.
Differentiated Exophytic Vulvar Intraepithelial Lesions: Case Reports and Review of Literature
Authors: Mendlowitz Ariel R. , Hoang Lien N. , McAlpine Jessica N. , Sadownik Leslie Ann
Published: April 2022

Objectives

The aims of this article were to describe 2 patients with a pathological diagnosis of differentiated exophytic vulvar intraepithelial lesion and to summarize the literature regarding this relatively new diagnosis.

Materials and Methods

The existing literature was searched on December 1, 2021, using the MEDLINE database (1966–2021), and all combinations of the following search terms were used: “differentiated exophytic vulvar intraepithelial lesion” and “differentiated vulvar intraepithelial neoplasia.”

Results

Patients were postmenopausal and reported persistent vulvar itch associated with white hypertrophic plaques. Initial biopsies did not identify differentiated exophytic vulvar intraepithelial lesion. Invasive squamous cell carcinoma was found in both cases after surgical excision.

Conclusions

Differentiated vulvar intraepithelial lesions and invasive squamous cell carcinoma should be considered in the differential diagnosis of vulvar itch associated with hypertrophic plaques in postmenopausal women. Excision of suspicious plaques is recommended for definitive diagnosis.