bluuebunny/crossref_metadata_2025 huggingface dataset:
P196 The changing role of biopsy and imaging in the diagnosis of giant cell arteritis prior to tocilizumab treatment
Authors: Hutton Lisa M M
Published: April 2023

Background/Aims

Vasculitis has always relied on pattern recognition, biopsy and imaging to secure a diagnosis. Historically, giant cell arteritis diagnosis has relied too heavily on pattern recognition without scrutiny. The current guidelines recommend securing a diagnosis by either temporal artery biopsy (TAB) or imaging. Ultrasound (US) has been given parity with biopsy in European guidelines for cranial giant cell arteritis (cGCA) although in the USA experience is more limited. Large vessel vasculitis (LVV) may not present with cranial symptoms and is diagnosed by axillary US, MRA or preferably PET. The Clyde GCA Fast Track US Pathway was introduced in 2018 and follows EULAR imaging guidelines. In a health board with access to all diagnostic modalities, how is GCA being diagnosed in patients treated with tocilizumab? How is this changing over time?

Methods

46 patients commenced on tocilizumab for GCA since 2017 had their diagnoses examined. Electronic records and US data were used to categorise diagnosis as a result of biopsy, MRA, PET, ultrasound or clinical diagnosis alone. Clinical diagnoses with neither imaging nor biopsy were reviewed in more depth.

Results

There were 37 women and 9 men; 33 cranial GCA and 13 LVV; 9 presenting with a relapsing pattern of disease and 37 with new presentations. Age range 59-91 (mean of 73 years). Only 3 of 46 patients had no additional proof of diagnosis. Diagnosis was secured by biopsy in 16 and imaging in 27 (14 US and 13 PET).

Conclusion

By 2022, cGCA was equally likely to be diagnosed by US as biopsy. The fast track US service provided support for patients, referrers and surgeons to determine if biopsy was needed to secure a diagnosis. Biopsy was most valuable in delayed presentations or if clinical suspicion was high but US negative. PET is the most useful imaging technique for diagnosing LVV; US of axillary arteries was only positive in a few cases and unable to cover the differential diagnosis. MRA was informative but not diagnostic. All GCA diagnoses should be based on good evidence to warrant the potential toxicity of steroids, tocilizumab and any future treatments for relapsing disease.

Disclosure

L.M.M. Hutton: None.
P199 Glucocorticoid taper success after one and two years treatment in the Imperial College Takayasu Arteritis Cohort
Authors: Alapat Ritu , Porter Andrew , Pericleous Charis , Youngstein Taryn A , Maughan Robert , Mason Justin C
Published: April 2023

Background/Aims

The large vessel vasculitis Takayasu arteritis (TA) is initially treated with high dose glucocorticoids (GC) (40-60mg/day), typically with a csDMARD to induce remission. Subsequently, GC doses are tapered to reduce adverse effects. Although current EULAR guidelines tentatively recommend a target GC dose of < 10mg/day after one year of treatment, data describing GC taper patterns in practice is limited. This study describes GC taper success at one and two years and explores associated baseline and follow-up parameters.

Methods

A retrospective analysis of the Imperial College Takayasu Arteritis Cohort (UK) was undertaken; 158 patients with median follow-up 8.4 [5-13.6] yrs. Patients with sufficient data and typical treatment initiation pattern were analysed, commencing either GC monotherapy or GC + csDMARD and no baseline immunosuppression. Primary outcome: GC < 10mg/day after one and two years of treatment. Secondary outcome: patients achieving the same without intensification (addition of a second DMARD or biologic agent). Evaluation of taper failure causes was supported by NIH disease activity scoring. Taper failure and taper success groups were compared for baseline parameters and treatment at 5 years. Data are median [IQR], comparisons non-parametric for continuous variables.

Results

Of 129 TA cases requiring treatment, 80 (62%) satisfied analysis criteria. Overall, 46 (57.5%) and 59 (73.7%) patients met the primary outcome at years one and two respectively. Of these, 43 (93.5%) and 46 (78%) did so without treatment intensification. Taper success was consistent over time, with 43 (94%) year one taper success cases maintaining status at year two. In most cases (90.5%), year two taper failure was due to inadequate treatment response as confirmed by disease activity scoring (Table). Baseline parameters were similar between groups, except ESR which was significantly lower in the taper success group. As expected, initial treatment with GC monotherapy tended to be lower in the taper success group. At year five, GC doses remained higher and biologic usage was greater in taper failure cases suggesting a more refractory disease course (Table).

Conclusion

The EULAR GC taper target was achieved in 57.5% of patients, increasing to 73.7% by two years. Clinical implementation of this target is practical and will aid in the reduction of cumulative GC exposure and identification of patients requiring treatment intensification.

Disclosure

R. Alapat: None. A. Porter: None. C. Pericleous: None. T.A. Youngstein: None. R. Maughan: None. J.C. Mason: None.
E001 Retroperitoneal fibrosis patients need a dedicated multidisciplinary team
Authors: Qian Evelyn , Harris Helen
Published: April 2023

Background/Aims

Retroperitoneal fibrosis is a rare chronic inflammatory fibrosing condition of the retroperitoneal tissues. Inflammation can cause tethering and occlusion of nearby structures, especially the ureters, leading to acute obstruction as well as long-term renal impairment. This condition usually either presents with nonspecific abdominal pain or when the patient is in crisis due to urological obstruction. There is little known about its treatment beyond steroids. A significant proportion of patients are at risk of relapse. We characterised patients with retroperitoneal fibrosis in our heath board to better understand how these patients present and what the unmet needs in their management are.

Methods

Patients were identified by contacting rheumatologists and by searching the urological stent registry from 2019 to 2022. The records were searched for demographics, events around diagnosis, initial treatment, investigations, including imaging reports and pathology, as well as follow up clinic letters detailing any relapses and complications.

Results

We found 22 patients in the health board with idiopathic retroperitoneal fibrosis. Half had sole care under urology. Only 6 received joint care from urology and rheumatology. Demographics of these patients were comparable to literature (mean age 60 (range 43-81 years), female to male ratio (1:2.6), compared to the reported mean age of 55-60 and female to male ratio of 1:2). Diagnosis was usually made by CT scan. The mean incidence of new diagnosis was 2 per year over the last 10 years in a catchment population of 850,000. In 19 patients with treatment information available, 4 never received steroids or immunomodulation therapy. For those that received steroid therapy, doses ranged from 0.2mg/kg to 0.8mg/kg over a range of 1 week to 6 months of maximum dose duration. 73% of patients now have chronic renal dysfunction with eGFR <60ml/min/1.73m2, and 27% with stage 4 renal failure with eGFR <30 ml/min/1.73m2. One of these patients had end stage renal disease and is deceased.

Conclusion

This characterisation study has shown that patients have had heterogenous journeys with their RPF diagnosis and treatment. 73% of these patients have developed chronic renal dysfunction which is dramatically higher than that of the published literature figure of 32%. In order to improve outcomes, there is a need for a standardized approach to diagnosis, treatment and follow up, involving a dedicated multidisciplinary team.

Disclosure

E. Qian: None. H. Harris: None.
E003 Why do rheumatologists request PET-CT scans and what do they show: an audit from a tertiary London Hospital
Authors: Biddle Kathryn , Chaabo Khaldoun
Published: April 2023

Background/Aims

(18F)FDG PET-CT is an imaging tool with utility in the diagnosis of inflammation, infection and malignancy. In rheumatology settings, it is most commonly used for the diagnosis and monitoring of large vessel vasculitis (LVV), sarcoidosis, polymyalgia rheumatica (PMR), IgG-4 disease and myositis. Whilst PET-CT is highly sensitive for the detection of inflammation, concurrent corticosteroid use impairs this. Furthermore, uptake can be non-specific and incidental abnormalities are often reported. Few cohorts have investigated the real-life use of PET-CT including clinical indication, rheumatological and non-rheumatological findings and patient outcomes.

Methods

98 PET-CT scans were requested by the rheumatology department at St Georges NHS Foundation Trust from January 2017 to December 2021. Data including patient demographics, pre-existing rheumatological disease, corticosteroid use and inflammatory marker levels were collected. Indication for PET-CT and PET-CT findings were reviewed.

Results

As summarised in Table 1, PET-CT scans were most commonly requested for the investigation of raised inflammatory markers, poor response to therapy, concerning clinical features, for the characterisation of abnormal imaging findings and for routine monitoring of disease. LVV and malignancy were the most commonly considered differential diagnoses. At the time of PET-CT scan, 59 (60%) patients were taking corticosteroids. 58 of these patients were prescribed prednisolone (dose ranging between 2mg to 80mg, mean dose 19.6mg OD, median dose 15mg OD) In our audit, 39.8% of PET-CT showed active rheumatological disease. 32.6% showed non-rheumatological abnormalities with 2% demonstrating new cancer diagnoses. The detection of incidental non-specific imaging findings commonly led to the request of further diagnostic tests including ultrasound imaging (11 patients) and endoscopy (7 patients).

Conclusion

In conclusion, PET-CT is a useful imaging tool in the diagnosis and monitoring of rheumatological inflammatory conditions. Despite a majority of patients taking corticosteroids at the time of scan, PET-CT remained an effective diagnostic adjunct. A large number of non-rheumatological imaging abnormalities were seen in our cohort; in most cases, the clinical significance was not immediately clear and further investigations were needed. Further guidance is needed to determine the characterisation and management of these incidental findings to avoid unnecessary, costly and sometimes invasive tests.

Disclosure

K. Biddle: None. K. Chaabo: None.
E022 Effect of upadacitinib in a patient with primary Sjogren syndrome: a case report
Authors: Majumder Muhammad Shoaib Momen , Haq Syed Atiqul
Published: April 2023

Background/Aims

Primary Sjogren syndrome (pSS) is a chronic autoimmune multi-system disease characterized by inflammation of exocrine glands, particularly the lacrimal and salivary glands, as well as multiple extra-glandular involvements. Treatment is often challenging, and until now, no disease-modifying anti-rheumatic drugs (DMARDs) have been approved for this condition. There is a lack of data about the efficacy of Janus kinase inhibitors in pSS. Here we report a patient with pSS successfully responding to upadacitinib.

Methods

A 68-year-old woman presented with pain in multiple joints for 16 years with intermittent use of NSAIDs. She had no low back pain and no self or family history of psoriasis or red eye. She denied dry mouth but required frequent water drinking during meals to aid swallowing and occasionally used artificial tears. MTX was started for her two-month articular flare and positive rheumatoid factor (RF). MTX caused severe vomiting and hyponatremia, and she was hospitalized. After the correction of hyponatremia, she was put on tofacitinib. We reevaluated the case when she came to us. She had grade 2-3 tenderness of most peripheral joints and was bedridden. Immunological parameters revealed RF 127 IU/ml (reference value <14), anti SSA antibody 147 U/ml (normal <3.2), anti SSB antibody 149 U/ml (reference value <8) and anti CCP antibody; ANA, anti-ds-DNA Ab were negative. There was no erosion on the X-ray hands. Schirmer's test was positive (3 mm bilaterally). Unstimulated salivary flow after five minutes was 0.04 ml/min (≤0.1 ml/min indicates salivary hypofunction). She fulfilled the 2016 ACR/EULAR classification criteria, and we diagnosed her with primary Sjogren syndrome. Hydroxychloroquine was initiated, but she discontinued it for anorexia. Considering her age, she was switched to upadacitinib, as European Medicines Agency restricted the use of tofacitinib beyond 65 years.

Results

Her EULAR Sjogren Syndrome's Disease Activity Index (ESSDAI) was six at baseline, indicating moderate disease activity. Her joint pain improved significantly within two months with infrequent use of pilocarpine in the sixth month. Six months after treatment with upadacitinib, ESSDAI came down to 2; the Patient's Global Assessment score was 02 and achieved STAR (Sjogren's Tool for Assessing Response) response 7 (STAR responder if score ≥5).

Conclusion

To our knowledge, this is the first case report on the efficacy of upadacitinib in pSS. Further high-quality clinical trials are required to confirm the benefit of upadacitinib in pSS.

Disclosure

M. Momen Majumder: None. S. Haq: None.
E032 Deficiency of Adenosine Deaminase 2: a rare diagnosis in a case of suspected vasculitis
Authors: Xenophontos Mikalena , Gan Jasmine , Seneviratne Anoushka C
Published: April 2023

Background/Aims

Deficiency of adenosine deaminase 2 (DADA2) is a rare autosomal recessive condition first described in 2014 which is characterised by vasculitis, systemic inflammation, immunodeficiency and cytopenias. The vasculitis is difficult to differentiate from polyarteritis nodosa and typically presents with recurrent strokes. It can also affect the skin and present with livedo racemosa. Clinical presentation varies widely; from vasculitic manifestations which tend to present later in life to severe haematological abnormalities such as bone marrow failure which tend to present earlier in life. Treatment with TNF inhibitors reduces the risk of additional strokes and controls inflammation in the presence of vasculitis but is not very effective against bone marrow failure.

Methods

We present the case of a 44-year-old gentleman who was being investigated for possible vasculitis by the rheumatology team in view of a history of Raynaud’s, 20-year history of recurrent leg ulcers and a previous pontine infarct. He presented acutely to the emergency department with numbness below the midthoracic level, weakness of his lower limbs and hands and urinary retention. His symptoms had progressed over a period of a few hours. On examination power was 4/5 on the MRC power scale for shoulder abduction and elbow flexion, 2/5 for elbow extension, 3/5 for wrist extension and 1/5 for finger extension. Power was 1/5 on his lower limbs. Sensation to pain was reduced with a T6 sensory level. Proprioception and vibration sense were intact. Upper limb reflexes were brisk. Knee jerks and left ankle jerk were difficult to elicit. Plantars were downgoing. Cranial nerves were normal.

Results

Bloods showed a white cell count of 6.7x109/l, haemoglobin of 96g/l (microcytic), platelets of 243x109/l, creatinine 119μmol/l (baseline 85μmol/l) and CRP of 42.9mg/l. Vitamin B12 was 200ng/l and folate levels were 2.2μg/L. ANA, ANCA, cryoglobulins and hepatitis serology were negative. MRI brain showed a 4mm area of hyper-density in the left pons. MRI whole spine was unremarkable. CSF showed normal protein, white cell count and glucose level. The patient was transferred to a tertiary neurology centre and a diagnosis of anterior spinal cord infarction was made. A nerve biopsy was performed which showed evidence of vasculitis and he was pulsed with methylprednisolone and commenced on high dose oral steroids. Genetic testing showed a pathogenic mutation in the adenosine deaminase 2 gene. He is currently awaiting to commence treatment with TNF inhibitors.

Conclusion

We conclude that DADA2 is an important differential in a young patient with suspected vasculitis especially in the presence of infarction. Identification of DADA2 allows initiation of treatment with TNF inhibitors which reduces the risk of additional strokes.

Disclosure

M. Xenophontos: None. J. Gan: None. A.C. Seneviratne: None.
E051 A systematic review of audit and feedback tools to reduce opioid prescribing for chronic non-cancer pain
Authors: Feldman Joshua , Jani Meghna
Published: April 2023

Background/Aims

Opioid prescribing has increased considerably over the 15 years for chronic non-cancer pain in the UK, including for musculoskeletal conditions. Whilst there are national and international guidelines to reduce inappropriate opioid prescribing, these are not always adhered to in practice. Audit and feedback is a common intervention for supporting clinical behaviour change. Little is known if such tools have been used to support safer opioid prescribing to date. This systematic review aimed to describe audit and feedback tools that were designed, implemented and led to changes in opioid prescribing practices.

Methods

A systematic review of the literature was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework (PRISMA). Both Embase and MEDLINE were searched to identify studies that included audit and feedback tools in patients prescribed opioids with chronic non-cancer pain until the 31st of May 2021.

Results

Of the 539 studies imported, following removal of duplicates, 497 studies were screened. Following title and abstract review 6 full-text studies were assessed for eligibility. A total of three studies were deemed to meet inclusion criteria. Approaches found included: The Controlled Medication Advisory Board (CMAB), Systems Consultation and the Opioid Safety Initiative (OSI). CMAB involved the use of a dashboard to provide feedback to clinicians on referred patients. As a result the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of co-prescription of benzodiazepines and opioids decreased by 56%. Systems Consultation involved the use of audit and feedback, academic detailing and external facilitation to reduce opioid prescribing. Systems consultation resulted in a statistically significant reduction in the morphine equivalent daily doses. The OSI used automatic electronic medical records auditing to enable clinic leaders to identify physician prescribing patterns via a dashboard. OSI enabled a 9.9% reduction in opioid prescriptions from 571,476 to 514,883.

Conclusion

Computerised audit and feedback tools may be effective interventions to support opioid stewardship initiative and promote safer opioid prescribing. Such approaches being used internationally could pave the way for similar initiatives in the UK and future research evaluating their impact on patient safety.

Disclosure

J. Feldman: None. M. Jani: Grants/research support; National Institute for Health and Care Research Advanced Fellowship (NIHR301413).
E055 COVID-19 in male elite Irish-based athletes at a national sports institute
Authors: McLarnon Michael , Rankin Alan T , Heron Neil
Published: April 2023

Background/Aims

The impact of COVID-19 has not been previously documented in an elite sporting population. Previous reports have documented cardiorespiratory sequelae in athletes, and expert opinion-based guidance is generally employed in their rehabilitation. However, there still persists a lack of information on how COVID-19 affects elite athletes, and a standardised approach to graduated return to play (GRTP). This case series describes a cohort of six elite Irish-based athletes diagnosed with COVID-19.

Methods

Six athletes were followed from symptom onset until their GRTP. A retrospective case series was performed using a standardised audit form for COVID-19 among elite athletes.

Results

Headache and fatigue (6/6) were the commonest presenting symptoms, with mean duration 4.5 days; all athletes experienced mild illness, none required further investigation. 3/6 athletes supplemented vitamin D. Mean rest period was 11.5 days and mean GRTP 19.2 days. All athletes had an unremarkable screening electrocardiogram.

Conclusion

This case series presents the first clinical summary of COVID-19 illness in elite athletes based in Ireland. Treatment is largely supportive although further consideration should be given to implementing supplementation, such as vitamin D, in the management of COVID-19. Larger, longer term studies are required to better understand the impact of COVID-19 in athletes and across different sports.

Disclosure

M. McLarnon: None. A.T. Rankin: None. N. Heron: None.
E075 Predictive factors for successful biologic disease-modifying anti-rheumatic drugs dose tapering in rheumatoid arthritis
Authors: Loh Min Yi , Jones Claire J , Peall Adrian , Trickey Jeanette
Published: April 2023

Background/Aims

Use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) have revolutionised the management of rheumatoid arthritis (RA). However, their use is not without side effects including infection and malignancy risk. Recent EULAR and ACR guidelines support consideration of dose tapering in patients in sustained remission. This study looks at identifying predictive factors for successful bDMARD dose tapering, to help select patients who may benefit from it, whilst minimising the risk of flare.

Methods

We searched our local biologic database retrospectively for RA patients who were dose tapered in line with our local guideline, between June 2015 and December 2021. 91 patients were identified, 17 patients were excluded due to death or cessation of bDMARD for unrelated reasons. Clinical and demographic data collected included: age, gender, rheumatoid factor and/or anti-cyclic citrullinated peptide antibody positivity, biologic choice, concurrent use of conventional synthetic DMARD (csDMARD), number of previous bDMARDs, and overall annual cost-saving.

Incidence of flares after tapering and outcome after resuming original dose of biologic were noted.

Results

Of the 74 patients included, 39 (53%) were on rituximab, 14 (19%) were on etanercept , 11 (15%) were on certolizumab pegol, 9 (12%) were on adalimumab, and 1 (1%) was on tocilizumab.

The incidence of flare is highest in the first 6 months after being tapered (47%; n = 18). Of those who flared (n = 38), 84% regained control following re-introduction of original dose.

After tapering, 67% (n = 18/27) of patients aged 70-89 remained in remission whilst more than 50% (n = 29/47) flared in younger age groups. Patients on rituximab were more likely to remain in remission.

There were no notable differences in gender, seropositivity and concurrent csDMARD use.

Despite reduced cost of biologics through use of biosimilars, we are estimated to save £68,783 per annum from dose tapering.

Conclusion

We find that patients in older age group or on rituximab have a higher chance of remaining in remission following bDMARD dose tapering. The risk of flare is not affected by gender, seropositivity or concurrent csDMARDs use. If patients were to flare post dose tapering, this is more likely to occur within the first 6 months after tapering.

Disclosure

M. Loh: None. C.J. Jones: Other; Received payment from Fresenius Kabi for participation in a focus group regarding publication of NICE TA 715. A. Peall: None. J. Trickey: None.
Effect of type I interferon on engineered pediatric skeletal muscle: a promising model for juvenile dermatomyositis
Authors: Covert Lauren T , Patel Hailee , Osman Alaa , Duncan Lavonia , Dvergsten Jeffrey , Truskey George A
Published: April 2023

Objective

To investigate pathogenic mechanisms underlying JDM, we defined the effect of type I IFN, IFN-α and IFN-β, on pediatric skeletal muscle function and expression of myositis-related proteins using an in vitro engineered human skeletal muscle model (myobundle).

Methods

Primary myoblasts were isolated from three healthy pediatric donors and used to create myobundles that mimic functioning skeletal muscle in structural architecture and physiologic function. Myobundles were exposed to 0, 5, 10 or 20 ng/ml IFN-α or IFN-β for 7 days and then functionally tested under electrical stimulation and analyzed immunohistochemically for structural and myositis-related proteins. Additionally, IFN-β-exposed myobundles were treated with Janus kinase inhibitors (JAKis) tofacitinib and baricitinib. These myobundles were also analyzed for contractile force and immunohistochemistry.

Results

IFN-β, but not IFN-α, was associated with decreased contractile tetanus force and slowed twitch kinetics. These effects were reversed by tofacitinib and baricitinib. Type I IFN paradoxically reduced myobundle fatigue, which did not reverse after JAKi. Additionally, type I IFN correlated with MHC I upregulation, which normalized after JAKi treatment, but expression of myositis-specific autoantigens Mi-2, melanocyte differentiation-associated protein 5 and the endoplasmic reticulum stress marker GRP78 were variable and donor specific after type I IFN exposure.

Conclusion

IFN-α and IFN-β have distinct effects on pediatric skeletal muscle and these effects can partially be reversed by JAKi treatment. This is the first study illustrating effective use of a three-dimensional human skeletal muscle model to investigate JDM pathogenesis and test novel therapeutics.
Regulatory Sandboxes and Fintech Funding: Evidence from the UK
Authors: Cornelli Giulio , Doerr Sebastian , Gambacorta Leonardo , Merrouche Ouarda
Published: April 2023

Over fifty countries have introduced regulatory sandboxes to foster financial innovation. This article conducts the first evaluation of their ability to improve fintechs’ access to capital and attendant real effects. Exploiting the staggered introduction of the UK sandbox, we establish that firms entering the sandbox see an increase of 15% in capital raised post-entry. Their probability of raising capital increases by 50%. Sandbox entry also has a significant positive effect on survival rates and patenting. Investigating the mechanism, we present evidence consistent with lower asymmetric information and regulatory costs.
Course Transformation to Enhance Student Learning in Undergraduate Nursing Course
Authors: Cho Hyun Jin , Hannigan Elaine , Davis Jan E. , Levesque-Bristol Chantal
Published: April 2023

AIM

The purpose of the study was to investigate whether course transformation teaching strategies using repetitive quizzing and peer-tutor supplemental instruction help enhance students' learning experiences and learning outcomes based on self-determination theory.

BACKGROUND

Undergraduate baccalaureate pharmacology and pathophysiology courses were redesigned as part of a campus-wide course transformation program to promote students' perceptions of learning and academic achievement.

METHOD

Students in the nursing pathopharmacology course participated in the two-time online perception survey (pretest and posttest) and knowledge-based exams.

RESULTS

Results revealed that the course transformation implemented to support students' basic psychological needs was significantly associated with both learning outcomes and students' feelings of competence while also decreasing attrition rates.

CONCLUSION

Considering the depth and breadth of pathopharmacology content, the teaching intervention using repetitive quizzing and peer-tutor supplemental instruction may contribute to improving students' understanding of the course content while promoting their competence.
Methylprednisolone Following Minimally Invasive Lumbar Decompression
Authors: Florence TJ , Say Irene , Rivera Joshua , Kim Jiyoon , Li Gang , Holly Langston T. , Lu Daniel C.
Published: April 2023

Study Design.

Prospective randomized.

Objective.

Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study.

Summary of Background Data.

Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups.

Materials and Methods.

Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period.

Results.

Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs. 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs. 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period.

Conclusion.

Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.
Novel Monitoring and Dose Adjustment of Argatroban, a Direct Thrombin Inhibitor, to Maintain Therapeutic Anticoagulation in a Patient With Antiphospholipid Antibody Syndrome, Heparin-Induced Thrombocytopenia, and COVID-19 Pneumonia
Authors: Ryan Christine E. , Newman Kelly A. , Roberts Russel J. , Frydman Galit H. , Rosovsky Rachel P.
Published: April 2023

BACKGROUND:

In patients who require systemic anticoagulation, a reliable monitoring method is required to ensure anticoagulation is maintained within the correct therapeutic window and patients are treated appropriately. When titrating direct thrombin inhibitors (DTIs), dilute thrombin time (dTT) measurements have been demonstrated to be more reliable and accurate than activated partial thromboplastin time (aPTT) measurements and thus often the preferred DTI assessment. However, a clinical need arises when both dTT measurements are not readily available and aPTT measurements are unreliable.

CASE SUMMARY:

A 57-year-old woman with a history of antiphospholipid antibody syndrome, heparin-induced thrombocytopenia, and multiple prior deep venous thromboses and pulmonary emboli was admitted with COVID-19 pneumonia and intubated due to hypoxic respiratory failure. Argatroban was initiated in place of her home medication warfarin. However, the patient had a prolonged aPTT value at baseline and overnight dTT assay measurements were limited at our institution. A multidisciplinary team of hematology and pharmacy clinicians created a modified patient-specific aPTT target range and argatroban dosing was titrated accordingly. Subsequent aPTT values in the modified target range corresponded to therapeutic dTT values, indicating therapeutic anticoagulation was successfully achieved and maintained. Patient blood samples were additionally evaluated retrospectively using an investigational novel point-of-care test that detected and quantified the argatroban anticoagulant effect.

CONCLUSIONS:

Therapeutic anticoagulation with a DTI in a patient with unreliable aPTT measurements can be achieved with use of a modified patient-specific aPTT target range. Early validation of an investigational rapid testing alternative for DTI monitoring is promising.
Temporalis Myofascial Flap and Conchal Bowl Cartilage Grafting for Temporomandibular Joint Arthritis
Authors: DeLeonibus Anthony , Swanson Marco , Coombs Demetrius M. , Maasarani Samantha , Papay Francis , Bassiri Gharb Bahar , Rampazzo Antonio
Published: April 2023

Temporomandibular joint (TMJ) arthritis arises from a multitude of etiologies; however, there is no consensus definitive treatment. The complication profile of artificial TMJs is well known, and outcomes are variable and are reserved for salvage attempts. This case details a patient with persistent traumatic TMJ pain, arthritis, and single-photon emission computed tomography scan of potential nonunion. The present study reports on the first novel use of an alternative composite myofascial flap to help arthritic TMJ pain. This study details the successful use of a temporalis myofascial flap and conchal bowl autologous cartilage graft in posttraumatic TMJ degeneration.
Assessing a Virtual Education Intervention for Patients With Atrial Fibrillation
Authors: Mihas Paul , Rosman Lindsey , Armbruster Tiffany , Walker Jennifer , Deyo Zack , Gehi Anil
Published: April 2023

Background

Authors of studies of patients with atrial fibrillation (AF) have identified several knowledge gaps and misconceptions regarding the condition and its management. The COVID-19 pandemic heightened isolation of patients and underscored the need for education and knowledge building in order for patients to effectively manage AF during times of increased health risk.

Objective

The aim of this study was to assess, using a qualitative approach, the experiences and perceived benefits of patients with AF regarding an 8-session virtual education intervention (AF-at-Home) during the early months of the COVID-19 pandemic.

Methods

A qualitative study with 3 focus groups using a semistructured focus group guide was conducted and recorded online with the same trained moderator.

Results

We identified 7 primary themes emerging from patients' experiences: (1) building knowledge beyond information available in clinic visits, (2) managing anxiety, (3) generating self-efficacy, (4) providing social comparison, (5) perceived benefits of both experiential and informational content, (6) facilitating self-management behaviors, and (7) facilitating communication with providers.

Conclusions

The analysis of the focus groups shows the benefits of a virtual education program in building knowledge, skills, and self-efficacy as well as reducing anxiety and normalizing one's experience by attending a program alongside other patients with AF.
The Effectiveness of Mind-Body Therapies for Women With Gynecological Cancer
Authors: Ong Jing Wen , Ong Qian-Er Oriana , Metsävainio Tea , Vaajoki Anne , Tian Jing Ling , He Hong-Gu
Published: April 2023

Background

Mind-body therapies (MBTs) have gained popularity among patients with cancer as a supportive therapy. To date, no systematic reviews have assessed the effect of MBTs on the health outcomes in women with gynecological cancer.

Objective

This systematic review and meta-analysis aimed to synthesize the effectiveness of MBTs on quality of life, anxiety, depression, cancer-related pain, and fatigue among women with gynecological cancer.

Methods

We searched and screened randomized controlled trials in 7 databases, trial registries, and gray literature from the databases’ inception to December 2021. Data were extracted from eligible studies, with each study’s quality assessed using the Cochrane risk-of-bias tool. Meta-analyses were conducted using RevMan 5.4. Sensitivity and subgroup analyses were performed. The quality of evidence across the studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

Results

Nine trials were included. Statistically significant effects of MBTs on depression (standardized mean difference, −0.56; 95% confidence interval, −1.01 to −0.11; P = .01), pain (standardized mean difference, −1.60; 95% confidence interval, −3.14 to −0.07; P = .04), and fatigue (standardized mean difference, −1.17; 95% confidence interval, −2.16 to −0.18; P = .02) were observed, but not on quality of life and anxiety. The quality of evidence was low due to the high risks of bias and high heterogeneity among the studies.

Conclusions

Mind-body therapies were effective in reducing depression, pain, and fatigue of women with gynecological cancer. However, the low quality of the evidence implies the need for more future studies with better methodologies.

Implications for Practice

Mind-body therapies may be used as an additional strategy to help manage depressive mood, pain, and fatigue among women with gynecological cancer.
A Case of Paradoxical Arthralgia Following Anti-TNF Monoclonal Antibody Administration in a Patient With New-Onset Pediatric Crohn’s Disease
Authors: Bellucca Simone , Calvo Pier Luigi , Giugliano Laura , Opramolla Anna
Published: April 2023

Anti-TNF antibodies have become a first-line therapy in moderate-to-severe inflammatory bowel diseases. However, there may be some rare paradoxical events and those affecting joints causing severe symptoms need a scrupulous differential diagnosis. When these events occur, it may be necessary to discontinue treatment and shift to another drug class. Herein, we report the case of a 15-year-old boy affected by Crohn’s disease, who developed a paradoxical reaction after the second dose of infliximab. Clinical remission was achieved shifting to budesonide and azathioprine and continuing maintenance therapy with azathioprine alone. To date, no other paradoxical events have occurred.
Pilot Study of Inclined Position and Infant Gastroesophageal Reflux Indicators
Authors: Paul Ian M. , Shedlock Katherine E. , Schaefer Eric W. , Stoute Ellen J. , Rosen Rachel
Published: April 2023

Objective:

To reduce gastroesophageal reflux, infants are commonly placed in an inclined position. We sought to observe the extent to which infants exhibit (1) oxygen desaturation and bradycardia in supine and inclined positions and (2) signs and symptoms of post-feed regurgitation in these positions.

Study Design:

Healthy infants aged 1–5 months with gastroesophageal reflux disease (GERD) (N = 25) and controls (N = 10) were enrolled into one post-feed observation. Infants were monitored in a prototype reclining device for consecutive 15-minute periods in supine position with head elevations of 0°, 10°, 18°, and 28° in random order. Continuous pulse oximetry assessed hypoxia (O2 saturation <94%) and bradycardia (heart rate <100). Regurgitation episodes and other symptoms were recorded. Mothers assessed comfort using an ordinal scale. Incident rate ratios were estimated using Poisson or negative binomial regression models.

Results:

Among infants with GERD, in each position, most had no episodes of hypoxia, bradycardia, or regurgitation. Overall, 17 (68%) infants had 80 episodes of hypoxia (median 20 seconds duration), 13 (54%) had 33 episodes of bradycardia (median 22 seconds duration), and 15 (60%) had 28 episodes of regurgitation. For all 3 outcomes, incident rate ratios were not significantly different between positions, and no differences were discovered for observed symptoms or infant comfort.

Conclusions:

Brief episodes of hypoxia and bradycardia as well as observed regurgitation are common for infants with GERD placed in the supine position after a feed with no differences in outcomes at various degrees of head elevation. These data may be used to power future, larger, and longer evaluations. ClinicalTrials.gov Identifier: NCT04542239.
Low-dose cone-beam computed tomography for assessment of alveolar clefts, a randomized controlled trial in image quality
Authors: Lemberger Mathias , Regnstrand Tobias , Karsten Agneta , Benchimol Daniel , Shi Xie-qi
Published: April 2023

Background:

Children born with an alveolar cleft receive bone grafts for improved function and aesthetics. The cleft area is radiologically examined before and post bone graft. Optimizing x-ray examination protocols is essential to protect these patients from possible delayed radiation injury later in life. This study investigates whether image quality of cone-beam computed tomography (CBCT) exposed with an ultra-low dose (ULD) protocol is comparable to the clinical default protocol, the standard dose (SD) protocol, in visualizing details of importance in bone grafting of alveolar clefts.

Methods:

In this randomized controlled study, 72 patients with uni- or bilateral alveolar clefts between 9-19 years (mean age 9.5) were randomized 1:1 with either a ULD or an SD CBCT examination protocol. The CBCT scans were conducted with Planmeca ProMax Mid with an 8x5cm field of view. Two experienced radiologists blindly evaluated the images and visibility of cortical bone border, trabecular bone, tooth anatomy, root development, periodontal space, and cleft width. The visibility was categorized as unacceptable, acceptable, or excellent.

Results:

Mann-Whitney U test showed no significant differences in structure visibility between ULD and SD protocols regarding anatomical structures of interest: cortical bone border (p=0.07), trabecular bone (p=0.64), tooth anatomy (p=0.09), root development (p=0.57), periodontal space (p=0.38), and cleft width (p=0.44).

Conclusions:

ULD and standard CBCT protocols provide comparable image quality in terms of structure visibility in the examination of alveolar clefts. The ULD protocol is preferred to the SD protocol due to the lower radiation dose without compromising diagnostic information of CBCT images.
Strongyloidiasis-related lung involvement: too much of a bad thing
Authors: Barkati Sapha , Greenaway Christina , Libman Michael
Published: April 2023

Purpose of review

Strongyloidiasis is a soil-transmitted helminthiasis, a neglected tropical disease that affects 300–900 million individuals globally. Strongyloides stercoralis is associated with cutaneous, respiratory, and gastrointestinal clinical manifestations. Chronicity is due to an autoinfective cycle, and host immunosuppression can lead to severe and fatal disease. Lung involvement is significant in severe strongyloidiasis, and Strongyloides has a complex association with a number of lung diseases, which will be discussed in this review.

Recent findings

The treatment of chronic lung diseases such as asthma and chronic obstructive pulmonary disease with corticosteroids is an important risk factor for Strongyloides hyperinfection syndrome (SHS)/disseminated strongyloidiasis. The use of corticosteroids in the treatment of coronavirus disease 2019 (COVID-19) and potentially COVID-19-induced eosinopenia are risk factors for severe strongyloidiasis. Recent findings have demonstrated a significant immunomodulatory role of Strongyloides in both latent and active pulmonary tuberculosis associated to an impaired immune response and poor outcomes in active pulmonary tuberculosis.

Strongyloides lung involvement is a common finding in severe infection. Prompt recognition of Strongyloides infection as well as prevention of severe disease by screening or presumptive treatment are important goals in order to improve Strongyloides outcomes in at-risk population.
Amebic encephalitis and meningoencephalitis: an update on epidemiology, diagnostic methods, and treatment
Authors: Haston Julia C. , Cope Jennifer R.
Published: April 2023

Purpose of review

Free-living amebae (FLA) including Naegleria fowleri, Balamuthia mandrillaris, and Acanthamoeba species can cause rare, yet severe infections that are nearly always fatal. This review describes recent developments in epidemiology, diagnosis, and treatment of amebic meningoencephalitis.

Recent findings

Despite similarities among the three pathogenic FLA, there are notable variations in disease presentations, routes of transmission, populations at risk, and outcomes for each. Recently, molecular diagnostic tools have been used to diagnose a greater number of FLA infections. Treatment regimens for FLA have historically relied on survivor reports; more data is needed about novel treatments, including nitroxoline.

Research to identify new drugs and guide treatment regimens for amebic meningoencephalitis is lacking. However, improved diagnostic capabilities may lead to earlier diagnoses, allowing earlier treatment initiation and improved outcomes. Public health practitioners should continue to prioritize increasing awareness and providing education to clinicians, laboratorians, and the public about amebic infections.
Predictive Factors of Hospital-Acquired Bacterial Infections in Patients With Systemic Lupus Erythematosus
Authors: Restrepo-Escobar Mauricio , Granda-Carvajal Paula A. , Aguirre-Acevedo Daniel C. , Jaimes Fabián , Vásquez Gloria M.
Published: April 2023

Objective

We aimed to identify the predictive factors of hospital-acquired bacterial infections in patients with systemic lupus erythematosus (SLE).

Methods

This chart review study included patients with SLE who were hospitalized between 2009 and 2020 for reasons other than infection. The outcome was defined as any infection confirmed using any bacterial isolation method or diagnosed by treating physicians and required treatment with intravenous antibiotics. For statistical analysis, logistic regression analyses were performed.

Results

In total, 1678 patients (87.6% women) were included. The median age was 33 years (interquartile range, 24–47 years). The incidence of hospital-acquired infections was 13.9% (233 infections). Age, Systemic Lupus Erythematosus Disease Activity Index score, Systemic Lupus International Collaborating Clinics damage score, blood urea nitrogen and C-reactive protein levels, dosage of steroid in the previous month, recent use of 1 or more immunosuppressants, admission with a central venous catheter (or dialysis catheter), and use of central venous catheter or bladder catheter in the first 5 days were the predictive factors of nosocomial infections.

Conclusion

The patients' infection risk profile should be assessed to accurately determine the risk-benefit balance of any therapeutic intervention, minimize exposure to steroids and immunosuppressants, and maintain a low threshold for the early diagnosis of infections. Further studies should assess whether the modification of some identified factors could reduce the incidence of nosocomial infections.
Risk Factors and Clinical Outcomes Associated With Sarcopenia in Rheumatoid Arthritis
Authors: Tam Keith , Wong-Pack Matthew , Liu Theodore , Adachi Jonathan , Lau Arthur , Ma Jinhui , Papaioannou Alexandra , Rodrigues Isabel B.
Published: April 2023

Sarcopenia is underrecognized in patients with rheumatoid arthritis (RA). Risk factors of sarcopenia and its impact on outcomes in RA patients are relatively unknown. We conducted a systematic review to identify factors and outcomes associated with sarcopenia in RA. We conducted this review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. We searched PubMed, Embase, CINAHL, and Web of Science databases by combining the following search concepts: (1) RA and (2) sarcopenia. Articles were included if they included RA patients, assessed for sarcopenia using a consensus working group definition, and assessed for clinical outcomes. Meta-analysis was performed using studies that shared the same sarcopenia definition and consistency in reporting patient or disease variables. Our search identified 3602 articles. After removal of duplicates, title and abstract screen, and full-text review, 16 articles were included for final analysis. All studies had observational study designs. The pooled prevalence of sarcopenia ranged from 24% to 30%, depending on the criteria for sarcopenia used. Factors associated with sarcopenia included higher 28-joint Disease Activity Scale scores (+0.39; 95% confidence interval, +0.02 to +0.77) and baseline methotrexate use (odds ratio, 0.70; 95% confidence interval, 0.51–0.97). Baseline glucocorticoid use had a positive correlation with sarcopenia in multiple studies. Several studies found lower bone mineral density and higher incidence of falls and fractures in patients with sarcopenia. Sarcopenia is prevalent in RA, and it may be associated with higher RA disease activity, lower bone mineral density, and increased falls and fractures. Therefore, early screening of sarcopenia in RA patients is important to incorporate into clinical rheumatology practice.