bluuebunny/crossref_metadata_2025 huggingface dataset:
P129 Interdisciplinary collaboration in the care of patients with connective tissue disease-related interstitial lung disease in Wales: an interview study
Authors: Evans Philip , Hett Kirsty , Hutchinson Nicola-xan , Beynon Celia
Published: April 2024

Background/Aims

Patients with connective tissue disease-related interstitial lung disease (CTD-ILD) often receive care from both rheumatologists and respiratory physicians to manage their conditions. As treatment options become increasingly complex with immunosuppressing and antifibrotic agents, there is a growing recognition of the importance of collaborative approaches to ensure accurate diagnosis, aid management decisions and deliver patient-centred care. However, there is currently no agreed optimal model for shared care, leading to significant practice variation. This study aimed to explore the perspectives of rheumatologists and respiratory physicians regarding the benefits and challenges of cross-speciality management in CTD-ILD. A better understanding of this will enhance the development of services and improve patient-centred care.

Methods

Semi-structured interviews, both face-to-face and virtual, were conducted with 11 respiratory physicians and nine rheumatologists working in Wales, ensuring representation from all health boards. Interview transcripts were analysed using thematic analysis to identify themes.

Results

Five main themes were identified: navigating complexity and uncertainty, reliance on clinical experience, prioritisation of efficiency, educational and training benefits, and inconsistent access to services for clinicians and patients.

Conclusion

The complexity of CTD-ILD care, combined with varying levels of physician expertise and a perceived lack of guidelines, presents significant challenges for clinicians. Cross-speciality collaboration is actively sought by physicians and is perceived to enhance patient care by improving efficiency, aiding confidence in decision-making and providing educational benefits to clinicians. However, resource limitations and geographical variations in service access hinder the implementation and development of shared care models. Physicians perceive that patients like being seen in joint clinics; future exploration of patient perspectives and experiences of joint care systems will be crucial to ensure the direction of clinical practice development remains patient-centred. In addition to implementing integrated cross-speciality clinical services, the development of joint respiratory and rheumatology guidelines as well as greater availability of training opportunities would assist physicians in delivering optimal care to patients with CTD-ILD.

Disclosure

P. Evans: None. K. Hett: None. N. Hutchinson: None. C. Beynon: None.
P144 Extended examination of post-challenge rewarming in patients with systemic sclerosis, as assessed by thermography
Authors: Ndosi Abigail , Dinsdale Graham , Manning Joanne , Mandzuk Melissa , Wilkinson Sarah , Herrick Ariane , Murray Andrea
Published: April 2024

Background/Aims

Clinical trials of systemic sclerosis (SSc)-related Raynaud’s phenomenon require better objective outcome measures. Thermography-monitored cold-challenge is a validated imaging technique. Cold-challenge is monitored for 15-minutes during rewarming, however, patients often do not fully rewarm. Knowing rewarming time enables better planning of daily trial protocols (e.g. challenges before and after treatment). The aim of this study was to test the hypotheses that 15-minute rewarming measurements are predictive of two-hour rewarming and that patients rewarm within a two-hour period.

Methods

Baseline thermography of the hands and cold-challenge was performed (1 minute, 15oC water, gloved hands submerged). Post-cold challenge, images were taken every 15s (to 15 minutes), every 5 minutes (to 30 minutes), every 10 minutes (to 60 minutes) and every 15 minutes (to 120 minutes). Baseline finger temperature (average, eight fingers, Tbase) and distal dorsal difference (DDD, temperature difference between dorsum ofthe hand and distal finger) were calculated from baseline images. Mean finger temperature difference (post-cold challenge-baseline, Tdiff), time to 25% (t25%), 50% (t50%), 100% (t100%) rewarming, maximum temperature achieved (Tmax), time to Tmax (tmax), area under the rewarming curve (AUC), and final temperature (Tf) were calculated. Cox regression assessed associations between Tbase, Tmax, Tf, DDD and AUC.

Results

Twenty patients with SSc were recruited; median (interquartile range) age 62 (53-69), duration of RP 16 (7-26) years. Fourteen patients (70%) rewarmed within two hours. Data, Table 1. Cox regression showed positive relationship between AUC and t25%, t50% and t100% and a negative relationship between Tbase, t50% and t100%. In the non-rewarming subset, 3/6 and 1/6 achieved t25%, t50% in 15 minutes. 13/14 patients that rewarmed achieved t25% and 11/14 achieved t50% within 15 minutes. Results suggest that the likelihood of longer-term rewarming is predicted the initial 15-minute rewarming.

Conclusion

Tbase was reached by the majority of patients with SSc in a two-hour window, therefore, a second or third cold challenge could be incorporated into early Phase II study protocols within a study day. Patients reaching t50% within 15 minutes were highly likely to rewarm fully over two hours; thus 15-minute rewarming may aid screening to identify patients who will fully rewarm.

Disclosure

A. Ndosi: None. G. Dinsdale: None. J. Manning: None. M. Mandzuk: None. S. Wilkinson: None. A. Herrick: None. A. Murray: None.
P147 M2 macrophage associated fibrosis in early stage systemic sclerosis: an update on plasma biomarkers
Authors: Leeves Laura A , Kannan Zestranjyan , Ali Yunus , Pan Liyang , Malley Tamir , Abraham David , Leask Andrew , Riser Bruce , Abdi Bahja Ahmed , Stratton Richard J
Published: April 2024

Background/Aims

Systemic sclerosis is an autoimmune connective tissue disease characterised by vasculopathy and fibrosis. The CCN family of matricellular proteins have a regulatory role in inflammation and fibrosis. CD206, an M2 macrophage surface marker, is cleaved by metalloproteases to release soluble form of CD206; this acts as an active disease marker in systemic sclerosis. We investigated the profile of CCN2 and CCN3 in the presence of soluble CD206 (sCD206) in patients with early and late stage diffuse systemic sclerosis (dcSSc).

Methods

Patients with a diagnosis of dcSSc at the UCL Centre for Rheumatology and Connective Tissue Diseases were recruited. Informed consent was obtained from patients and healthy controls (HC). Blood samples were taken from which plasma was isolated and stored at -80 °C prior to assay. Expression of CCN2, CCN3, and sCD206 was measured in these plasma samples by ELISA. Study participants were categorised into healthy controls (n = 20), early stage dcSSc (n = 20) and late dcSSc (n = 20), with early stage defined as the blood sample taken within two years since diagnosis, and late stage defined as over five years since diagnosis.

Results

Plasma CCN2, CCN3 and sCD206 levels were significantly higher in early dcSSc patients, when compared to HC. CCN2 was raised in early dcSSc patients (early dcSSc mean 20,221pg/ml, SD 16,503, p < 0.05) with concentration in late disease matching that of HC (late dcSSc 12,893pg/ml, HC 11,289pg/ml). CCN3 was significantly higher in early and late disease when compared to HC (early mean 16,526pg/ml, late 12,838pg/ml, HC 4,201pg/ml, p < 0.05). sCD206 levels were higher in early dcSSc (mean 5356pg/ml, SD 3154, p < 0.05), with there being no significance between levels in late dcSSc (mean 4184pg/ml, SD 3900, p > 0.05) and HC (mean 3319pg/ml, SD 1925). CCN2 expression was higher compared to that of CCN3 in early disease, with CCN2:CCN3 ratio elevated in early dcSSc (mean 3.17, SD 8.26) compared to late dcSSc (mean 1.26, SD 0.99) and HC.

Conclusion

This investigation demonstrates that upregulation of CCN2 and CCN3 expression has a regulatory role in fibrosis in early stage dcSSc. These biomarkers of M2 macrophage associated fibrosis are to be correlated with their clinical phenotype and have potential for a role in targeted treatment of systemic sclerosis.

Disclosure

L.A. Leeves: None. Z. Kannan: None. Y. Ali: None. L. Pan: None. T. Malley: None. D. Abraham: None. A. Leask: None. B. Riser: None. B. Ahmed Abdi: None. R.J. Stratton: None.
P159 Development of digital neuropsychological battery: a use case in Indian SLE patients
Authors: Singhal Pragya , Srivastava Priyanka , Rajasekhar Liza , Samhitha Nallapothula Sai
Published: April 2024

Background/Aims

While cognitive dysfunction and mood disorders are frequently reported as adverse effects of SLE, there is a scarcity of neuropsychological (NP) data for Asian SLE patients. Existing English-centric NP tests are inadequate for the linguistic and culturally diverse population. This study examines SLE's effects on mood and cognitive functions using an indigenously developed language-neutral digital NP test battery and validated anxiety, stress, depression and quality of life instruments.

Methods

We recruited SLE patients fulfilling 2012 SLE classification criteria as cases and caregivers (CG) and college students (CS) as controls aged above 18 years and at least 10th standard education. All participants provided written informed consent. Institutional ethics committees approved the study. The NP battery comprised five cognitive tasks: Montreal Cognitive Assessment (MoCA) and modified versions of attention network test (ANT), sustained attention to response task (SART), picture naming and N-back, and five psychological tests (PHQ-9, GAD-7, STAI-T, PSS-4 and WHOQOL-BREF). Mann-Whitney test with conditional Bonferroni's corrections was used to compare cases with CG and CS.

Results

Total of 142 volunteers (age: median = 25.0, IQR = 9.0, cases [n = 82], CG [n = 40] and CS [n = 20]) participated in the study. Cases exhibited delayed response latencies in N-back, SART, and picture naming tasks compared to controls. They demonstrated reduced accuracy in all N-back conditions, with significant differences observed in hit rate, miss rate, false alarms, and d-prime scores compared to CS with effect size ranging from 0.298 to 0.736 (Table 1). However, the difference was only significant in the 2-back condition compared to CG. Cases displayed lower accuracy in SART Go trials (higher omission errors) than controls but better inhibition in SART No-Go trials (lower commission errors). No differences were observed in alerting, orienting and executive control functions. Cases showed significantly lower scores in MOCA than controls. Cases reported poorer psychological health through increased anxiety and stress levels and reduced WHO-quality of life scores compared to CG.

Conclusion

Contrary to earlier research that often relied on isolated cognitive assessments, our pioneering approach introduces a tailored test battery to establish cognitive baselines for Indian SLE patients.

Disclosure

P. Singhal: None. P. Srivastava: None. L. Rajasekhar: None. N. Samhitha: None.
P161 Self-reported barriers to exercise from a national United Kingdom systemic lupus erythematosus cohort
Authors: Baranskaya Aliaksandra , Wadley Alex J , Reynolds John
Published: April 2024

Background/Aims

Patients with systemic lupus erythematosus (SLE) are more inactive than the general population. Regular physical activity (PA) positively impacts many health parameters, including cardiovascular health. To better understand patient barriers to leisure time PA we conducted a national survey of patients with SLE in the UK.

Methods

An online survey was disseminated via LUPUS UK social media platforms between 5/05/2023 and 28/10/2023. Participants self-reported demographic data including postcodes. Indices of Multiple Deprivation (IMD) were used to define socioeconomic deprivation and were split into quantiles, where quartile 5 represents participants living in 20% least deprived areas in England. Categorical and continuous data were analysed using Fisher’s exact test and Mann-Whitney U test respectively.

Results

There were 249 individual responses. Table 1 describes the cohort demographics alongside response data. On a 0-10 scale (very unsatisfied to very satisfied), 171/244 (70%) of participants rated their satisfaction with their amounts of leisure time PA as ≤ 4. The most commonly reported barriers to PA were fatigue (221/249, 88.8%), pain (155/249, 62.2%) and lupus-related symptoms/flares (145/249, 58.2%). Dislike of exercise was reported by < 10% of cohort (22/249, 8.8%). When asked to identify the primary barrier to PA, 119/244 (48.8%) reported fatigue. Lack of motivation (40/244, 16.4%) and knowledge about exercise (18/244, 7.4%) were other predominant barriers. Concern around injury differed between ethnic groups (p = 0.016). Other barriers did not differ by sex, ethnic group or socioeconomic deprivation. Participants reporting lack of time were younger with a median age of 45 (35-53) versus 54 (43-63) years, p = <0.001. Patients reporting fatigue, pain and self-consciousness had higher BMI in kg/m2 (27.7 [23.6-32.3] vs 23.4 [20.8-28.2]; 28.7 [23.8-33.1] vs 25.4 [22.6-28.8]; 31.4 [27.9-38.4] vs 25.8 [23.1-30.2]), p = <0.001. Lupus-related symptoms/flares and concern that PA may worsen lupus were reported by participants with a shorter disease duration in years (8 [3-17] vs 12 [4.5-24] p = 0.002, and 7 [2-15] vs 10 [4.5-23] p = <0.001 respectively).

Conclusion

70% of patients were dissatisfied with their level of leisure time PA. Fatigue and pain were the most commonly reported barriers to PA. Reported barriers differ between patients highlighting the need for personalised exercise programmes for patients with SLE.

Disclosure

A. Baranskaya: None. A.J. Wadley: None. J. Reynolds: None.
P173 The positive utility of PSAID-12 score in remote monitoring and the impact of gender and treatment on patient reported outcomes in psoriatic arthritis
Authors: Chan Antoni , Soe Nwe Ni
Published: April 2024

Background/Aims

Psoriatic arthritis (PsA) is a chronic inflammatory disease that significantly impacts the quality of life (QOL) of patients. The PSAID-12 score reflects the impact of the PsA from the perspective of the patients. This study assessed patient reported outcomes using the PSAID-12 and evaluated the impact of gender, treatment and disease duration.

Methods

This study was a cross-sectional, observational study of patients with PsA meeting CASPAR critieria. Patients were recruited consecutively from clinic and completed the PSAID-12 questionnaires 14 days prior to their clinic visit digitally or by paper. Demographic and clinical data, including age, gender, disease duration, medication were collected. Disease activity was measured using the the tender/swollen joint count, patient/physician assessment and CRP.

Results

The total number of patients in the study was n = 225. The female:male ratio was 1.0:0.8. The mean disease duration was 27 years (range 2 months to 44 years). The mean age was 52 years (range 18 to 86 years). The number of patients on DMARDs was 89.3 % (201/225) and combined DMARDs and biologics was 26.67 % (60/ 225). The mean PSAID-12 score was 4.09 (SD 2.47). There was a positive correlation between the pre-clinic PSAID-12 score and the in-person calculated tender joint count (r = 0.58), swollen joint count (r = 0.51) and the Likert pain score (r = 0.84). All domains of the PsAID-12 score were higher in female than male (4.53 vs 3.47 respectively), Table 1. Fatigue, discomfort, and pain were the most reported score for females (mean 5.52, 5.22, 5.02 respectively) whereas for males the commonest scores were discomfort, pain and fatigue (mean 4.10, 3.88, 3.88 respectively). The fourth commonest score for both genders was the impact on work and or leisure activities (4.67 for females and 3.83 for males). In terms of disease duration, discomfort is the most common reported score for patients with a disease duration of less than 5 years (mean 5.09) whereas fatigue was the most common complaint in patients with the group of 5-10 years and >10 years (4.56 and 5.11 respectively). There was a lower mean score of skin problems in the biologics compared to the non-biologic group (2.78 vs 3.90). There was a trend towards lower coping, embarrassment, and social participation scores in the biologics group.

Conclusion

The PSAID-12 score correlated well with PsA disease activity. The impact on QOL from PsA was higher in females than males. Fatigue, pain and discomfort were the commonest symptoms and higher scores were reported in early disease, with discomfort being the highest in this group. Fatigue was more commonly reported in patients with longer disease duration. The benefits of the biologics on QOL and skin problems were seen in these patients despite their longer disease duration.

Disclosure

A. Chan: None. N. Soe: None.
P185 Anatomical patterns of pain in primary care patients with polymyalgia rheumatica compared to the general population
Authors: Hammad Niall , Partington Richard , Hider Samantha , Butt Henna , Helliwell Toby , Mallen Christian , Muller Sara
Published: April 2024

Background/Aims

Polymyalgia rheumatica (PMR) is common in older adults, causing severe pain and stiffness, particularly in the shoulder and hip girdles. A tapered course of glucocorticoids is recommended, but not always straightforward, with frequent symptom recurrence. Reasons are unclear, but partial masking of painful comorbidities (e.g., osteoarthritis) may play a part.

Methods

652 people with incident PMR were recruited from English general practice (2012-2014) to a postal survey study (questionnaires at diagnosis, 1, 4, 8, 12, 18, 24, [mean] 61 months). Surveys included a body manikin (front and back views). Participants were asked to shade anywhere they experienced pain >1 day in the last month. 44 mutually exclusive areas were defined as painful or not. For comparison, an age-gender matched random sample of 652 people was selected from a general population survey in North Staffordshire that used the same manikins. Pain prevalence was compared between the 2 studies.

Results

In the PMR study, surveys were completed by 244 participants at 24 months and 197 at 61 months. Pain was reported in a mean of 17.1 areas at diagnosis (Table). Bilateral shoulder and hip pain were present in the majority at diagnosis (shoulder 81%; hips 59%) and in around a third and a fifth of patients respectively throughout the study. The prevalence of bilateral shoulder and hip pain remained higher than in the general population sample, while unilateral pain in these areas was less common. Bilateral hand (27%) and knee (45%) pain were also common at diagnosis. After 1 month, the mean number of pain areas was 7 - similar to the general population. However, prevalence of bilateral shoulder and hip pain remained higher than the general population throughout follow-up. Unilateral hip and knee pain were persistently less common in those with PMR, whilst unilateral hip pain was more common.

Conclusion

Bilateral pain was reported more commonly across the disease course in people with PMR than the general population. Causes of pain cannot be accurately attributed, but are likely multifactorial, including PMR disease activity, treatment and painful comorbidities. However, the persistence of bilateral pain suggests untreated PMR symptoms, requiring further research.

Disclosure

N. Hammad: None. R. Partington: None. S. Hider: None. H. Butt: None. T. Helliwell: None. C. Mallen: None. S. Muller: None.
P191 Giant cell arteritis relapses occur in a different arterial territory as compared to diagnosis
Authors: Alanoor Shruti , Ducker Georgina , Mukhtyar Chetan B
Published: April 2024

Background/Aims

Ultrasonography (US) for diagnosis of large vessel vasculitis (LVV) is a recommended first line diagnostic procedure. We have been running an US led diagnostic pathway in our centre since January 2017. This pathway is also used to diagnose relapsing disease. We present US defined anatomical distribution of relapses in consecutive patients.

Methods

Patients in whom new and relapsing disease was diagnosed using US were included. Protocolised US examination of the common carotid system (segments of common carotid, external carotid and branches) and those of the subclavian system (segments from origin of subclavian to end of axillary artery and branches) were carried out at diagnosis and relapse. Halo sign in at least two different arteries was needed for establishing new or relapsing disease. Disease characterisation was classified as being in the carotid system, subclavian system, or both. The nature of the disease at relapse was compared to that at diagnosis.

Results

279 patients were diagnosed with LVV using US since Jan 2017. 57 (20%) were diagnosed as having a relapse using US. 43/57 (75%) and 28/57 (49%) had involvement of the carotid system at baseline and relapse respectively. 22/57 (39%) and 44/57 (77%) had involvement of the subclavian system at baseline and relapse respectively. A comparison of the disease involvement is as in Figure 1.

Conclusion

The branches of the common carotid artery (external carotid artery) are commonly involved at diagnosis, but relapse occurs more frequently in the subclavian artery branches. This is especially true when disease affects the carotid system at baseline. The presentation of patients with subclavian system disease is often with only constitutional symptoms and with shoulder girdle pain and stiffness. This may be mistaken for being a polymyalgia rheumatica relapse. It is essential to examine the subclavian system of arteries in patients with LVV before diagnosing polymyalgia rheumatic relapse.

Disclosure

S. Alanoor: None. G. Ducker: None. C.B. Mukhtyar: None.
E013 Looking back at back pain: how well do our referrals measure up to available criteria?
Authors: Akpabio Akpabio , Camillieri Mary Louise , Williams Tom , Sengupta Raj
Published: April 2024

Background/Aims

According to the Global Burden of Disease Study 2021, low back pain remains the leading cause of years lived with disability (YLDs) globally affecting about 619 million people as of 2020. Inflammatory back pain affects fewer patients but remains an important referral indication. A previous audit from the early back pain clinic of cases seen between 2015-16 at the Royal National Hospital for Rheumatic Diseases, Bath, identified an axial spondyloarthritis (AxSpA) diagnosis in 21% of patients of whom, two thirds were HLAB27 positive. This follow-up audit aimed to evaluate for interval change in axSpA prevalence and assess the referrals against NICE and ASAS criteria respectively. While the NICE referral guidance is largely clinical, ASAS incorporates extra musculoskeletal manifestations and investigations.

Methods

We reviewed 100 of the 271 early back pain clinic referrals received between July 2022-23. The completed referral proforma was evaluated against the NICE and ASAS criteria respectively. Electronic medical records and clinic letters of patients were also reviewed including demographics, baseline investigations and imaging.

Results

The patients were 54% male with an average age of 38.7 ± 13.7years. An axSpA diagnosis was made in 19 patients (19%) of which 12 were HLAB27 positive (63.1%). The median symptom duration was 24 months (6-72) with an appointment delay of 128 days (36-182). Discharge rate was 35% after the first appointment. Overall, 62% of referrals satisfied NICE criteria compared to 71% for ASAS. This was after excluding 21 referrals which did not satisfy the ASAS entry criterion of symptoms > 3months in patients <45 years.

Among our cohort, sensitivities were 68.4% for NICE and 73.7% for ASAS while specificities were 39.5% for NICE and 29.6% for ASAS. Three patients all above 45 years with a normal CRP met neither criteria, but were diagnosed with axSpA after MRI while one patient who satisfied both criteria turned out to have lung cancer with bony metastases.

Conclusion

There has been minimal interval change in AxSpA prevalence from our referrals between 2015-23. The ASAS criteria was easier to satisfy and can serve as an alternative referral indication for patients who do not meet NICE criteria. Both criteria are still very useful in terms of ensuring the quality of referrals received. Improvements in the referral pathway are being planned to reduce primary and secondary care delays thus enhancing earlier diagnosis and treatment.

Disclosure

A. Akpabio: None. M. Camillieri: None. T. Williams: None. R. Sengupta: None.
E016 An audit on patient initiated follow up in rheumatology in Manchester Royal Infirmary
Authors: Cheung Annie , Nowell George , Ling Stephanie , Chiu Yee Ho , Ho Pauline
Published: April 2024

Background/Aims

PIFU is not a new concept in rheumatology. Instead of arranging regular routine appointments for patients with stable diseases, PIFU empowers patients to seek help when needed, enabling them to take control of their care and reduce pressure on rheumatology services. NHS England recommends PIFU for rheumatology patients with stable inflammatory arthritis. They should also have a good understanding of their disease management and be able to contact the service promptly. If patients on PIFU contact the service and require face-to face appointments, they should be seen within 2-4 weeks. Despite existing recommendations, there appears to be wide variation between clinicians and managers on the understanding of PIFU. The aim of this audit is to compare diagnoses of rheumatology patients for PIFU in a single rheumatology department, and the waiting time for review once patients placed on PIFU have made contact, to NHS England standards.

Methods

A list of rheumatology patients placed on PIFU between October 2022 and July 2023 at Manchester Royal Infirmary was obtained. Data were collected from electronic patient records.

Results

A total of 130 (1.5%) patients were listed on PIFU by 18 clinicians. The table outlines the demographics and detailed breakdown of diagnoses1. 1 (1%) was put on PIFU after patient declined biologic treatment for active inflammatory arthritis. 3 patients contacted the department whilst on PIFU, 2 of them required face-face review. Median time from start of PIFU to patient-initiated contact was 60 days (IQR 47.5-107.5). One with palindromic rheumatism was seen at 6 weeks and one with osteoarthritis had no appointment date yet 8 weeks after initial contact.

Conclusion

The audit confirmed that only 22 (17%) patients followed NHS England guidelines and 0% was seen as recommended once the patient contacted the department. Currently, 1.5% of patients in the rheumatology department are placed on PIFU, which is below 5% as per NHS England guidelines. This audit highlights the urgency to educate clinicians and managers on the cohort of patients listed on PIFU and to ensure all these patients are seen within the recommended time. Work is being done in the department to address these issues.

Disclosure

A. Cheung: None. G. Nowell: None. S. Ling: None. Y. Chiu: None. P. Ho: None.
E017 An early inflammatory arthritis questionnaire to enable enhanced triage and a scoping exercise to assess clinical utility
Authors: Burton Jessica , Sathananthan Rosh , Levy Sarah , Horwood Natalie , Ahmed Tazeen , Suresh Resmy
Published: April 2024

Background/Aims

The quality of early inflammatory arthritis (EIA) referrals from primary care can vary even with a standardised referral form leading to large numbers of non-EIA patients being seen. Poor utilisation of EIA slots places pressure on an EIA service’s ability to see suspected EIA patients within 3 weeks of referral. To overcome this challenge, a questionnaire was devised to enable enhanced EIA triage and a scoping exercise was carried out to assess clinical utility.

Methods

50 patients attending the EIA clinic completed the questionnaire (Table 1) either self-administered or via telephone prior to their appointment. Early Inflammatory Arthritis Screening Questionnaire (Table 1)

Positive answers were scored 1 with a maximum score of 11. Following their appointment, the patient diagnosis was collected from patient records.

Results

Of the 50 patients, 14 (28%) had a confirmed EIA diagnosis and the other 36 (72%) patients had a range of alternative diagnoses. In the confirmed EIA group, the scores ranged from 5-8/11 with an average mean score of 7.0 and median of 7. Further analysis showed patients with a score over 5/11 including symptom duration of 12 months and under (Q1) identified all the confirmed EIA patients. Applying the above criteria to our 50 study patients resulted in 27/50 patients qualifying for an EIA appointment slot and 14/27 (52%) would have been confirmed with EIA. After applying these cut off criteria the sensitivity of the questionnaire was 100% and the specificity was 64%. The non-EIA group scores ranged from 0 - 8/11 with an average mean score of 4.9 and median score of 5.

Conclusion

In our service triage of EIA referrals on a standardised form resulted in poor utilisation of EIA slots. Triage using the questionnaire improved the EIA slot allocation and increased EIA conversion rate from 28% to 50%. This questionnaire appears to be a promising tool to improve utilisation of EIA appointments. Telephone assessment could be delivered by any member of the multidisciplinary team.

Disclosure

J. Burton: None. R. Sathananthan: None. S. Levy: None. N. Horwood: None. T. Ahmed: None. R. Suresh: None.
E035 Tocilizumab and the reversible cerebral vasoconstriction syndrome
Authors: Corney Benjamin , Rhys-Dillon Ceril
Published: April 2024

Background/Aims

Reversible cerebral vasoconstriction syndrome (RCVS) describes a group of conditions characterised by thunderclap headache and radiographic evidence of multifocal cerebral artery vasoconstriction. While typically following a benign course to resolution within a period of days to weeks, a small proportion of patients experience complications such as stroke, seizure or cerebral oedema. While a wide range of aetiological factors have been implicated in the clinical literature, there is, to our knowledge, only one prior publication reporting an association between tocilizumab and RCVS.

Methods

Here, we describe the case of a patient who developed RCVS following treatment with tocilizumab for rheumatoid arthritis.

Results

A 41 year old lady presented to her local emergency department after waking from sleep with sudden onset thunderclap headache with associated photophobia and vomiting. There was no prior history of headache. Her past medical history included rheumatoid arthritis and depression. At time of admission, her prescribed medications included folic acid, sertraline, methotrexate and tocilizumab. For the past 5 years, her rheumatoid arthritis had been controlled with a combination of methotrexate and etanercept, but, with her disease flaring, the etanercept was switched for tocilizumab six weeks prior to admission. Initial evaluation with CT head, CT venogram and lumbar puncture did not reveal any underlying abnormalities. A subsequent CT angiogram of the head and neck revealed multiple smooth stenoses bilaterally within the anterior cerebral arteries (ACA), middle cerebral arteries (MCA) and posterior cerebral arteries (PCA). A diagnosis of RCVS was made and tocilizumab was discontinued.

Conclusion

In patients taking tocilizumab, particular consideration should be given to the possibility of RCVS when performing a diagnostic evaluation of thunderclap headache. Tocilizumab may be an aetiological factor in this condition and its discontinuation may prevent the development of more serious complications.

Disclosure

B. Corney: None. C. Rhys-Dillon: None.
E040 Differences in clinical characteristics in patients with extremes of discordance in bone mineral density in the hips
Authors: Saeed Aamir , Bukhari Marwan
Published: April 2024

Background/Aims

Osteoporosis is a clinical condition which is characterised by low bone mineral density (BMD) and is associated with increased risk of fractures and subsequent increased morbidity and mortality. Usually BMD is measured at either the spine or the non-dominant hip (usually the left hip). However, our DEXA scanner routinely measures BMD at both hips and enables discordance in terms of BMD to be measured. This study aimed to ascertain whether patients with extremes of discordance in their BMD between both hips are more likely to have certain clinical characteristics and different risk for fractures.

Methods

Data from a dual-energy X-ray absorptiometry (DEXA) scanner in the North West of England were used. Patients who were referred between 2004-2011 were studied. Patients had both hips scanned as well as risk factors and presence of fracture recorded. Those that had a BMD T-score difference from 0 and upwards formed the positive discordance group. Those that had a BMD T-score difference of either less than or equal to -1SD formed the negative discordance group. These two groups were compared using independent sample t-tests for continuous variables and chi-squared tests for categorical variables. Logistic models were then fitted to look at the odds of fracture in each group.

Results

The hip BMD T-scores of 10,335 patients were measured. Mean age was 62.41 (±12.99) with 82.61% being female. The odds ratio for the measured risk factors and the association with fracture are shown in Table 1 below. Significant risk factors are highlighted

Conclusion

Patients that had a positive discordance had lower weight and BMI. Also, there was a higher proportion of females in the positive discordance group. These are important risk factors used in fracture risk assessment. It is possible that if BMD is only measured in one hip, patients may be misclassified as not having osteoporosis. However, if BMD is measured in both hips, discordance might be present suggesting osteoporosis in the right hip. This discordance in BMD in our study is associated with some risk factors like age and sex which may increase future fracture risk.

Disclosure

A. Saeed: None. M. Bukhari: None.
E046 Lytic lesions; metastatic disease or gout?
Authors: Stewart Sarah K , Coulter Daniel J , Masih Claire
Published: April 2024

Background/Aims

Uric acid crystal deposition in the spine is uncommonly diagnosed, although the frequency of axial involvement is thought to be as high as 14-35%. Studies have shown that spinal gout is more common in men aged 35-75 years, with a history of chronic polyarticular tophaceous gout which is not optimally controlled being a key risk factor. Recent studies have shown that spinal gout is under and misdiagnosed due to its non-specific presentation of back pain or absence of symptoms. Our case report exemplifies this diagnostic challenge.

Methods

In this report we describe a case of a 79-year-old male with a history of polyarticular tophaceous gout, chronic kidney disease and previous renal carcinoma treated with curative radiotherapy. He presented with a 4-week history of progressive exertional dyspnoea and orthopnoea. He was commenced on intravenous diuretics which lead to an acute kidney injury, with his eGFR dropping to 14mL/min. His preadmission allopurinol and colchicine were held and clinically he developed a flare of gout affecting his right wrist and right second and third MCP joints. A CT scan of his abdomen and pelvis, carried out to investigate potential bowel obstruction, showed no evidence of obstruction but it did reveal multiple lytic lesions in the spine with potential extension into the spinal canal at T9 and L5. He did not have any back pain and his neurological examination was normal.

Results

A working diagnosis of spinal metastasis with potential cord compression was made and the patient was commenced on high dose steroids. He subsequently underwent an MRI whole spine which showed marrow abnormalities and destructive soft tissues changes affecting various facet joints in the thoracic and lumbar spine. The primary differential remained metastases but due to the unusual distribution of the marrow changes in which the vertebral bodies were completely spared, the initial CT images were reviewed on spectral scanning which demonstrated uric acid deposition in the affected facet joints. The diagnosis was confirmed as gout in the spine when a PET-CT scan revealed no potential primary source of malignancy. The gout flare in his hand settled with the steroids prescribed to treat the potential cord compression and he continued to deny suffering from back pain.

Conclusion

A literature search demonstrates that reports of spinal gout being described as lytic lesions on CT are rare. Spinal gout should be considered as a differential in a patient with facet joint lytic lesions on imaging, without involvement of the vertebral body and where no primary malignancy is found. Our case demonstrates how dual energy CT scanning can prevent the need for invasive biopsy in cases of diagnostic uncertainty in patients with a history of poorly controlled chronic tophaceous gout.

Disclosure

S.K. Stewart: None. D.J. Coulter: None. C. Masih: None.
E058 Disease activity measurement in rheumatoid arthritis - simpler in not always better!
Authors: Crawshaw Helena , Gates Emer , Acebes Carlos , Jamal Muhammad Safwan
Published: April 2024

Background/Aims

Rheumatoid arthritis is one of the commonest inflammatory arthritis (1). The traditional method of disease activity assessment would incorporate activity measures like DAS 28, CDAI and SDAI which have been validated in clinical research (2). All these indices use 28 joint assessment method. These measures use different aspects of disease activity including swollen joint count, tender joint count, patient global scores and physician global assessment scores and inflammatory markers are included in some of the measures. We conducted a small study to compare these outcome measures in patients with moderate RA (per DAS criteria) who were recruited for disease activity assessment through MSK ultrasound.

Methods

Of the 30 biologic naive patients recruited, 27 were included in this study. Patients with moderate disease activity (per DAS criteria) were recruited for MSK ultrasound evaluation by a single rheumatologist. Patients with a diagnosis of fibromyalgia were excluded. These patients had been reviewed by two assessors prior to USS assessment and disease activity measures updated. Patient data was collected through electronic patient records. Data was analysed through MS Excel.

Results

The median age was 63. There were 66% females and 34% male patients. Majority were sero positive for either RhF, Anti CCP or both (77%). Mean DAS-28 score was 4.4 and corresponding mean CDAI and SDAI scores were 22.8 and 23.5 respectively. Mean HAQ score 1.08 and median CRP was 8.6. The median composite EULAR OMERACT synovitis score was 9.18. The average physician global assessment score for disease activity before USS was 4.9/10 and it correlated well with decision to escalate treatment in 41% patients as a result of USS assessment.

Conclusion

With a small sample size, this project shows that simplified disease activity measures do not necessarily provide clear evidence of disease activity and are heavily influenced by patient reported outcome measures (tender joint count and global pain scores). CDAI scores can be slightly higher compared to DAS and SDAI scores for the similar patients. Physician assessment and ultrasound can provide robust evaluation of disease activity and help in decision-making. A multicentric study with a large simple size to evaluate these findings would be helpful. Judicious use of clinical evaluation and imaging can help in tailoring treatment according to patient’s clinical condition and can also save money.

Disclosure

H. Crawshaw: None. E. Gates: None. C. Acebes: None. M. Jamal: None.
E076 Incidence of adrenal insufficiency in patients with giant cell arteritis tapering glucocorticoids with the Norwich prednisolone regimen
Authors: Ducker Georgina , Mukhtyar Chetan B
Published: April 2024

Background/Aims

Glucocorticoids continue to be the main treatment for giant cell arteritis (GCA). It is widely recognised that treatment with oral glucocorticoids is associated with adverse events including adrenal insufficiency. Reports suggest the risk of adrenal insufficiency is dependent on the dose and the duration of therapy. The Norwich regimen has been devised to deliver prednisolone at a rate 1mg/kg of lean body mass tapering over 100 weeks. We report the incidence of adrenal insufficiency related to the Norwich regimen.

Methods

The Norwich regimen has been used in all patients diagnosed with GCA from 01/01/2012. A notes review of all patients diagnosed after that date was undertaken to look for evidence of adrenal insufficiency. We routinely check 9am cortisol when symptoms of adrenal insufficiency were reported. The 9am cortisol was recorded as normal, indeterminate, or low. Patients with a low 9am cortisol remained on long term prednisolone; no further test was required. Patients with an indeterminate result were referred for a short synacthen test (SST). If the results of the SST were normal patients were weaned off prednisolone, patients with an inadequate SST result remained on long term prednisolone.

Results

From 01/01/2012-31/05/2022 353 patients diagnosed with GCA were treated with the Norwich regimen. 9am cortisol was checked in 76 patients (21.5%). Of these, 34 patients (9.6%) had a normal result, 35 patients (9.9%) had an indeterminate result requiring SST. 7 patients (2.0%) had a low 9am cortisol. Of the 35 patients referred for SST: 27 patients (7.6%) had an adequate result, 8 patients (2.3%) had an inadequate result resulting in long term prednisolone.

Conclusion

We report the incidence of adrenal insufficiency in patients diagnosed with GCA, tapering prednisolone using the Norwich regimen. In total 15/353 (4.3%) patients developed adrenal insufficiency because of long-term glucocorticoid use.

Disclosure

G. Ducker: None. C.B. Mukhtyar: None.
Systematics and biogeography of a Sunda-Papuan snake lineage (Natricidae: Tropidonophis Jan 1863)
Authors: Roberts Jackson R , Kraus Fred , Allison Allen , Richards Stephen J , Iova Bulisa , Tjaturadi Burhan , Ruane Sara , Austin Christopher C
Published: April 2024

Sunda-Papuan keelback snakes (Serpentes: Natricidae: Tropidonophis Jan 1863) include 20 species distributed from the Philippines south-east through the Moluccas to New Guinea and Australia. Diversity of this insular snake lineage peaks on the island of New Guinea. Previous phylogenetic studies incorporating Tropidonophis have been limited to multi-locus Sanger-sequenced datasets with broad squamate or family-level focus. We used a targeted-sequence capture approach to sequence thousands of nuclear ultraconserved elements (UCEs) to construct the most comprehensive sequence-based phylogenetic hypothesis for this genus and estimate ancestral biogeography. Phylogenies indicate the genus is monophyletic given recent taxonomic reassignment of Rhabdophis spilogaster to Tropidonophis. All UCE phylogenies recovered a monophyletic Tropidonophis with reciprocally monophyletic Philippine and New Guinean clades. Divergence dating and ancestral range estimation suggest dispersal to New Guinea from the Philippines to have occurred during the Mid-Miocene via the Oceanic Arc Terranes. From Late Miocene into the Pliocene the genus experienced rapid diversification from orogeny of the New Guinean Central Cordillera from Oceanic Arc Terrane accretion on the northern boundary of the Sahul Shelf. Future collecting of missing taxa from the Moluccas and Indonesian Papua will better the understanding of non-volant faunal biogeography and diversification in this tectonically complex Pacific arena.
National, Regional, and Global Estimates of Preterm Birth in 2020, With Trends From 2010: A Systematic Analysis
Authors: Ohuma Eric O. , Moller Ann-Beth , Bradley Ellen , Chakwera Samuel , Hussain-Alkhateeb Laith , Lewin Alexandra , Okwaraji Yemisrach B. , Mahanani Wahyu Retno , Johansson Emily White , Lavin Tina , Fernandez Diana Estevez , Domínguez Giovanna Gatica , de Costa Ayesha , Cresswell Jenny A. , Krasevec Julia , Lawn Joy E. , Blencowe Hannah , Requejo Jennifer , Moran Allisyn C.
Published: April 2024

(Abstracted from Lancet 2023;402:1261–1271

Birth before 37 weeks of gestation is classified as preterm birth (PTB) and represents the highest contributor to neonatal mortality, including both short- and long-term effects. Adverse effects of PTB include higher risks of poor health, poor growth, intellectual or mental disability, early onset of chronic disease, and others.
Cell-Free DNA Screening for Trisomy 21 in Twin Pregnancy: A Large Multicenter Cohort Study
Authors: Dugoff Lorraine , Koelper Nathanael C. , Chasen Stephen T. , Russo Melissa L. , Roman Ashley S. , Limaye Meghana A. , Ranzini Angela C. , Clifford Caitlin M. , Biggio Joseph R. , Subramaniam Akila , Seasely Angela , Patil Avinash S. , Weed Samantha , Page Jessica M. , Nicholas Sara , Idler Jay , Rao Rashmi R. , Crowder Amber , Shree Raj , McLennan Graham , Bromley Bryann
Published: April 2024

(Abstracted from Am J Obstet Gynecol 2023;229:435.e1–435.e7

Cell-free DNA (cfDNA) screening is an effective way to identify trisomy 21 in singleton pregnancies and has been shown to have both a high detection rate and a low false-positive rate. For twin pregnancies, however, there are challenges relating to fetal fraction and the ability to obtain and distinguish fetal DNA.
Top Advances of the Year: Ovarian Cancer
Authors: Lumish Melissa A. , Kohn Elise C. , Tew William P.
Published: April 2024

(Abstracted from Cancer 2024;130:837–845

Although novel systemic therapies have prolonged survival in ovarian cancer, it remains the fifth leading cause of cancer-related death in women. In 2022, data showing an overall survival (OS) benefit from poly(ADP-ribose) polymerase (PARP) inhibitor (PARPi) were published after a 7-year follow-up period.
Apixaban Versus Vitamin K Antagonists in Patients With Antiphospholipid Syndrome: A Cohort Study
Authors: Sikorska Martyna , Chmiel Jakub , Papuga-Szela Elzbieta , Broniatowska Elzbieta , Undas Anetta
Published: April 2024

Current guidelines recommend that direct anticoagulants should not be used in prevention of recurrent thrombosis in patients with antiphospholipid syndrome (APS). However, except for triple-positive APS and rivaroxaban use, little evidence supports such recommendation. In a real-life cohort study, we evaluated the risk of thromboembolism and bleeding in patients with APS on apixaban versus vitamin K antagonists (VKA). We enrolled 152 patients with APS (aged 44 years [interquartile range 36–56], 83% women), including 66 patients treated with apixaban 5 mg bid and 86 with warfarin (target international normalized ratio [INR] 2–3). During a median follow-up of 53 months, we recorded venous thromboembolism, ischemic stroke, or myocardial infarction, along with major bleeding. We observed 4 thrombotic events (6.1%, 3 venous thromboembolism and 1 ischemic stroke) in patients on apixaban and 12 events (14%, 9 venous thromboembolism, 2 ischemic strokes and 1 myocardial infarction) in VKA patients. Patients with APS on apixaban had similar risk of recurrent thromboembolism compared with those on warfarin (hazard ratio [HR] = 0.327, 95% confidence interval [CI]: 0.104–1.035). Thromboembolic events occurred less commonly in statin users (8% vs. 50%, P = 0.01) and more frequently in triple-positive APS (50% vs. 22.1%, P = 0.028) and in patients with higher D-dimer at baseline (P = 0.023); the latter difference was present in the apixaban group (P = 0.02). Patients on apixaban had similar risk of major bleeding compared with warfarin (HR = 0.54, 95% CI: 0.201–1.448). In real-life patients with APS, apixaban appears to be similar to VKA for the prevention of thromboembolism and risk of bleeding, which might suggest that some patients with APS could be treated with apixaban.