bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract

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

Abstract

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 &gt; 3months in patients &lt;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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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.