bluuebunny/crossref_metadata_2025_split huggingface dataset:
P118 Drive-through phlebotomy - is this the future?
Authors: Begum Julie , Nisar Muhammad K 
Published: April 2022

Abstract

Background/Aims
Centralised phlebotomy services have been an integral part of providing blood monitoring facility for people with chronic diseases prescribed vital therapies. However, the patient experience is not always optimal due to the issues of congestion, parking, long waiting times; this has been accentuated during COVID-19 pandemic with the need for minimising physical contact. In response to the growing pressure on phlebotomy service at our institution enhanced by the COVID-19 pandemic, our rheumatology service implemented a drive-through phlebotomy clinic to provide the option for patients and families to stay in their vehicles whilst having venepuncture.

Methods
At our large university teaching hospital, we set up a drive-through phlebotomy service provided by a senior HCA supervised by the lead nurse. Patients were identified from the departmental database and were offered the facility via telephone. Eligibility was assessed using a standardised proforma focusing on logistics such as ability to drive and access to a mobile phone. Appointments were scheduled in advance with patients choosing this care option. All the data was prospectively collated with patients’ consent and anonymised for analysis. In addition to demographics, diagnosis and drug record, duration of visit and patient feedback was collected.

Results
112 patients were offered the service during a 12-week pilot. Mean age of the participants was 49.5 yrs (19-91) with 73 (65%) women. 74 (65%) were of Caucasian and 28 (25%) of Asian origin. 94 (84%) had inflammatory arthritides and all were prescribed DMARDs and/or bone active agents. 69 (61%) had blood samples taken using this service. Most common reason to decline was an already arranged appointment with standard phlebotomy (n = 14, 12.5%). Six (5%) could not be bled due to difficult venepuncture. Mean duration of appointment was 12.5 mins (5-60). 68 (60%) provided feedback with 61 (90%) rating 5/5 and 60 (89%) rating it better than standard phlebotomy. All would like to have the option for future and 67 (98%) were highly likely or likely to recommend the service to family and relatives.

Conclusion
To our knowledge, this is the first study to demonstrate the utility of drive-through phlebotomy for people with rheumatic diseases prescribed DMARDs. Excellent feedback of the participants confirms the need and desire for such innovation in health care. In post COVID-19 services reconfiguration, the availability of drive-through appointments and the close physical proximity to the clinic made it an appealing option for a vulnerable group of patients evidenced by their outstanding experience and feedback. Overall, an HCA-delivered, nurse-supervised drive-through pathway is highly effective, safe and provides an innovative solution to strained phlebotomy services.

Disclosure
J. Begum: None. M.K. Nisar: None.
P132 Does weight-bearing physical activity track through the lifecourse? Findings from the Hertfordshire Cohort Study
Authors: Zhang Jean , Jameson Karen , Westbury Leo , Fuggle Nicholas , Ward Kate , Cooper Cyrus , Dennison Elaine 
Published: April 2022

Abstract

Background/Aims
Physical activity is known to be beneficial for musculoskeletal health across the lifecourse. We have previously demonstrated that regular participation in weight-bearing physical activity (WBPA) at the time of peak bone mass acquisition is associated with higher hip bone mineral density in late adulthood in women. Understanding how WBPA tracks across the lifecourse may help us develop interventions to promote WBPA for musculoskeletal benefit; we consider these relationships here.

Methods
The study population consisted of 128 men and 130 women from the Hertfordshire Cohort Study. Questionnaire data on participation in sports and leisure time exercise involving WBPA e.g. running, racquet sports, football, rugby, hockey and dancing, but not walking, cycling or swimming were collected for the following age bands: &lt;18 years; ages 18-29 years; ages 30-49 years; and ≥50 years. Responses were coded as none/ once a month/ once a week/ ≥once a week. Data on current lifestyle and physical activity levels were also collected.

Results
The mean age of participants was 75.4 (SD 2.5) years in men and 75.7 (SD 2.6) years in women. Men tended to report higher levels of past WBPA throughout the lifecourse, with significant differences in WBPA up to the age of 18 years (p = 0.006) and 18-29 years (p &lt; 0.001). Table 1 shows kappa statistics of relationships between reported WBPA levels at different ages. These decreased over time, and while broadly similar, the tracking was generally stronger in women than men. For example, we observed that participants who were active at 30-49 years were more likely to remain active in late adulthood with kappa in men 0.393 (95%CI: 0.295-0.442) and kappa in women 0.492 (95% CI: 0.400-0.555).

Conclusion
WBPA decreased with advancing age in both sexes, though was generally higher in men than women in this retrospective cohort study. The correlation between WBPA at different stages of the lifecourse weakened as time between the measurements increased in both sexes. Our results highlight the need for further work to understand the drivers to encourage WBPA at different stages in the lifecourse and to facilitate development of appropriate interventions to promote WBPA for musculoskeletal benefit.

Disclosure
J. Zhang: None. K. Jameson: None. L. Westbury: None. N. Fuggle: None. K. Ward: None. C. Cooper: None. E. Dennison: None.
P152 A rare case of necrotising vasculitis presenting with calf swelling in a 15-year-old female
Authors: Earl Susannah C , Smith John-Paul , Ramanan Athimalaipet 
Published: April 2022

Abstract

Background/Aims
We present the case of MF, a 15-year-old female who presented to the paediatric clinic with swelling and pain affecting her right calf. She was previously fit and well.
Initial imaging was suggestive of localised myositis but a subsequent muscle biopsy was in keeping with necrotising vasculitis.

Methods
In May 2021, MF presented to a general paediatric clinic with a 6-week history of right lateral calf pain and swelling to the lateral border of the right proximal fibula. She was systemically well. Blood tests and an x-ray were normal. An ultrasound scan of the right calf showed fusiform thickening of the peroneus longus muscle proximally. There was no discrete mass. The appearance was thought to be an inflammatory process such as myositis. An MRI scan was advised. Over the course of the next few weeks, the swelling and pain to the right calf progressed and she was unable to fully weight bear. Repeat blood tests were normal except CRP 11. CK was normal. At the end of June, an MRI scan of the right lower leg showed significant swelling and oedema along the length of the peroneus longus musculature as demonstrated on ultrasound. Florid oedema extended to involve the soleus and to a lesser extent the lateral head of gastrocnemius. There was thickening and oedema through the subcutaneous fat circumferentially compared to the left side (see images). The appearances were thought to be consistent with myositis but an inflammatory malignancy could not be fully excluded and an opinion from the Birmingham team was recommended. The Birmingham MDT advised that malignancy was unlikely but a CT scan was recommended. The CT scan confirmed the MRI findings (see image).

Results
MF's symptoms progressed rapidly over a short period of time with diffuse swelling of the right lower limb with associated pain and numbness. She also developed purpuric lesions around the ankle (see photos). The CRP increased to 59 and then 123. CK remained normal. Local rheumatology opinion was sought once malignancy had been excluded. The initial impression was of a focal myositis but a muscle biopsy was requested urgently. IV steroids were administered followed by high dose oral prednisolone as a reducing course. The symptoms improved rapidly. The subsequent biopsy showed a florid necrotising vasculitis affecting the small-medium arterial vessels. There was no evidence of myositis (see image). ANCA was negative and CT renal and abdominal angiogram was normal. Nerve conduction studies showed a very severe sensory lesion of the right sural nerve, which explained the persistent numbness. Mycophenolate mofetil was added and clinical improvement is ongoing.

Conclusion
We present a rare case of localised vasculitis in the right calf. A literature review indicates this is the first case presented in an adolescent.

Disclosure
S.C. Earl: None. J. Smith: None. A. Ramanan: Grants/research support; Abbvie.
P157 Poverty and paediatric rheumatology
Authors: Crosby Laura 
Published: April 2022

Abstract

Background/Aims
30% of UK children live in poverty, which is associated with a multitude of long-lasting adverse outcomes. Healthcare workers have a vital role in addressing the psychosocial wellbeing of children, which extends to identifying children living in poverty and how this impacts upon their health. Navigating this is challenging. This project reviews the literature to present how poverty impacts child health, with particular reference to patients with juvenile idiopathic arthritis (JIA). Practical suggestions are outlined to signpost and support children and families in need.

Methods
Information was sought from resources such as the Royal College of Paediatricians, British society of Rheumatology and Child Poverty Action Group. Further literature was sought via sequential PubMed searches with relevant terms. This project provides a report, rather than systematic review, of the literature.

Results
Poverty disproportionately affects children with JIA from diagnosis to adulthood. A US study demonstrated that children living in deprived areas were significantly more likely to experience delays in presenting to a paediatric rheumatologist. In the UK poorer children are more likely to present via the emergency department, reflecting potential areas to improve the patient journey. Low socioeconomic status is a strong predictor of poor medication adherence and appliance poverty may prevent appropriate drug storage. Families that are experiencing in-work poverty may also be ‘time poor’, which could result in suboptimal appointment attendance and engagement. JIA places an additional financial stressor on families in poverty due to the cost of travel, parking, childcare and loss of income. Additionally, JIA may impact on the earning potential of young people themselves. JIA impacts school attendance and achievement and is associated with reduced employment. The impact of JIA on education is likely to be amplified for children living in poverty, which has a strong link with absenteeism. Children with JIA from low socioeconomic groups experience more severe disease outcomes and are more likely to have a poorer health reported quality life. Lower socioeconomic status in childhood is also associated with higher prevalence of chronic pain in both childhood and adulthood.

Conclusion
It is vital that we think beyond the investigations we order and drugs we prescribe, and consider social investigation and prescribing as part of our practice. An ‘Ask, Action, Advocate’ strategy is recommended. Evidence suggests that families welcome healthcare staff asking about financial difficulty during consultations. Professionals can take action by signposting families to the wealth of resources available to help meet basic needs, increase income, and provide social and emotional support. Advocating for the most vulnerable families by considering where your service could be improved for those in financial hardship is crucial. Professionals are encouraged to learn more, and share knowledge.

Disclosure
L. Crosby: None.
P159 The potential impact of whole-body MRI on the rheumatologists’ disease activity assessment and treatment plan for patients with juvenile idiopathic arthritis
Authors: Choida Varvara , Tattersall Rachel S , Manson Jessica J , Sen Debajit , Ciurtin Coziana , Hall-Craggs Margaret A 
Published: April 2022

Abstract

Background/Aims
To assess the potential for whole-body MRI (WBMRI) to modify rheumatologists’ impression of disease activity and treatment management in adolescent patients with JIA.

Methods
Two rheumatology consultants experienced in managing people with JIA reviewed anonymised clinical data from an opportunistic sample of 30 patients with JIA (aged 15-24), not under their care. The cohort were clinically assessed by a senior rheumatology fellow before undergoing a research WBMRI scan, reported for musculoskeletal inflammation by a radiologist blinded to clinical information. The clinical findings and patient-reported outcomes recorded on that visit, alongside the patients’ present and past treatments, imaging and laboratory results were included in the clinical summaries examined by each rheumatologist. They then independently rated their impression of disease activity (See Table 1) and documented their resulting treatment recommendations per patient, in a two-stage approach. The first stage data analysis did not include the WBMRI reports. In stage two, the rheumatologists re-rated disease activity and treatment suggestions in light of WBMRI findings. The responses without and with the WBMRI findings were compared for each consultant and between them.

Results
Disease activity ratings were changed after reviewing the WBMRI reports in 16/30 and 17/30 patients by the rheumatologist A and B respectively. The activity category (‘active’ to ‘inactive’ or vice versa) changed in 7/16 and 4/17 cases, respectively. The certainty in the activity status increased for both rating clinicians (from ‘likely’ to ‘definitely’ in the same category or from ‘not sure’ to any other category) in 7/16 and 11/17 cases, respectively, whilst decreased for both in two cases. Disease activity assessments and treatment recommendations with and without WBMRI, are summarised in Table 1. Inter-rater agreement without and with WBMRI regarding disease activity (active/inactive) was 84.00% and 82.1% respectively, and regarding the intention to change treatment (yes/no) was 63.3% and 83.3%, respectively.

Conclusion
WBMRI scan findings changed the rheumatologists’ impression or level of certainty regarding disease activity in about half the patients and treatment plan in about one-third. Therefore, a larger study involving a greater number of rheumatologists across the country, should be considered to validate these results.

Disclosure
V. Choida: None. R.S. Tattersall: None. J.J. Manson: None. D. Sen: None. C. Ciurtin: None. M.A. Hall-Craggs: None.
P162 Socio-economic status in patients with juvenile idiopathic arthritis in the United Kingdom
Authors: Tan Yvonne , Costello Ruth , Hyrich Kimme , Humphreys Jenny 
Published: April 2022

Abstract

Background/Aims
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory condition affecting children and young people (CYP) with onset &lt;16 years, and may be associated with long-term joint damage and disability if treatment is delayed. CYP with JIA from low socio-economic status (SES) have been shown to have poorer performance in school activities and self-reported functional assessments compared to those from higher SES groups, however SES association with incidence of JIA has rarely been explored. Therefore, this study aimed to investigate the association between socio-economic status and incident JIA in England.

Methods
CYP &lt;16 years with a first JIA diagnostic code were identified in the Clinical Practice Research Datalink (CPRD) between the years 2000 and 2018, using a pre-defined codelist and were validated through linkage to Hospital Episode Statistics. Age- and gender-matched controls were identified at a ratio of 4:1. SES was defined using quintiles of indices of multiple deprivation (IMD). Descriptive analyses compared baseline characteristics (age, gender, age of first JIA code, IMD, region) in cases and controls. Logistic regression investigated the association between IMD quintiles in JIA cases compared to controls, adjusting for baseline characteristics, and linear regression analysed the association between age at first JIA code and IMD quintile.

Results
There were 1649 cases and 4748 controls included in this study. Most cases (1048, 64%) were female with median (interquartile range (IQR)) age at first JIA code 8.49 (4.20-12.05) years. Amongst cases, males were older at first JIA code, median (IQR) 9.80 (6.09-12.68) years, compared to females 7.55 (3.45-11.70) years. In both cases and controls, the proportion of CYP was highest in the most deprived quintile (IMD 1), 375/1649 (22.7%) and 1108/4738 (23.4%) respectively, and proportions remained similar in the remaining quintiles. There was no association identified between IMD quintile and occurrence of JIA, the multivariable odds ratio (95% CI) comparing most and least deprived groups was 0.98 (0.83-1.17). However, amongst cases there was an association between older age at diagnosis and higher SES [ß(95%CI) 0.15 years (0.01-0.29)] such that CYP in the IMD 5 quintile (highest SES) were on average 8 months older at their first JIA code compared to CYP in IMD 1.

Conclusion
This study found CYP from higher socio-economic groups appeared to be diagnosed at an older age than those from the least deprived backgrounds. Factors such as later presentation to healthcare after disease onset, delays in referrals to specialist care, delays in diagnosis by specialist care or differences in population demographics across IMD quantiles may all contribute to the older age of diagnosis in high SES group. Further research is required to explore these factors.

Disclosure
Y. Tan: None. R. Costello: None. K. Hyrich: None. J. Humphreys: None.
P163 The cytokine horror: Kawasaki disease shock syndrome complicated with macrophage activation syndrome
Authors: Rajagopala Lavanya , Jagoda Jayathri , Gunatilaka Mahesh L 
Published: April 2022

Abstract

Background/Aims
Kawasaki disease (KD) is an acute febrile systemic vasculitis of unknown aetiology, affecting medium-sized vessels. It often occurs in children less than 5 years old. During the acute phase of the disease, less than 5% of children develop hypotension and shock. This severe form is called Kawasaki Disease Shock Syndrome (KDSS). Macrophage activation syndrome (MAS) is a heterogenous syndrome complex encompassing a broad spectrum of clinical features. MAS associated with KDSS is an extremely rare life threatening entity that warrants a high index of clinical suspicion, prompt and proper management.

Methods
We present our experience in the dilemmas and challenges faced in the diagnosis and management of KDSS complicated with MAS in a poor resource setting. It is our first experience of encountering MAS in KDSS.

Results
A 9-month-old baby with fever and a maculopapular rash involving palms and soles for 5 days duration was transferred from a peripheral hospital. A preliminary diagnosis of acute Kawasaki disease was made with the classical features that included the rash, cracked lips, pedal oedema, BCG scar inflammation, perianal excoriation and irritability. The fever did not settle following standard therapy that included three doses of intravenous immunoglobulins 2g/kg, aspirin and low dose dexamethasone. The child quickly began to decompensate. She developed cold clammy skin with hypotension on the 8th day of the illness. There was evidence of hepatosplenomegaly with transaminitis. 2D Echo revealed normal coronary vasculature without any dilatations or strictures. However, there was evidence of myocarditis supported by diffuse T inversions in the anterolateral leads and a highly positive troponin titre. Investigations revealed aa leucocytosis (22,100/dl), an abrupt drop in platelet count (350,000/dl to 80,000/dl), red blood cells, haemoglobin (11g/dl to 8g/dl) and erythrocyte sedimentation rate 95mm/hr to 50mm/hr. Hyperferritinemia, hypertriglyceridemia and hypofibrinogenemia supported the diagnosis of MAS. Blood culture was sterile. Initial bone marrow biopsy was inconclusive. High dose dexamethasone 10mg/m2/day and cyclosporine 2mg/kg/day was initiated. The circulatory collapse was managed with fluid boluses and a low dose adrenaline infusion. Subsequently there was dramatic clinical improvement and her cell counts and transaminases normalised on day 15.

Conclusion
We emphasise the importance of early recognition of refractory MAS in pediatric populations with rheumatic diseases and we suggest early initiation of cyclosporin as a rapid and effective treatment option in the poor resource settings where the ideal management with anakinra is beyond the realms of possibility.

Disclosure
L. Rajagopala: None. J. Jagoda: None. M.L. Gunatilaka: None.
P171 Reasons for stopping biologic and non-biologic disease-modifying treatments in children and young people managed by a tertiary paediatric rheumatology centre
Authors: Hartley Karen , Sen Ethan S 
Published: April 2022

Abstract

Background/Aims
The Paediatric Rheumatology Department at Newcastle upon Tyne Hospitals looks after children and young people (CYP) across the North East and Cumbria region. The centre treats around 220 patients (250 active prescriptions) using homecare services to deliver injectable medicines. These prescriptions are for five medicines: methotrexate, adalimumab, anakinra, tocilizumab and etanercept. This project aimed to analyse the reasons treatments were stopped and identify potentially-modifiable factors to optimise treatment.

Methods
Patients were identified from the departmental database. Cases were included if they stopped one of the 5 subcutaneous treatments during the period 1st July 2020 to 30th June 2021. Demographic details, the underlying diagnoses and reasons for stopping treatment were extracted from electronic patient records.

Results
During the 12-month period analysed, 109 prescriptions were stopped. This represented 104 unique patients (56% female). The commonest indications for treatment were juvenile idiopathic arthritis in 80% (87/109), idiopathic uveitis in 11% (12/109) and autoinflammatory diseases in 5.5% (6/109). The following treatments were stopped: methotrexate in 47 patients, adalimumab in 43, etanercept in 7, tocilizumab in 6 and anakinra in 6. The reasons for stopping prescriptions are shown in Table 1.
After excluding 17 cases whose prescriptions were taken over by another unit, 92 prescriptions were stopped for clinical reasons. Of these, 28% were stopped due to side effects. All 19 patients who suffered nausea or vomiting, and all 5 patients with abnormal liver function tests, were receiving methotrexate. The 2 patients who stopped treatment due to neutropenia were both receiving tocilizumab. Almost 23% (21/92) of prescriptions were stopped due to inefficacy. All cases were switched to another biologic drug.

Conclusion
A substantial proportion of subcutaneous disease-modifying treatments were stopped due to inefficacy or side effects. Stopping and switching treatments represents a period of uncertainty for CYP and their families, with potential impact on disease control and quality of life. Management could be improved by a stratified medicine approach, using biomarkers to predict patients at highest risk of side effects or most likely to respond to a particular treatment. This is a key aim of current research.

Disclosure
K. Hartley: None. E.S. Sen: None.