Rheumatology Consultation Research Articles

E042 The Newcastle Giant Cell Arteritis (GCA) Fast Track Clinic: a clinical service evaluation

Abstract Background/Aims Patients with suspected new-onset giant cell arteritis (GCA) require urgent specialist assessment to establish a diagnosis. Early review reduces unnecessary treatment with high dose glucocorticoids in those without GCA and enhances sensitivity of temporal artery ultrasound. Ensuring patients are rapidly triaged and diagnosed poses a logistical challenge for rheumatology departments working alongside colleagues in both primary care and ophthalmology. To address this, we established a rheumatology-led Newcastle Hospital GCA fast track clinic, a service led by four consultant rheumatologists who perform clinical assessments and temporal artery ultrasound scans. Methods Data were collected prospectively from 2017. We performed a clinical service evaluation based on a retrospective review of clinical records of patients assessed in this service between 2017 to 2020. Results A total of 626 consecutive patients were assessed, with 145 (23%) diagnosed with GCA over the four-year period. Average age was 72 (range 41-96 years) and 452 (72%) were female. The cardinal symptoms of headache, jaw claudication and visual disturbance were present in 518, 103 and 283 patients respectively. The majority of referrals came from ophthalmology (42%) and primary care (34%). 614 patients had an ultrasound scan performed, returning a positive result in 121 (19.7%), negative in 415 (67.6%) and inconclusive in 78 (12.7%). A biopsy was requested for 147 patients over the four-year period; 33 were positive, 95 negative and six were inconclusive. Within this cohort, 47 patients had a biopsy performed despite a negative ultrasound scan, of which five were found to be positive for GCA. Conclusion Our data illustrate the key clinical, imaging and histological findings within one of the largest inception cohorts of GCA in the UK and demonstrate the feasibility of a one-stop rapid access clinical service for patient benefit. Disclosure C.M. Lin: None. J. Berry: None. B. Thompson: None. J. Heaney: None. K. Houghton: None. K. Baker: None. G. Reynolds: None. A. Lorenzi: None.

E048 A review of published data on reported staffing ratios for rheumatology specialist physiotherapists in rheumatology departments

Abstract Background/Aims The NHS England Getting It Right First Time (GIRFT) Rheumatology Report published in 2021 identified that Rheumatology departments in England were not getting best use of the multidisciplinary skills mix of their teams and that this expertise could be harnessed to address capacity challenges, optimise services and increase service resilience and sustainability. The British Society for Rheumatology (BSR) Workforce Report, published the same year, suggests that services require approximately one Rheumatology Consultant per 60,000-80,000 population and a one-to-one ratio of Rheumatology Specialist Nurses to Consultants. There were no suggestions in either report for Allied Health Professionals' staffing levels. Data presented in the BSR Report show that 50% of UK departments do not have a physiotherapist embedded in their multi-disciplinary team, and 7% of Trusts reported not having access to physiotherapy services. The aim of this project was to review published data on ratios of Rheumatology Specialist Physiotherapists per 100,000 population and to estimate current ratios of Rheumatology Specialist Physiotherapists per Consultant Rheumatologist in UK rheumatology services. Methods A literature review was undertaken, date range 2012-2022, on UK rheumatology staffing ratios for physiotherapists including full papers and abstracts. In addition, the BSR Workforce Report data on the average UK rheumatology department Whole Time Equivalent (WTE) staffing was used to calculate current average ratio of rheumatology physiotherapists to 100,000 population. Results Review of published literature identified one full paper and two conference abstracts. A cross-sectional study in 2017 found an average adjusted mean WTE of 0.3 per 100,000 population. The raw data from published conference abstracts on a repeated survey, in 2017 and 2021, of north-west England Rheumatology Specialist Physiotherapists was reviewed and calculated to show 0.34 and 0.32 WTE respectively for rheumatology physiotherapy per 100,000 population. Analysis of the BSR Workforce Report shows that the current UK average is 0.27 Rheumatology Specialist Physiotherapists per 100,000 population. These BSR data equate to 1 WTE Rheumatology Specialist Physiotherapist for every 5.25 WTE Rheumatology Consultants. Or for every full-time Rheumatologist, a requirement of approximately 1 day per week of rheumatology physiotherapy provision. The data from the three sets of survey data found on literature review, with an average of 0.32 WTE per 100,000 population, equate to 1 WTE rheumatology physiotherapist for every 4.5WTE rheumatology consultants. Conclusion Despite the established wide variation in staffing ratios with regard to multi-disciplinary teams in Rheumatology and a dearth of published information, the data that are available show a remarkable consistency in reported current Rheumatology Specialist Physiotherapist staffing ratios. These data are from surveys of current provision and do not replace evidence-based recommendations, which are still very much required as well as a standard for commissioning as part of an essential package in high-quality service provision. Disclosure W.J. Gregory: None.

OA41 Online MDT patient education for early inflammatory arthritis

Abstract Background/Aims Patient education in early inflammatory arthritis (EIA) promotes understanding and engagement with treatment, empowering patients to use self-management in their long-term health condition. It is embedded in national guidance and audit. Individual appointments are time consuming, and groups sessions became impossible during the COVID-19 pandemic. Our education sessions have evolved to a monthly online meeting which aims to be engaging, effective and time efficient. Methods Face-to-face group education afternoons were previously embedded into our early arthritis pathway. Presentations and opportunities for questions were given by a rheumatology consultant, nurse, physiotherapist, podiatrist and occupational therapist. Sessions lasted 2 hours and local charity representatives attended. Group education sessions completely stopped with the COVID-19 pandemic restrictions. This successful MDT model was moved to a monthly Microsoft Teams meeting and condensed to 1 hour. Sessions continue to consist of five short presentations, introduction to charity representatives and opportunity for questions. Following the session, all patients received links to videos of the talks for future reference, contact details for the MDT and local charities, and a link to download our local rheumatology self management app. Patients who are unable to attend also receive this content by email. Patient feedback was gathered through an online questionnaire. Results Attendance has increased over time with 75% of our new EIA patients now attending each month. Feedback from 16 patients rated 75% of all talks as extremely useful or useful. 89% are interested in attending future meetings. 93% had already used or plan to use our rheumatology self management app. Positive patient feedback included: “the whole team were brilliant giving advice and answering questions”, “nice to see the specialists' faces, and to get the feeling they really cared”, and “a perfectly sensible and productive way to introduce all the options for help and support”. Some patients did not feel confident to ask questions in the meeting. Email and telephone advice lines were signposted. Attendance was increased by 40% by a short telephone reminder of the appointment. Conclusion An online meeting has proven to be a time efficient and effective way of providing multidisciplinary education and introducing self management. A short time investment from each MDT member gives breadth to the education. Inviting all newly diagnosed early arthritis patients and encouraging attendance by a short telephone call has maximised reach. Ensuring all patients are sent presentation videos to re-watch and the self referral details further facilitates self management. The format could easily be adapted to other patient education events. Disclosure C. Gwynne: None. S. Gilbard: None. Z. Weller: None. M. Clemence: None. C. Parsons: None. R. Penford: None.

P018 Non-alcoholic fatty liver disease in spondyloarthritis: identifying patients on therapy at high risk of serious liver disease

Abstract Background/Aims People with Spondyloarthritis (SpA), especially those with psoriatic disease (PsD) [psoriasis (PsO) and psoriatic arthritis (PsA)], are at higher risk of non-alcoholic fatty liver disease (NAFLD) due to increased prevalence of metabolic syndrome, obesity, hypertension, dyslipidaemia and disease-specific factors such as duration/ severity of psoriasis. There is significant concern that both synthetic and biological DMARDs (including methotrexate) may worsen liver function in PsD patients with NAFLD. The Leeds Teaching Hospitals Trust (LTHT) NAFLD pathway uses three screening tools (ELF, FIB-4 and fibroscanning) to identify those needing further investigation/ treatment by hepatology. However, the pathway is not validated in PsD. Our aim was to survey the prevalence of liver disease in our PsD population and explore the performance of our hepatology referral pathway. Methods We audited consecutive patients referred from the Leeds Specialist SpA service at LTHT with persistently abnormal ALT, whom the consultant Rheumatologist felt required Hepatology referral for suspected NAFLD. Data collected were: age, sex, BMI, history of diabetes, ALT, AST, platelets, albumin, hepatitis B and C, ELF score, FIB-4 score, fibroscan score, abdominal ultrasound, liver biopsy result and final hepatology diagnosis (NAFLD, fibrosis/cirrhosis or other). Results 72 patients were included; 84.2% had PsD (61/72), and 15.8% (11/62) had ‘Other’ forms of SpA (including axial spondyloarthritis, enteropathic arthritis, etc). Baseline characteristics, drug treatment and liver biochemistry/virology were similar between PsD and Other arthritis groups (Table 1) except for age which was lower in the Other. The average ELF scores were similar between PsD and Other, however FIB-4 scores were higher in PsD, and was associated with higher rates of fibrosis/cirrhosis (Table 1). FIB-4 >1.3, but not ELF>9.5, was statistically significantly associated with a high fibroscan score (p = 0.038 and p = 0.443 respectively). Conclusion PsD patients had higher rates of significant fibrosis/cirrhosis compared with patients with Other SpAs. FIB-4 was better than ELF for identifying which PsD patients required fibroscan and further investigation to exclude significant fibrosis/ cirrhosis. These findings will now be validated in a larger prospective study. Disclosure S.R. Harrison: None. U. Nandasoma: None. R. Parker: None. C. Chimakurthi: None. P. Laws: None. A. Barr: None. C. Vandevelde: None. H. Marzo-Ortega: None. J. Freeston: None.

P032 Starting work as a rheumatology doctor: how to do it well

Abstract Background/Aims Starting work in a specialty for the first time can be extremely challenging. This has implications for patient care, junior and supervising doctor enjoyment and future career choices. A focus group was established to explore what resources junior doctors would want when starting Rheumatology. This determined that a blended learning package with podcasts, webinars and eLearning with topics including history and examination skills, understanding investigations and prescribing disease modifying drugs (DMARDs) would be ideal. Furthermore, it would be well placed to include resources to help junior doctors consider a career in Rheumatology. Methods The focus group results were used to design online ‘how to’ resources guiding doctors through tasks that they might be expected to do as a Rheumatology doctor. These were created by teams of junior doctors alongside Consultant Rheumatologists with creative support from the British Society for Rheumatology (BSR) education team. Content was pitched at an introductory level to help doctors when they first start working in Rheumatology. The most appropriate delivery modalities were selected for each topic e.g. a podcast for ‘how to talk to patients about DMARDs’ and eLearning including a video for ‘how to do disease activity scoring’. The resources are hosted on the BSR eLearning site and are free for anyone to use (no membership required) https://www.rheumatology.org.uk click eLearning. BSR communications and twitter were used to advertise the launch of the ‘how to’ series prior to junior doctor rotations in August. Results Since the ‘how to’ eLearning site was launched there have been 258 users. All content has been accessed. To date the most popular topics have been ‘how to’ - Interpret antibodies-Use DMARDs safely-Interpret x-rays-Score disease activity Feedback has been extremely positive with an overall satisfaction of 4/5. An example of written feedback from a user “ … it was a good overview, I would recommend to new IMT doctors starting in departments, or those considering Rheumatology as a career, I like how you have incorporated different modalities for learning e.g. mixture of lectures, podcasts, reading.” Conclusion The response to the resources created so far have been extremely positive. 258 users is a good start but increasing awareness of the resources should allow many more doctors to benefit from these resources. The authors plan to develop and improve content and welcome any feedback or suggestions for future topics. Disclosure R. Benson: None. E. Appleby: None. C. Gledhill-Flynn: None. K. Maxey: Other; Kate is a member of the Education team at the British Society for Rheumatology. D. Southam: Other; Daisy is employed by the British Society for Rheumatology as Head of Education. J. Little: None. P.A. Watson: Other; I am employed by the British Society for Rheumatology as eLernaing Editor.

E052 Implementation of a disease modifying anti-rheumatic drug blood monitoring software: 8 years of experience in a single centre

Abstract Background/Aims Who is responsible for the blood monitoring of disease modifying anti-rheumatic drugs (DMARDs)? It may be Primary Care, Specialist Rheumatology teams or a combination. In Greater Manchester, it was deemed good practice to initiate ‘amber’ conventional synthetic DMARDs (cs-DMARDs) by Rheumatology and then transfer to Primary Care under shared care after 3 months or when blood monitoring was stable. ‘Red’ drug prescribing and monitoring for targeted synthetic DMARDs (ts-DMARDs) and biologics (b-DMARDs) would remain under Specialist care long-term. In 2013, the process began for the Rheumatology team at Bolton to take on the ‘in house’ initiation of cs-DMARDs and the implementation of formal shared care. It would not be possible to manage this with paper slips of pathology results and shared care booklets, as the workload and safety implications would be un-manageable for our small team. The Rheumatology department purchased blood monitoring software, allowing only abnormal results or concerning trends to filter through. The implementation of this new way of working required collaborative working with the Informatics, Laboratory, Software and Rheumatology teams, as well as Primary care. At the time, the likely numbers of patients monitored and the workload of abnormal results/trends was unknown. Here we share our experience of software-based rheumatology DMARD monitoring in a district general hospital setting, serving a population of nearly 300 000. Methods Roles and responsibilities were allocated across the multidisciplinary, administration/clerical and informatics teams. A workflow and weekly timetable of activity and cross cover for leave was implemented. Two ‘super-users’ (AP/LB) undertook the initial testing of the software with informatics support (DE) and still work closely to address any data flow issues, software updates and testing related to emerging DMARDs. The patient cohort included those starting ‘amber’ DMARDs (to the point of shared care), stabilization following a dose increase and those remaining on specialist only ‘red’ DMARDs. Since 2019, a monthly monitoring report has allowed a more detailed documentation of workload. Results There were 518 patient licenses in use December 2019, 589 in 2020 and 635 in 2021. In the pre-pandemic year of 2019, 203 patients were newly registered or re-registered. Abnormal results and concerning trends were ‘flagged’ by the software for 719 patients. 263 shared care agreements were generated for monitored DMARDs. Conclusion This workload data relates to the use of software-based DMARD monitoring in a Rheumatology department, where patient flows relate to 1 whole time equivalent Rheumatology Consultant per 100 000 population. Centres considering taking on a similar form of DMARD monitoring can extrapolate this data for their population and patient flow to guide regarding staffing needs. Disclosure A. Paul: None. L. Bromilow: None. D. Eckersley: None.

P112 Patient Experience of Remote Healthcare during the Pandemic in Rheumatoid Arthritis and Adult Juvenile Idiopathic Arthritis

Abstract Background/Aims COVID-19 challenged traditional care models and necessitated introduction of remote consultations. We wanted to understand the experiences of people with rheumatoid arthritis (RA)/adult juvenile idiopathic arthritis (AJIA) on accessing healthcare remotely, and how well people understood their condition and treatment. Methods This collaborative work between the National Rheumatoid Arthritis Society (NRAS) and clinicians in Oxford led to the development of an electronic questionnaire that was disseminated in July 2021 for four weeks through e-newsletters and all NRAS social media platforms. Those living in the UK with RA and AJIA aged 18 and over were eligible. Analyses of data were performed in Microsoft Excel and IBM SPSSv28. Results We analysed 316 responses. There was a middle-aged (ages 46 to 54, 54.1%, n = 171), Caucasian (97.5%, n = 306), female (92.4%, n = 292) preponderance. Most had RA (93%, n = 294) followed by another inflammatory arthritis (4.1%, n = 13) and AJIA (2.8%, n = 9). The majority had their condition for >10 years (43.4%, n = 137) but some were diagnosed <12 months ago (3.2%, n = 10). Two thirds of participants (66.5%, n = 210) did not know their DAS28 score. Of the remaining third, the most commonly reported measure was moderate disease activity (12%, n = 38). Those with higher self-reported DAS28 scores were using analgesia more regularly (p < 0.01) but we found no difference in NSAID, DMARD or steroid use. Age did not influence steroid usage (p = 0.35), but those who had their condition for longer used more steroids and regular analgesia. Only 33.9% (n = 107) of responders felt their condition had been managed adequately in the pandemic, with more reporting poor status (40.8%, n = 129) rather than good (16.8%, n = 53). Those living in the South of England reported statistically better disease control than those from the North, despite having more virtual assessments (p = 0.02). Travelling and fear of Covid appeared more important than consultation skills. Just over a fifth (20.3%, n = 64) felt greater focus should be given to patient concerns. Of the 9.1% of patients (n = 29) with a new diagnosis made during the pandemic, 24.1% (n = 7) unable to book a GP appointment easily. Patients experienced a median symptom time of 4-10 weeks before consulting GPs. Once assessed, 31% (n = 9) were referred immediately while the median time was 4-8 weeks. We found 58.6% (n = 17) of patients received their diagnosis within their initial rheumatology consultation and 76.5% (n = 13) of these started a DMARD immediately. Conclusion Despite a greater emphasis on patient education and PROMs influencing clinical decision-making, it is staggering that two-thirds did not know their DAS28 score. Analgesia and steroid use were common in patients with well-established disease which remains a concern. Accessing appointments was a significant barrier to patients and delays in care were experienced at every step in the NHS management pathways. Remote consultations need greater emphasis on patient concerns. Disclosure R.S. Andev: Member of speakers’ bureau; RSA received speaker funds from Novartis. A. Bosworth: None. C. Jacklin: None. S. Dubey: None.

Prevalence Rate of Rheumatoid Arthritis among Patients Attending Rheumatology Consultation Clinic at Baquba Teaching Hospital

Background: Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that causes progressive and painful of multiple joints damage. Objective: To explore the prevalence of Rheumatoid arthritis (RA) among middle-aged and older of Iraqi patients attended the outpatients’ clinics. Patients and Methods: A prospective cross-sectional study was conducted from 1st February to 31st July 2022 at the rheumatology outpatient clinic at the Baquba teaching hospitals, Diyala province, Iraq. The eligible patients were interviewed using semi-structured questionnaires. Diagnosis of RA is based on clinical and serological parameters in accordance with criteria issued by American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) guideline. Descriptive, bivariate, and logistic regression analysis was performed. All statistical analyses were performed using SPSS 16.0 software. P-value < 0.05 was considered statistically significant. Results: A total of 417 patients with an average age of 55.05 (+10.31) (ranged 40-79 years) have been included in the study. More than half were females (57.8%), married (74.3%), unemployed (67.9%), and 41.0% doctor-diagnosed arthritis. The prevalence of RA in adults was 0.96% compared to 2.34% in doctor-diagnosed arthritis group (females 1.75% vs. males 0.59%, P= 0.011). Results of the multiple logistic regressions showed that older age (odds ratio (OR) = 1.100, 95% CI: 1.070 to 1.130) was associated significantly with "doctor-diagnosed arthritis" (p < 0.001). The female patients (OR = 4.928, 95% CI: 2.826 to 8.593), single or had no spouse (unmarried, widow, divorce) (OR = 5.076, 95% CI: 2.742 to 9.396) and had diabetes mellitus (DM) (OR = 7.251, 95% CI: 4.247 to 12.378) were associated significantly with "doctor-diagnosed arthritis" (p < 0.001). Conclusion: With aging, the Iraqi females who have no spouse and suffer from diabetes mellitus become more vulnerable to symptomatic arthritis.

Prevalence Rate of Rheumatoid Arthritis among Patients Attending Rheumatology Consultation Clinic at Baquba Teaching Hospital

Background: Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that causes progressive and painful of multiple joints damage. Objective: To explore the prevalence of Rheumatoid arthritis (RA) among middle-aged and older of Iraqi patients attended the outpatients’ clinics.
 Patients and Methods: A prospective cross-sectional study was conducted from 1st February to 31st July 2022 at the rheumatology outpatient clinic at the Baquba teaching hospitals, Diyala province, Iraq. The eligible patients were interviewed using semi-structured questionnaires. Diagnosis of RA is based on clinical and serological parameters in accordance with criteria issued by American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) guideline. Descriptive, bivariate, and logistic regression analysis was performed. All statistical analyses were performed using SPSS 16.0 software. P-value < 0.05 was considered statistically significant.
 Results: A total of 417 patients with an average age of 55.05 (+10.31) (ranged 40-79 years) have been included in the study. More than half were females (57.8%), married (74.3%), unemployed (67.9%), and 41.0% doctor-diagnosed arthritis. The prevalence of RA in adults was 0.96% compared to 2.34% in doctor-diagnosed arthritis group (females 1.75% vs. males 0.59%, P= 0.011). Results of the multiple logistic regressions showed that older age (odds ratio (OR) = 1.100, 95% CI: 1.070 to 1.130) was associated significantly with "doctor-diagnosed arthritis" (p < 0.001). The female patients (OR = 4.928, 95% CI: 2.826 to 8.593), single or had no spouse (unmarried, widow, divorce) (OR = 5.076, 95% CI: 2.742 to 9.396) and had diabetes mellitus (DM) (OR = 7.251, 95% CI: 4.247 to 12.378) were associated significantly with "doctor-diagnosed arthritis" (p < 0.001). Conclusion: With aging, the Iraqi females who have no spouse and suffer from diabetes mellitus become more vulnerable to symptomatic arthritis.

Acute zonal occult outer retinopathy misdiagnosed as giant cell arteritis: a challenging case

Background: Acute zonal occult outer retinopathy (AZOOR) is a rare autoimmune retinopathy that is challenging to diagnose and treat. It usually presents with subtle fundus changes and severe visual symptoms. Herein, we report a challenging case of AZOOR, emphasizing that multimodal imaging could be valuable in diagnosis and monitoring of treatment response.
 Case Presentation: A 53-year-old woman presented to the emergency department with a one-week history of subacute, severe, painless vision loss without photopsia in her right eye. Her best-corrected distance visual acuity was 20/800 in the right eye and 20/20 in the left eye. Slit-lamp examination findings were unremarkable, and intraocular pressure was normal in both eyes. Initially, fundus examination findings appeared normal; however, serum levels of inflammatory markers were elevated. Brain and orbital magnetic resonance imaging results were unremarkable. A relative afferent pupillary defect was present in subsequent follow-up examinations at the hospital. The patient initially received a diagnosis of posterior ischemic optic neuropathy secondary to occult giant cell arteritis, underwent steroid treatment, and was evaluated by rheumatology and neurology consultants. Both consultants concurred with the presumed diagnosis. Subsequent multimodal imaging in the ophthalmology clinic revealed a trizonal pattern of fundus autofluorescence. Corresponding to these areas, we noted a loss of the ellipsoid zone on optical coherence tomography, depression on multifocal electroretinogram, and scotoma on visual field testing. Accordingly, the diagnosis of AZOOR was made. The patient was referred back to the rheumatologist for initiation of steroid-sparing treatment, and methotrexate was administered. Five months after the initial presentation, the patient showed significant visual field improvement in both eyes.
 Conclusions: Eye care practitioners should consider AZOOR in the differential diagnosis of patients with subacute painless severe unilateral vision loss and unremarkable findings on fundus examination. Multimodal imaging could be valuable in diagnosis and monitoring of treatment response, as observed in the current case. Further studies with larger sample sizes are needed to confirm the value of multimodal imaging and the available management options for AZOOR.

Obsessive-compulsive disorder comorbid with rheumatoid arthritis: case report and review of literature

IntroductionObsessive-compulsive disorders are complex pathologies causing a major psychosocial handicap. However, their association with a disabling somatic pathology such as rheumatoid arthritis makes management more difficult.ObjectivesTo investigate through a case analysis and a review of literature the association between obsessive-compulsive disorder (OCD) and rheumatological disorders.MethodsWe reported a case of a woman with a long history of obsessive compulsive disorder who presented rheumatoid arthritis and we conducted a review of literature through search on Pub-Med/MEDLINE following the terms “obsessive-compulsive disorder”, “rheumatoid arthritis”, “association”, “inflammation”.ResultsCase presentation: A 62-years old woman who had been followed at the psychiatric consultation for 20 years for OCD. She had been stabilised on clomipramin at a dose of 100 mg per day until 2012 and since then she had been lost to follow-up with the notion of poor compliance with the treatment. She re-consulted in August 2022 for worsening psychiatric symptoms such as phobic obsessions with delusional beliefs, verification compulsions, sleep disorders and multiple somatic complaints including diffuse arthralgia and chronic arthritis evolving for 6 months.The patient was put on risperidone 2mg with anxiolytic without improvement. She was referred to the rheumatology consultation where the diagnosis of very active rheumatoid arthritis was retained, hence she was put on 20mg of prednisolone per day with methotrexate.The evolution was marked by the accentuation of obsessions and compulsions with the appearance of depressive elements, hence the introduction of fluoxetine 40 mg per day, the increase in the dose of risperidone to 4 mg with the anxiolytic with an improvement on the somatic and psychiatric symptoms.ConclusionsLiterature had shown that patients with this OCD usually suffer from inflammatory or rheumatological comorbidities. This association could complicate the management of these patients.Disclosure of InterestNone Declared

The DETAIL questionnaire is a useful and effective tool to assess spondyloarthritis in patients with inflammatory bowel disease.

This study aimed to determine the effectiveness of adding a simple questionnaire related to musculoskeletal system to routine outpatient examination to detect undiagnosed axial and peripheral arthropathy in patients with inflammatory bowel disease (IBD). A musculoskeletal symptom questionnaire was given to all patients with IBD during their follow-up examinations between January 2020 and November 2021. The DETAIL questionnaire consisting of six questions about the musculoskeletal system was administered by asking the patients with IBD. All patients who answered yes to at least one of these questions were directed to specialists in the rheumatology department to undergo a detailed examination. The patients who were diagnosed with rheumatological disease after further investigation were recorded. Patients with a known diagnosis of rheumatological disease were excluded from the study. There were 333 patients with IBD included in the study. Of these patients, 41 (12.3%) had a previously diagnosed rheumatological disease and were excluded from the evaluation. Of the remaining 292 patients (147 with ulcerative colitis, 139 with Crohn's disease and six with indeterminate colitis; mean age 42 years), 67 (23%) answered yes to at least one of the questions and were referred to a rheumatology consultation. Rheumatological examination was completed in 52 patients. As a result of the evaluations, 24 patients (8.2%) were diagnosed with enteropathic arthritis (14 axial, 9 peripheral, and 1 axial plus peripheral). Patients with newly diagnosed enteropathy had a lower median disease age than patients without enteropathy. The DETAIL questionnaire is an effective and easy tool for identifying missed cases of SpA in patients with IBD.

Knee pain as a reason for referral to a paediatric rheumatologist: A retrospective study.

Knee pain is the most frequently reported type of lower extremity pain among children and adolescents. The objective of this study was to establish the features distinguishing inflammatory knee pain from non-inflammatory knee pain and to determine the specific variables to consider in suspected juvenile idiopathic arthritis (JIA). A retrospective chart review was performed among children with knee pain evaluated through paediatric rheumatology consultations at a single centre between 2012 and 2019. Among the 262 children, 32 patients (12.2%) were diagnosed with JIA, 46 patients (17.6%) presented with inflammatory knee pain (IP) of an origin different than JIA, and 57 patients (21.7%) with non-inflammatory knee pain (NIP). In 127 cases (48.5%), no musculoskeletal disorder was diagnosed (NDD). The presence of limping, joint swelling, decreased passive range of motion and decreased active range of motion of the knee joint were registered more frequently in the JIA group compared to the other three groups. Multivariate analysis showed that a family history of autoimmune diseases and pain in other joints were associated with inflammatory pain. Increased pain after physical activity, pain only in the knee joint and absence of limping were predictors of NIP. The risk factors of JIA were limping and an erythrocyte sedimentation range of ≥10 mm after an hour. In the NDD group, the risk factors included no increase in pain after physical activity, serum C-reactive protein level < 5mg/L and normal musculoskeletal ultrasound image. The majority of children with knee pain referred to a paediatric rheumatologist do not have arthritis. Knee pain alone, as a chief complaint, rarely leads to a final JIA diagnosis. Further studies are necessary in order to design the appropriate diagnostic and therapeutic algorithms.

Pregnancy Outcumes and Contraceptive Use in Women with Rheumatoid Arthritis: A Comparative Study

Background. Rheumatoid arthritis (RA) is a common chronic autoimmune disorder that has a female predominance and commonly affects women of childbearing age. It is shown to remit during pregnancy in most studies and improve in about half of the patients when assessed with objective disease activity measures.Objective — to assess the pregnancy outcomes in women with RA prior and after the diagnosis and compare them with those in women with no chronic illness, to evaluate contraceptive practices and contraceptive method efficacy with the use of concomitant rheumatic medications (methotrexate, leflunomide).Patients and Methods. Female patients diagnosed with RA according to ACR/EULAR 2010 classification criteria were compared with apparently healthy female controls matching in age in this case-control study. Data were collected by questionnaires and interviews. The questionnaires included demographic data and pregnancy outcomes, mode of delivery, contraceptive methods used by patients against the background of methotrexate and leflunomide therapy.Results and discussion. One hundred patients with RA were included. The mean age of the patients and controls was 38.4±5.1 and 36.7±4.5 years, respectively. The live births significantly decreased in female patients with RA compared to the controls and the period before the diagnosis (p=0.01, p=0.002, respectively). Caesarean section frequency was higher in the control group compared to patients with RA (p=0.001). But in patients with RA, frequency of caesarean section increased after the diagnosis (p=0.021). Frequency of unplanned pregnancy significantly decreased after the diagnosis of RA compared to the period before the diagnosis (p&lt;0.001). About 75.4% of patients had the desired number of children in their family before the diagnosis, and 24.6% feared the effect of RA on themselves and their children. 81% of 100 women with RA used methotrexate, 43.2% of them received rheumatological consultation regarding the contraceptive methods, and 56.8% did not. 30.86% of patients treated with methotrexate used ineffective contraceptive methods, 27.16% — long-acting reversible methods, 14.81% — effective contraceptive methods, and 24.69% did not use any contraceptive methods. 19% of RA patients used leflunomide, and 73.7% of them received rheumatological consultation regarding the type of contraceptive methods, 36.84% used effective methods of contraception, 31.58% — long-acting reversible methods, 15.79% — ineffective contraceptive methods and 15.79% did not use any contraceptive methods.Conclusion. There is a decrease in live births and an increase in preterm birth frequency as well as caesarean sections in Iraqi female patients with RA. There is lack of knowledge about the importance of contraceptive methods efficacy in relation to teratogenic medications (methotrexate, and leflunomide).

Epidemiology of rheumatic diseases: a cohort of 23,550 patients in rheumatology clinics in Burkina Faso.

The aim of this work is to study the epidemiological characteristics of rheumatic conditions in a cohort of 23,550 patients followed up in Ouagadougou, Burkina Faso. This was a descriptive observational study on records conducted from February 2006 to December 2019 in Ouagadougou (Burkina Faso). All patients seen in rheumatology consultation in the city of Ouagadougou were included. The diagnosis of mechanical and degenerative osteoarthropathies was based on clinical and radiological findings; osteoarticular infection was based on clinical and biological findings. The diagnosis of gout was based on the clinical findings, uricemia, and/or the presence of sodium urate crystals in the synovial fluid on microscope. The diagnosis of rheumatoid arthritis and systemic lupus erythematosus was based on the ACR/EULAR criteria. In total, 23,550 patients were included in the study. These were 14,995 female patients (63.70%) and 2555 male patients (36.30%). The average age of patients was 49.61 ± 15.36years with extremes of 9months to 120years. Degenerative osteoarthropathies were the most common presentation (13,377 patients; 59.35%) followed by tendinopathies (2199 patients; 9.34%); chronic inflammatory rheumatism was in third place (841 patients; 3.57%) led by rheumatoid arthritis (434 patients); 51.61% of chronic inflammatory rheumatism, systemic lupus erythematosus and ankylosing spondylitis accounted for 71 patients (0.4%) and 63 patients (0.27%), respectively. The epidemiology of rheumatic conditions is characterized by its diversity in hospital setting. The scarcity of some conditions such as systemic lupus erythematosus, psoriatic arthritis, and ankylosing spondylitis has been confirmed in this cohort. Key Points • Twenty-three thousand five hundred and fifty patients were included in the study • Rheumatoid arthritis was the most frequent (51.61%) chronic inflammatory rheumatism • Contrary to studies from Europe and America, systemic lupus seems rare in our series.

Uyi Ima-Edomwonyi: building rheumatology capacity in Nigeria.

Practicing rheumatology in Nigeria means thinking about a lot more than rheumatology. “You cannot just make a clinical diagnosis and expect that to be the end of the story”, explains Uyi Ima-Edomwonyi, consultant rheumatologist at Lagos University Teaching Hospital in the southwest of Nigeria. “You have to factor in social dynamics and the patient's economic status”, he continues. “There are a series of diagnoses. Are the drugs you wish to prescribe available? If they are available, can the patient afford them? If not, what can be done instead? Always ask yourself ‘am I telling my patient to do something unreasonable?’”

Scleritis as the harbinger of Granulomatosis with polyangiitis.

Ocular and orbital involvement in Granulomatosis with polyangiitis (GPA) is common. GPA can lead to life and sight threatening complications due to necrosis and tissue melting. We report four cases presenting with ocular pain and redness for varied durations. One had diminution of vision. All of them had deep sectoral/diffuse congestion with one having scleral thinning. All were diagnosed with anterior necrotizing/non-necrotizing scleritis. One had associated penetrating ulcerative keratitis. Topical steroids and systemic non-steroidal anti-inflammatory drugs were started in all cases and rheumatology consultation was taken. Pertinent investigations were sent, and GPA was diagnosed. Intravenous immunosuppressive regimens and oral steroid were started and significant improvements were seen, preventing untoward complications. Scleritis could be manifesting feature of GPA so cautious history taking and evaluation is important. Management often requires multidisciplinary care and ocular features could be the reference guidelines to adjust dose of systemic medications of GPA.

Rheumatology expertise in advising immunocompromised healthcare workers: Insights from a survey of Australian rheumatologists.

Healthcare workers (HCW) with an inflammatory disease may be at increased risk of infections and their complications, however there is no evidence to guide specific measures to reduce the risk of immunocompromised HCW acquiring infection in the workplace. This cross-sectional study aimed to define the attitudes of rheumatologists and rheumatology trainees towards counselling immunocompromised healthcare workers about additional workplace precautions to minimise workplace risk of infection. A cross-sectional survey was administered via Zoom poll during a webinar held in August 2020. Participants were Victorian and Tasmanian members of the Australian Rheumatology Association, which includes consultant rheumatologists and rheumatology trainees. Descriptive statistics were used to analyse survey responses. Of the 52 participants, 41 provided care to at least one immunocompromised healthcare worker. 21 out of 52 participants estimated that the majority of these patients sought their advice about infection risk in the workplace. The most common source of information for counselling patients on workplace infection risks were colleagues (38/50). Participants were most confident in providing information on influenza and hepatitis but less confident in providing information in tuberculosis, shingles and COVID-19. Most participants believed employers of immunocompromised HCW should play a role in providing advice on managing infection risks in the workplace. Our study reveals a level of uncertainty and discomfort amongst rheumatologists in providing recommendations to immunocompromised healthcare workers about managing their workplace risk of infection. We recommend the development of a framework to guide the clinician in making individualised recommendations for immunocompromised HCW.

Better Clinical Results in Rheumatoid Arthritis Patients Treated Under a Multidisciplinary Care Model When Compared with a National Rheumatoid Arthritis Registry.

To describe clinical characteristics and effectiveness of health care in patients with rheumatoid arthritis (RA) as part of a multidisciplinary care model (MCM) in a specialized rheumatology center, compared with the results of a national registry of RA (NARRA) as evidence of real-world management. We conducted a real-world study (July 1, 2018 to June 30, 2019) based on an analysis of electronic health records of a cohort of RA patients managed with the "Treat-to-Target" strategy in a specialized rheumatology center in Colombia with an MCM, compared with the NARRA that includes different models of usual care. We have analyzed 7053 subjects with RA treated at a specialized rheumatology center and 81,492 patients from the NARRA. Cohorts were similar in their baseline characteristics, with women in predominance and diagnosis age close to 50 years. At the time of diagnosis, a higher proportion of clinical diagnostic test use and rheumatology consultation access was observed in the specialized rheumatology center than in the national registry (4-6 per year versus three or less). In addition, higher proportions of patients in remission and low disease activity were reported for the specialized rheumatology center, with a >40% amount of data lost in the national registry. Pharmacological management was similar regarding the analgesic use. In the specialized center, Certolizumab was more frequently used than in the NARRA registry; also, there were significant differences in methotrexate, leflunomide, and sulfasalazine use, being higher in the specialized rheumatology center. The MCM of a specialized center in RA can guarantee comprehensive care, with better access to all the services required to manage the disease. It ensures specialist management and evidence-based care that facilitates the achievement of therapeutic objectives. In addition, better patient records and follow-ups are available to evaluate health outcomes.

Variation of Diagnostic Approaches and Treatment Practices for Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome Among Pediatric Subspecialists

To assess the diagnostic and treatment practices among a variety of subspecialists at pediatric institutions in the US. Using a web-based survey, we assessed the consultation, diagnostic, and treatment preferences of providers from the different pediatric subspecialties who care for pediatric patients with hemophagocytic lymphohistiocytosis (HLH)/macrophage activating syndrome (MAS). Domains included demographics, provider training level and specialty, experience and comfort level with the diagnosis and treatment of HLH/MAS, and institutional approaches toward the diagnosis and management of HLH/MAS. Participants also were given 2 case scenarios: one describing Epstein-Barr virus-associated HLH and another describing an underlying rheumatologic condition with MAS. Of 263 respondents, 23%, 29%, 39%, and 7% identified as hematology/oncology, rheumatology, general pediatrics/critical care/hospitalist, and allergy/immunology, respectively. For Epstein-Barr virus/HLH, hematology/oncology was the preferred first consultant by most respondents other than rheumatologists, of whom only 47% agreed. For MAS, 92% of respondents from all specialties favored a rheumatology consultation. Preferred diagnostic tests varied by subspecialty, with hematology/oncology more likely than rheumatology to order an infectious workup, natural killercell function, soluble interleukin-2receptor, bone marrow biopsy, and genetic testing. First-line therapy also varied, with hematology/oncology preferring dexamethasone and etoposide and rheumatology more often preferring methylprednisolone and anakinra. One-half of respondents were unaware of institutional algorithms for diagnosis and treatment of HLH/MAS. Most (85.6%) favored the development of treatment algorithms for HLH/MAS, and 90% supported a multidisciplinary approach. Current consulting patterns, diagnostic workup, and treatment approaches of HLH/MAS vary by specialty, highlighting the need for standardized management algorithms and institutional multidisciplinary HLH/MAS teams.