Non-inflammatory Causes Research Articles

OP01 MRI is of utility in the evaluation of disease activity in axial Spondyloarthritis- data from a tertiary rheumatology centre

Abstract Background Assessing disease activity in axial spondyloarthritis (axSpA) is challenging, with heavy reliance on patient reported outcome measures. These measures are subjective and can be influenced by non-inflammatory causes of symptoms, potentially resulting in inappropriate changes to therapy. Despite its unanimous use in the diagnosis of axSpA, the most recent EULAR/ASAS guidelines do not support the use of MRI to assess disease activity due to the lack of evidence and cost implications. However, it is often a pragmatic approach taken in clinical practice. Aims To assess current usage of MRI to assess disease activity in axSpA at Leeds Teaching Hospitals NHS Trust (LTHT), particularly in patients experiencing treatment non-response and how findings influence treatment decision making at the bedside. Methods As part of a larger service evaluations, MRIs of the whole spine and SIJ requested at LTHT between May 2020 and December 2023 to assess disease activity in patients with previously diagnosed axSpA nr-axSpA, r-axSpA or axial psoriatic spondyloarthritis [axPsA]) were identified. Clinical data was extracted from electronic health records and clinic letters. Results In total 237 MRI scans were performed on 231 patients. The average age was 47, 131 (55.3%) were male and 145 (60.3%) were HLA-B27 positive. 109 had a diagnosis of radiographic axSpA, 95 non-radiographic and 27 axial PsA. 167 were on a b/ts-dmard at time of MRI. Overall, 116 (48.9%) had inflammation in spine or SIJ and 137 (57.8%) had non-axSpA related pathology on MRI. Patients with active inflammation were more likely to have their treatment switched or escalated than those without (48% vs 18%). 12 patients were referred to spinal surgical services, 6 to the pain team and 1 to oncology services, based on the results of the MRI scan. Conclusions Findings on MRI to assess disease activity influences treatment decisions in a large proportion of patients. Further research into the utility and health economics of MRI to assess disease activity in routine clinical practice, particularly in those experiencing treatment non-response is urgently required.

Clinical, outcome and aetiological chacteristics of inflammatory optic neuropathies. A series of Algerian patients

Introduction. Inflammatory optic neuropathies (ION) are frequent neuro ophthalmological emergencies. They often pose an etiological problem. Objectives. To study the clinical, radiological, etiological and evolutionary particularities of ION in Algerian patients. Patients and methods. Retrospective study of 23 patients, followed over a period of 6 years (from January 2016 to January 2022). All non-inflammatory causes were excluded, as well as any patient whose etiology was multiple sclerosis. Results. The etiologies identified were seropositive neuromyelitis optica (10 patients), seronegative forms (6 patients), idiopathic forms (4 patients), Mogopathies (2 patients) and one form related to an optic nerve glioma. Radiologically, optic nerve lesions with contrast were found in 9 patients whose causes varied between neuromyelitis optica, mogopathy and idiopathic forms. Discussion. Neuromyelitis optica seems to be the most frequent etiology, which is consistent with the literature. The response to the various immunological treatments is variable and depends on the proposed treatment and the earliness of its initiation. Nevertheless, a few cases of blindness have been reported despite optimal management. Conclusion. The management and prognosis of these conditions depend on the aetiology and the early initiation of treatment. Neuromyelitis optica dominates the causes in our series. The lesions observed on MRI centred on the optic nerve and their extent constitute an additional argument, helping the etiological research.

Evaluating Factors Associated With Telehealth Appropriateness in Outpatient Rheumatoid Arthritis Encounters Using the Encounter Appropriateness Score for You (EASY).

Telehealth has been proposed as a safe and effective alternative to in-person care for rheumatoid arthritis (RA). The purpose of this study was to evaluate factors associated with telehealth appropriateness in outpatient RA encounters. A prospective cohort study (January 1, 2021, to August 31, 2021) was conducted using electronic health record data from outpatient RA encounters in a single academic rheumatology practice. Rheumatology providers rated the telehealth appropriateness of their own encounters using the Encounter Appropriateness Score for You (EASY) immediately following each encounter. Robust Poisson regression with generalized estimating equations modeling was used to evaluate the association of telehealth appropriateness with patient demographics, RA clinical characteristics, comorbid noninflammatory causes of joint pain, previous and current encounter characteristics, and provider characteristics. During the study period, 1823 outpatient encounters with 1177 unique patients with RA received an EASY score from 25 rheumatology providers. In the final multivariate model, factors associated with increased telehealth appropriateness included higher average provider preference for telehealth in prior encounters (relative risk [RR] 1.26, 95% CI 1.21-1.31), telehealth as the current encounter modality (RR 2.27, 95% CI 1.95-2.64), and increased patient age (RR 1.05, 95% CI 1.01-1.09). Factors associated with decreased telehealth appropriateness included moderate (RR 0.81, 95% CI 0.68-0.96) and high (RR 0.57, 95% CI 0.46-0.70) RA disease activity and if the previous encounters were conducted by telehealth (RR 0.83, 95% CI 0.73-0.95). In this study, telehealth appropriateness was most associated with provider preference, the current and previous encounter modality, and RA disease activity. Other factors like patient demographics, RA medications, and comorbid noninflammatory causes of joint pain were not associated with telehealth appropriateness.

E010 Impact of rheumatologist ultrasound clinic on the management of inflammatory arthritis at a tertiary centre rheumatology department

Abstract Background/Aims Musculoskeletal ultrasound plays an important role in the assessment and management of inflammatory arthritis, enabling early diagnosis and prompt initiation of disease modifying therapy, as well as escalation of therapy as part of a treat-to-target strategy. It can help clinicians distinguish between true joint inflammation and non-inflammatory causes of increased pain scores. We reviewed our weekly rheumatology ultrasound clinic service where patients are referred to aid in clinical decision making. The study aimed to evaluate the cohort of patients attending the rheumatology ultrasound clinic at University Hospitals of Leicester, a busy tertiary centre, serving a multi-ethnic population, and to assess the impact of this clinic on the management of inflammatory arthritis in these patients. Methods Data was collected retrospectively from the ultrasound clinic at University Hospitals of Leicester between June 2022 and June 2023. Outcome measures included: date of scan request, date of scan, underlying disease, C - reactive protein (CRP), anti-CCP level, presence of radiographic erosions, presence of active synovitis or erosions on ultrasound, other rheumatologic disease and how the ultrasound findings changed the patient’s management. Results The total number of patients attending the clinic during the study period was 91. Of these, 70% were female and 30% male. Over the study period, 11.8% of patients did not attend their appointment. At the time of referral, 68% of patients had a CRP<5, 91% had a negative anti-CCP and 83% had no radiographic erosions. Following the scan, 13% of the patients had active synovitis, and 10% received at least one steroid injection. Interestingly, 86% had no active inflammation and no indication to escalate their disease modifying drug. In our patient cohort, 16% had pre-existing fibromyalgia. In all appointments, the clinician performing the scan showed the ultrasound images to the patient and explained the findings. Conclusion This ultrasound clinic is a key part of the treat-to-target strategy for inflammatory arthritis, enabling escalation of disease modifying therapy where indicated. It allows ultrasound guided and marked injections to be given when needed and identifies patients with non-inflammatory causes of increased pain scores, preventing patients from receiving unnecessary immunosuppression. Disclosure A. Mohammed Murad: None. A. Jubber: None. A. Moorthy: None.

Critical review of diagnosis in rhinology and its therapeutical implications

Diagnosis in rhinology is currently based on the concept of inflammation (chronic rhinosinusitis [CRS]) or the clinical concept of chronic nasal dysfunction (CND). The complementarity between these two approaches can be discussed by a critical review of the literature structured by the analysis of the fundamental and diagnostic bases and the therapeutic implications linked to each. The concept of CRS is based on the anatomical continuity of the nasal and sinus respiratory mucosa and molecular biology data, seeking to analyze the mechanisms of chronic inflammation and to identify proteins and biomarkers involved in the different supposed endotypes of chronic inflammation of this mucosa. The concept of CND seeks to analyze medical, instrumental or surgical diagnostic and therapeutic strategies, taking account of both inflammatory and non-inflammatory causes impacting the anatomy or physiology of each of the three noses (olfactory, respiratory and sinus) that make up the mid-face sinonasal organ of evolution-development (Evo-Devo) theory. Thus, the concept of CRS offers an endotypic approach, based on biological characterization of mucosal inflammation, while the concept of CND offers a compartmentalized phenotypic and pathophysiological approach to sinonasal diseases. The joint contribution of these two concepts in characterizing nasal functional pathology could in future improve the medical service provided to patients.

Mimics of Autoimmune Encephalitis: Validation of the 2016 Clinical Autoimmune Encephalitis Criteria.

The clinical criteria for autoimmune encephalitis (AE) were proposed by Graus et al. in 2016. In this study, the AE criteria were validated in the real world, and common AE mimics were described. In addition, criteria for probable anti-LGI1 encephalitis were proposed and validated. In this retrospective cohort study, patients referred to our national referral center with suspicion of AE and specific neuroinflammatory disorders with similar clinical presentations were included from July 2016 to December 2019. Exclusion criteria were pure cerebellar or peripheral nerve system disorders. All patients were evaluated according to the AE criteria. In total, 239 patients were included (56% female; median age 42 years, range 1-85). AE was diagnosed in 104 patients (44%) and AE mimics in 109 patients (46%). The most common AE mimics and misdiagnoses were neuroinflammatory CNS disorders (26%), psychiatric disorders (19%), epilepsy with a noninflammatory cause (13%), CNS infections (7%), neurodegenerative diseases (7%), and CNS neoplasms (6%). Common confounding factors were mesiotemporal lesions on brain MRI (17%) and false-positive antibodies in serum (12%). Additional mesiotemporal features (involvement extralimbic structures, enhancement, diffusion restriction) were observed more frequently in AE mimics compared with AE (61% vs 24%; p = 0.005). AE criteria showed the following sensitivity and specificity: possible AE, 83% (95% CI 74-89) and 27% (95% CI 20-36); definite autoimmune limbic encephalitis (LE), 10% (95% CI 5-17) and 98% (95% CI 94-100); and probable anti-NMDAR encephalitis, 50% (95% CI 26-74) and 96% (95% CI 92-98), respectively. Specificity of the criteria for probable seronegative AE was 99% (95% CI 96-100). The newly proposed criteria for probable anti-LGI1 encephalitis showed a sensitivity of 66% (95% CI 47-81) and specificity of 96% (95% CI 93-98). AE mimics occur frequently. Common pitfalls in AE misdiagnosis are mesiotemporal lesions (predominantly with atypical features) and false-positive serum antibodies. As expected, the specificity of the criteria for possible AE is low because these criteria represent the minimal requirements for entry in the diagnostic algorithm for AE. Criteria for probable AE (-LGI1, -NMDAR, seronegative) and definite autoimmune LE are applicable for decisions on immunotherapy in early disease stage, as specificity is high.

Indications, techniques, and graft survival of mini and corneo-scleral tectonic keratoplasties: A retrospective single-center case series.

Tectonic keratoplasties (TK) are used to treat corneal and scleral perforations and to prevent the loss of the eye. In this study, we retrospectively analyzed indications, surgical procedures, and outcomes of eccentric mini and corneo-scleral tectonic keratoplasties with respect to anatomical survival and clear graft survival rates to identify risk factors for graft failure. This retrospective study includes 33 eccentric mini (graft diameter <6 mm) and/or corneo-scleral TK of 32 consecutive patients of a total of 41 TK carried out between 2005 and 2020 in the Eye Center, University of Freiburg, Germany, making up 0.7% of all keratoplasties performed during this period (n = 5557). Patient and graft specific data were extracted from medical files. Anatomical survival-defined as achieving integrity of the globe without further surgical interventions-and clear graft survival-defined as persisting graft clarity-were estimated using the Kaplan-Meier method. We also fitted Cox proportional hazard models to account for factors influencing anatomical and clear graft survival. Median duration of anatomical success was 72.5 months (95% confidence interval (CI) 18.1-infinite (inf.)) and median duration of clear graft survival was 29.6 months (95% CI 12.5-Inf.). The 1-year survival rate for anatomical survival was 67.6% (95% CI 52.2% - 87.6%) and for clear graft survival 66.4% (95% CI 50.5%- 87.1%). No enucleation was necessary during this time-period. Non-inflammatory primary causes (n = 14) presented a trend towards better anatomical survival rates (median remained above 0.75 during follow-up) compared to inflammatory primary causes (n = 19, median 18.1 months (95% CI 2.8 - inf.)) and longer clear graft survival (median 29.6 months (95% CI 12.5 - inf.) versus 13.1 months (95% CI 3.2 - inf.)). Corneo-scleral grafts (n = 18) compared to corneal grafts (n = 15) showed a trend towards better anatomical survival (more than 50% of eyes did not fail during follow-up period (95% CI 21.9-Inf. months) versus 18.1 months (95% CI 2.4-Inf.)) and clear graft survival (median 29.6 months (95% CI 12.6-Inf.) versus 6.2 months (95% CI 2.8-Inf.)). Old age (n = 11, 75.2 - 90.1 years) compared to young age (n = 11, 6.2 - 60.2 years) was the only hazard ratio (hazard ratio 0.04 (95% CI 0.002-0.8)) that reached the level of significance (p = 0.03). Eccentric TK is helpful in the successful treatment of a variety of severe eye diseases. Patients at young age, with pre-existing inflammatory conditions or corneal TK are at higher risk for anatomical failure as well as clear graft failure and therefore need to be monitored closely.

Pain in the joints and beyond; the challenge of rheumatoid arthritis.

Pain is a common and often debilitating symptom for people living with rheumatoid arthritis. Although pain is a generic feature of inflammation and often improves with successful treatment that targets inflammatory pathways, pain experience can persist. Emerging data suggest that the magnitude of pain relief might vary according to the therapeutic target of pharmacological intervention within the inflammatory cascade. Both inflammatory and non-inflammatory causes contribute to the pain experience, which depends on tissue origin, peripheral sensory mechanisms and their transmission, integration, and interpretation within the nervous system. Contemporary neuroimaging is transforming our understanding of these mechanisms and the role of sensory, emotional, and cognitive contributions to the experience of pain. This understanding paves the way for therapeutic approaches that recognise the existence of multiple, cognitively driven, supraspinal mechanisms for pain modulation and could complement pharmacological inflammation suppression. Such approaches include neuropsychological interventions that have the potential to modify human brain cortical structure and reduce suffering that is often associated with pain experience.

E084 Analysis of the Early Inflammatory Back Pain Clinic at the Royal National Hospital for Rheumatic Diseases

Abstract Background/Aims The Royal National Hospital for Rheumatic Diseases (RNHRD) has a long-standing history of excellence in the care and management of axial spondyloarthritis (axSpA). Research has shown that early diagnosis of axSpA is associated with health-related benefits. However, because diagnosis earlier in the disease trajectory can be clinically challenging, there is often a significant delay. New referrals of possible axSpA are reviewed in the early inflammatory back pain clinic, and this audit of the demographics and diagnoses of clinic attendees aims to follows-up the patients post clinical evaluation to assess the frequency of missed diagnoses. Methods Electronic medical records of 100 consecutive new referrals attending for back pain between 03/09/2015 and 27/07/2016 were retrospectively reviewed. The information abstracted included sex, age, smoking status, investigations, and diagnosis. Clinic letters and follow-up records at the Royal United Hospitals until July 2022 were reviewed. Results The average age of the patients was 37.4 years; 42% were male and 58% female. The diagnostic breakdown of the 100 patients is presented in Table 1. Of the 21 patients diagnosed with axSpA, 14 (66%) were human leukocyte antigen B27 (HLA-B27) +ve; compared to only 7 (8.8 %) of the 79 patients who did not have an axSpA diagnosis. The electronic records of these 7 HLA-B27+ve patients were reviewed in July 2022, and no indication of a subsequent axSpA diagnosis was found; notably, one patient subsequently developed enteropathic arthritis. Of the 71 HLA-B27-ve patients categorised as having a non-inflammatory cause of their symptoms, three were re-referred to the RNHRD, but none were diagnosed with axSpA. Conclusion We found no evidence of a subsequent diagnosis of axSpA in patients who did not have the disease diagnosed at the time of initial referral. This audit identified a small cohort of HLA-B27+ve patients without evidence of axSpA; a more in-depth analysis of this patient group is planned. Disclosure M. Cowan: None. R. Sengupta: None.

Effect of comorbid benign joint hypermobility and juvenile fibromyalgia syndromes on pediatric functional gastrointestinal disorders

ABSTRACT Objectives Musculoskeletal pain has a considerable frequency in pediatric outpatients. Benign joint hypermobility (BJHS) and juvenile fibromyalgia syndrome (JFMS) are non-inflammatory causes of musculoskeletal pain. In these syndromes, pain is often accompanied by various symptoms such as fatigue, sleep difficulties, mood disorders, cognitive dysfunction, dizziness, headaches, abdominal pain, irritable bowel syndrome, and restless legs syndrome. Functional dyspepsia, functional vomiting, functional abdominal pain, functional constipation, and irritable bowel syndrome all together are termed functional gastrointestinal (GI) disorders. We aimed to evaluate the functional gastrointestinal disorders association of BJHS and JFMS. Methods Patients aged 10–18 years who were diagnosed with functional GI disorder in the pediatric gastroenterology department were included in the study. The findings of BJHS and JFMS were evaluated by the pediatric rheumatology department. Scales for anxiety, somatization, and depression were administered by a child psychiatrist. COMPASS 31 scoring was used in autonomic dysfunction. Results The prevalence of JFMS and BJHS was 64% and 32%, respectively in children with a functional GI disorder. Retrosternal chest pain, dysphagia, early satiation, nausea, vomiting, and regurgitation were common in JFMS (p = 0.007; p = 0.005; p = 0.018; p = 0.002, p = 0.013; p = 0.014, respectively). Gastrointestinal symptoms did not differ with BJHS. One hundred six (88.3%) and 99 (82.5%) had orthostatic intolerance and reflex syncope, respectively. One hundred three (85.6%) had anxiety symptoms, 101 (84.2%) had somatization symptoms, and 102 (85%) had depression symptoms. Conclusions Functional GI disorders, JFMS, and BJHS are complex intertwined disorders influenced by emotional distress. Therefore, a multidisciplinary approach is necessary for the diagnosis and treatment process.

Spinal epidural arteriovenous fistula with nerve root enhancement mimicking myeloradiculitis: a case report

BackgroundGadolinium enhancement of spinal nerve roots on magnetic resonance imaging (MRI) has rarely been reported in spinal dural arteriovenous fistula (SDAVF). Nerve root enhancement and cerebrospinal fluid (CSF) pleocytosis can be deceptive and lead to a misdiagnosis of myeloradiculitis. We report a patient who was initially diagnosed with neurosarcoid myeloradiculitis due to spinal nerve root enhancement, mildly inflammatory cerebrospinal fluid, and pulmonary granulomas, who ultimately was found to have an extensive symptomatic SDAVF.Case presentationA 52-year-old woman presented with a longitudinally extensive spinal cord lesion with associated gadolinium enhancement of the cord and cauda equina nerve roots, and mild lymphocytic pleocytosis. Pulmonary lymph node biopsy revealed non-caseating granulomas and neurosarcoid myeloradiculitis was suspected. She had rapid and profound clinical deterioration after a single dose of steroids. Further work-up with spinal angiography revealed a thoracic SDAVF, which was surgically ligated leading to clinical improvement.ConclusionsThis case highlights an unexpected presentation of SDAVF with nerve root enhancement and concurrent pulmonary non-caseating granulomas, leading to an initial misdiagnosis with neurosarcoidosis. Nerve root enhancement has only rarely been described in cases of SDAVF; however, as this case highlights, it is an important consideration in the differential diagnosis of non-inflammatory causes of longitudinally extensive myeloradiculopathy with nerve root enhancement. This point is highly salient due to the importance of avoiding misdiagnosis of SDAVF, as interventions such as steroids or epidural injections used to treat inflammatory or infiltrative mimics may worsen symptoms in SDAVF. We review the presentation, diagnosis, and management of SDAVF as well as a proposed diagnostic approach to differentiating SDAVF from inflammatory myeloradiculitis.

Role of Procalcitonin and C-reactive Protein as Predictors of Sepsis and in Managing Sepsis in Postoperative Patients: A Systematic Review.

Systemic inflammatory response syndrome (SIRS) and sepsis are inflammatory responsesto infection or trauma, causing symptoms and adverse outcomes such as organ shutdown and death. Different scoring systems can help in the diagnosis of SIRS and sepsis. Several biomarkers such as C-reactive protein (CRP), procalcitonin (PCT), and white blood cells (WBCs) can serve as predictors of sepsis. Surgery, trauma, and burns are the non-inflammatory causes of SIRS and sepsis. In postoperative patients, both inflammatory and non-inflammatory causes of immune response may co-exist. The role of inflammatory biomarkers in identifying sepsis development, deciding to use antibiotics, and discharging patients needs further exploration and clarity. We searched medical databases such as PubMed/Medline, PMC, ScienceDirect, Cochrane Library, and Google Scholar for relevant medical literature. The identified papers were screened, eligibility criteria were applied, and 15 research papers were identified. The finalized papers explored the roles of CRP and PCT in postoperative patients. Both CRP and PCT are raised in a postoperative patient, and then, gradually, the levels decrease. However, in case of an infection, these levels continue to rise and signify an infection, which may progress to sepsis. The cut-off values can guide decision-making about when to start antibiotics and discharge the patient. PCT was found to be more reliable in identifying the infection and preventing the development of sepsis. Further research is needed to identify the exact cut-off values that can help in decision-making.

Identification of specific causes of myelopathy in a large cohort of patients initially diagnosed with transverse myelitis

Background and objectivesIdentifying the etiologic diagnosis in patients presenting with myelopathy is essential in order to guide appropriate treatment and follow-up. We set out to examine the etiologic diagnosis after comprehensive clinical evaluation and diagnostic work-up in a large cohort of patients referred to our specialized myelopathy clinic, and to explore the demographic profiles and symptomatic evolution of specific etiologic diagnoses. MethodsIn this retrospective study of patients referred to the Johns Hopkins Myelitis and Myelopathy Center between 2006 and 2021 for evaluation of “transverse myelitis”,the final etiologic diagnosis determined after comprehensive evaluation in each patient was reviewed and validated. Demographic characteristics and temporal profile of symptom evolution were recorded. ResultsOf 1193 included patients, 772 (65%) were determined to have an inflammatory myelopathy and 421 (35%) were determined to have a non-inflammatory myelopathy. Multiple sclerosis/clinically isolated syndrome (n = 221, 29%) and idiopathic myelitis (n = 149, 19%) were the most frequent inflammatory diagnoses, while spinal cord infarction (n = 197, 47%) and structural causes of myelopathy (n = 108, 26%) were the most frequent non-inflammatory diagnoses. Compared to patients with inflammatory myelopathies, patients with non-inflammatory myelopathies were more likely to be older, male and experience chronic symptom evolution (p < 0.001 for all). Hyperacute symptom evolution was most frequent in patients with spinal cord infarction (74%), while chronic symptom evolution was most frequent in patients with structural causes of myelopathy (81%), arteriovenous fistula or arteriovenous malformation (81%), myelopathy associated with rheumatologic disorder (71%), and sarcoidosis-associated myelopathy (61%). ConclusionsPatients initially diagnosed with “transverse myelitis” are eventually found to have a more specific inflammatory or even non-inflammatory cause, potentially resulting in inappropriate treatment and follow-up. Demographic characteristics and temporal profile of symptom evolution may help inform a differential diagnosis in these patients. Etiological diagnosis of myelopathies would provide better therapeutic decisions.

Difficult-to-Treat Rheumatoid Arthritis in Older Adults: Implications of Ageing for Managing Patients.

Difficult-to-treat rheumatoid arthritis is a heterogeneous term in which patients may present with difficulties in their management for different reasons. This can ultimately lead to patients being exposed to multiple treatments because of inefficacy (resulting from mechanisms intrinsic to rheumatoid arthritis or from non-inflammatory causes such as chronic pain syndrome or structural damage, among others), toxicity or adverse effects that may be linked to comorbidities. One particular group in which such characteristics may be more patent is older patients. Increasing life expectancy, an ageing population and the late onset of rheumatoid arthritis have led to an increased interest in the particularities of treating older patients. This may pose a challenge for physicians, as ageing has implications for optimal patient treatment owing to the potential presence of comorbidities, the risk of adverse events and perceptions of disease status by both physicians and patients. All of these factors may have implications for classifying and managing patients aged >65 years as difficult-to-treat rheumatoid arthritis, as these patients could be misclassified. This can occur when a significant proportion may still exhibit signs of active disease but not necessarily be difficult to treat because the treatment criterion has not been fulfilled. Alternatively, patients may be exposed to multiple biologic/targeted disease-modifying antirheumatic drugs because of contraindications and/or comorbid conditions. Treatment-to-target strategies and an adequate assessment of inflammatory rheumatoid arthritis activity in older patients should be undertaken, taking special care with associated comorbidities, polypharmacy and risk profiles. Such an approach can help to ensure appropriate treatment for older adults and avoid the misclassification of difficult-to-treat patients.

1594P Outcome, mortality and 30-day readmission of pericardial effusion in cancer patients

A pericardial effusion (PE) with various inflammatory and non-inflammatory causes can range from an incidental finding to a life-threatening emergency such as a cardiac tamponade. In the literature, little is known about the outcomes of PE in cancer patients. The study's primary objective was to assess whether intervention in PE affects in-hospital mortality and 30-days readmission among cancer patients. A retrospective study of a nationally representative cohort of hospital admissions was conducted from January 1, 2016, to December 31, 2019. Data was collected from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmissions Database. All adult patients ≥18 years admitted with primary diagnosis of pericardial effusion in cancer patients were included in the study. We used the International Classification of Diseases, 10th revision, diagnostic codes to identify variable. The type of cancer included in the study were Breast, Lung, pancreatic, bladder, renal, colorectal, lymphoma and acute leukemia. The patients were stratified as PE in cancer patients underwent intervention versus no intervention. A total of 37,430 index hospitalizations for PE in cancer patients were identified for the years 2016-2019 in the NRD with the 27,980 index hospitalizations for PE without intervention, and 9,450 index hospitalizations for PE with intervention. There was no difference in in-hospital mortality for PE with and without intervention (4.5% vs 4.4%; p 0.76). However, PE without intervention had a significantly higher 30-day readmission rate than PE with intervention (31% vs 4.2.0%; p <0.001). The PE with intervention group had higher multi-organ complications including cardiogenic shock (8.6% vs 5.5%; p-value <0.001), Acute Kidney Injury (AKI) (29% vs 24.0%; p-value <0.001), respiratory failure (25% vs 20%, p-value <0.001), pneumonia (15% vs 12.6%, p-value 0.004), atrial fibrillation (27% vs 23.8%, p-value<0.001). Survival rates were not different between patients who received intervention and those who did not, but 30-day readmission rates were significantly higher for patients who did not receive intervention. Cancer patients would benefit from PE intervention.

Sacroiliac joint beyond sacroiliitis-further insights and old concepts on magnetic resonance imaging.

The sacroiliac joint (SIJ) is an amphiarthrosis composed of a posterior syndesmosis and an anterior cartilaginous portion, with limited yet present mobility. Its main function is to transmit the load from the axial skeleton to the lower limbs and vice-versa; it is susceptible to early mechanical and degenerative changes which are much more common than inflammatory sacroiliitis. Magnetic resonance imaging (MRI) has increasingly been used to evaluate these changes, and while subchondral bone marrow edema (BME) is a common finding related to both, care must be taken when applying the ASAS research MRI definition for sacroiliitis without considering lesion BME topography, size and depth, concomitant structural damage and, of course, the clinical picture. In this review, we will discuss the anatomy and biomechanics of the SIJ, the noninflammatory causes of SIJ subchondral BME, and how these concepts combined can be used to increase our diagnostic confidence.

CAUSES AND CLINICAL MANIFESTATIONS OF MASQUERADE SYNDROMES IN INTRAOCULAR INFLAMMATORY DISEASES.

To identify the clinical characteristics and prevalence of neoplastic and nonneoplastic inflammatory masquerade syndromes (IMSs) in a tertiary center and determine the useful diagnostic tests. A retrospective cohort study of consecutive 1906 patients diagnosed with intraocular inflammatory disease. Of all patients initially diagnosed with intraocular inflammatory disease, we identified 116 (6%) patients with noninflammatory causes (neoplastic IMSs in 36/116; 31% and nonneoplastic IMSs in 52/116; 45%). In addition, 26 patients (22%, 1.4% of all) had drug-induced uveitis and 2 (2%, 0.1% of all) had paraneoplastic uveitis. The large B-cell lymphoma was the most common neoplastic IMS (78%), and the major clinical features were presence of cells and floaters in the vitreous (69%) and chorioretinal lesions (33%). The causes of nonneoplastic IMSs included retinal vascular disorders (38%), hereditary retinal diseases (31%), and degenerative ocular disorders (19%). The common clinical manifestations consisted of chorioretinal scars (27%), small white-yellow retinal lesions (17%), and leaking vessels on fluorescein angiography (14%). Noninflammatory causes were determined in 6% of a large population with initial diagnosis of intraocular inflammatory disease. Although neoplastic IMS was commonly characterized by vitreous cells and opacities, most common definitive diagnoses in nonneoplastic IMS encompassed diverse retinal disorders.

Quantitative effect of subretinal fluid and intraretinal edema on visual acuity in uveitic cystoid macular edema

BackgroundThe effect of subretinal fluid (SRF) in uveitic cystoid macular edema (CME) is not fully understood. This study evaluates the quantitative effect of SRF and intraretinal thickness on visual acuity in eyes with uveitic CME. We separately measured SRF and intraretinal area on Optical Coherence Tomography (OCT) to determine the associations of each component with visual acuity and response to treatment.Main textMedical records were reviewed of patients with CME presenting to the University of Colorado uveitis clinic from January 2012 to May 2019. All available OCTs were reviewed to classify eyes as either having only CME or CME with SRF. Intraretinal area was manually measured using Image J along the central 1-mm section of B-scan OCT spanning from the internal limiting membrane to the outer most portion of the outer retina including both cysts and retinal tissue. SRF cross-sectional area was measured spanning from the outermost portion of the outer retina to retinal pigment epithelium. Response to treatment was assessed one to four months after presentation. Eyes with CME secondary to structural or non-inflammatory causes were excluded.Forty-seven (50.5%) eyes had CME alone and 46 (49.5%) eyes had SRF with CME. Measured SRF cross-sectional area was not associated (p = 0.21) with LogMAR at presentation. Conversely, intraretinal area was strongly correlated with visual acuity in eyes with SRF (p < 0.001) and without SRF (p < 0.001). Following treatment, there was a significant decrease in intraretinal area for both groups (p < 0.001), with a larger decrease in the SRF group compared to the non-SRF group (p = 0.001). Similarly, logMAR improved in both groups (p = 0.008 for SRF eyes and p = 0.005 for non-SRF eyes), but the change was more prominent in the SRF group (p = 0.06).ConclusionsThere was no direct association observed between the amount of SRF and visual acuity. In contrast, increased intraretinal area was significantly associated with decreased visual acuity. This relationship between intraretinal thickening and visual acuity may explain differences observed in response to treatment between SRF and non-SRF eyes, with a larger decrease in the intraretinal cross-sectional area in SRF eyes associated with a greater improvement in logMAR visual acuity.

Vitamin D level and telogen hair loss: A Case control study

Abstract&#x0D; &#x0D; Background: Hair loss is a common skin condition. Hair is not a vital organ but losing it has a worse effect on the psychological state of the patient and may interrupt his daily social activities. Telogen effluvium founded to be the commonest noninflammatory cause to diffuse hair loss. Since nutritional disturbances are one of the triggering factors for it. It might be useful in the management of TE Due to the limited number of studies&amp; little information is available on this subject possible role of vitamin D or its deficiency should be studied further.&#x0D; Aim of the study: to determine the association between Telogen effluvium and vitamin D level.&#x0D; Materials and methods: This is a case-control study performed in a period between December 2018 until June 2020; in Baghdad dermatology center at medical city. One hundred women who were seeking treatment for diffuse hair shedding and who hadn’t received treatment or supplements yet and One hundred fifty control subjects are chosen from patients who were referred to the dermatology clinic for the treatment of nevi and who are not pregnant or lactating, had no systemic or local scalp diseases are included in the study. Full History, physical examination performed for all cases including looking for cutaneous diseases, supplements &amp; drug intake. Serum Vitamin D3 is measured using (Ichroma (TM), Boditech Med Inc., Korea).&#x0D; Result: A total of 250 females were included in this study, 100 of them got telogen effluvium &amp; 150 were patients who attend dermatology clinic seeking treatments for nevi or skin tag (control group) .The mean age of cases was (22.59 ±4.837 year) that wasn’t significantly different from mean age of control group (23.647±6.022 years) (p-value =0.127). The mean level of Vitamin D was significantly lower than that of control group (11.16±4.49) Vs (18.98±10.65), P value &lt;0.001. Vitamin D mean level in acute phase was significantly higher than that of chronic phase pts. (11.68±4.77 &amp; 9.93 ±3.55 respectively), p value=0.04. Mean vit. D among symptomatic patients. (9.7 ± 3.5) was significantly lower than that among asymptomatic pts. (13±4.19) (p=0.001).No significant association were noticed between job &amp; residence of the patients of both groups, (P-value =0.283 &amp; 0.069 respectively (.&#x0D; Conclusion: Age mean difference was not significant among cases and controls. Deficiency in vitamin D may assume a possible leading cause of telogen effluvium among women with hair loss. Cases were significantly associated with low level of Vitamin D3 than controls.Low level of vitamin D was dominant among housewives, urban women, and among symptomatic patients with acute duration.

Inflammatory conditions of the pediatric hand and non-inflammatory mimics.

Hand involvement can assume an outsized role in the perception and presentation of disease as a result of functional impairment, visual conspicuity and susceptibility to early structural damage. Rheumatologic referral for inflammatory conditions can be delayed because of assumptions of a traumatic, infectious or neoplastic etiology; conversely, initial rheumatologic evaluation might be pursued for many of the same non-inflammatory causes. This pictorial essay highlights inflammatory conditions affecting the pediatric hand, including juvenile idiopathic arthritis, infectious arthritis, systemic connective tissue disorders, and a variety of less common inflammatory diseases, as well as non-inflammatory congenital, vascular, neoplastic and metabolic differential considerations.