Clinical management of Lupus patients during the COVID-19 pandemic

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), the virus causing Coronavirus disease 2019 (COVID-19), has had a huge impact on health services with a high mortality associated with complications including pneumonia and acute respiratory distress syndrome. Historical evidence suggests that Lupus patients have a higher incidence of several viral infections. This is likely due to a combination of immune dysfunction, immunosuppressive therapy and excess co-morbidities. In this context there has been concern that Lupus patients may be at a higher risk of developing COVID-19 and suffering a severe disease course. As a result, many Lupus patients have been advised to ‘shield’ by isolating from social contact in the hope that this will reduce the likelihood of infection. Early clinical data does not appear to show that the incidence of COVID-19 is higher in Lupus patients. Reassuringly, the clinical course of COVID-19 in Lupus does not generally seem to be more severe than in the general population. There has been huge interest in repurposing existing drugs as potential treatments, including several used to treat Lupus. Of these, corticosteroids and hydroxychloroquine are the most well researched so far. The current evidence suggests that the corticosteroid dexamethasone improves outcome for the sickest COVID-19 patients requiring respiratory support. Initial reports suggested that hydroxychloroquine could have a positive impact on the course of COVID-19, however larger prospective studies have not supported this. Janus kinase inhibitors, currently being investigated for efficacy in lupus, have been shown to have anti-viral effects in vitro and inhibiting the JAK-STAT pathway may dampen down the host hyper-inflammatory response. Several trials are ongoing to assess the outcome of the use of JAK inhibitors in COVID-19 positive patients. For most patients continuing with their existing therapies to prevent a lupus flare or adverse events associated with sudden corticosteroid withdrawal is important whilst an Individualised risk assessment remains vital.

The development of clinical thinking in trainee physicians: the educator perspective

BACKGROUND

An important element of effective clinical practice is the way physicians think when they encounter a clinical situation, with a significant number of trainee physicians challenged by translating their learning into professional practice in the clinical setting. This research explores the perceptions of educators about how trainee physicians develop their clinical thinking in clinical settings. It considers what educators and their colleagues did to help, as well as the nature of the context in which they worked.

METHOD

A qualitative approach was used in this study with in depth interviews carried out with educators as key informants. Rich data derived from 15 interview transcripts were analysed thematically in a rigorous and iterative process.

RESULTS

Three broad and overlapping themes were identified: working in an educationally minded culture; proximity of the educator to the trainee physician; and trajectory of the trainee physician. The departments in which these educators worked emphasised the importance for the education of trainee physicians. All members of the team were responsible for education of the team, and all members, particularly senior nurses, were able to give feedback upon the trainee physicians' progress. Educators described working side by side with their trainee physician and frequently being in close proximity to them which means that the educator was both easily accessible and spent more time with their trainee physicians. They described a trajectory of the trainee physicians through the placement with close monitoring and informal assessment throughout.

CONCLUSION

Recommendations are made as to how trainee physicians can be supported to develop their clinical thinking. Educators and managers can analyse their own and their department's practice and select the recommendations relevant to their local circumstances in order to make change. This study adds the educator perspective to a body of literature about the importance of context and supportive learning environments. As such the discussion is applicable to the education of other health professionals.

Feasibility of Dual Energy X-Ray Absorptiometry Based Images for Measurement of Height, Sitting Height, and Leg Length in Children

BACKGROUND

Interpretation of pediatric bone mineral density by dual energy absorptiometry (DXA) requires adjustment for height (Ht). This is often not easily obtainable in nonambulant subjects.

AIMS

To investigate the feasibility of using DXA images to evaluate measurements of Ht, sitting height (SH), and leg length (LL).

METHODOLOGY

A total of 2 observers performed measurements of Ht, SH, and LL on 3 separate occasion using DXA digital images in 125 children. Intraclass correlation and relative technical error of measurement (rTEM) were performed to assess reliability of repeated measurements. In 25 children, Ht and SH were measured in clinic on the same day and Bland-Altman analysis was performed to compare DXA measured Ht, SH, LL with clinic measurements for these 25 children.

RESULTS

Intraclass correlation for DXA based Ht, SH, and LL measurements ranged from 0.996 to 0.998 (p < 0.0001). rTEM of Ht, SH, and LL for observer 1 was 0.0016%, 0.002%, and 0.0034%, respectively. rTEM of Ht, SH, and LL between observer 1 and 2 was 0.0047%, 0.0049%, and 0.0087%, respectively. Mean difference between clinic and DXA measurements from Bland-Altman plots were +0.57 cm (95% confidence interval [CI] -0.54 to +1.68) for Ht, +1.33cm (-1.60 to +4.24) for SH, and -0.76cm (-3.88 to +2.37) for LL.

CONCLUSIONS

Our study demonstrated for the first time that Ht, SH, and LL in children can be measured very precisely using DXA images. Ht can be measured accurately. We believe this may be a convenient method to obtain Ht measurements to allow size adjustment of DXA bone mineral density in immobile children with chronic conditions.

A222 EPIDEMIOLOGICAL, PHENOTYPIC AND CLINICAL PATTERNS OF EXTRAINTESTINAL MANIFESTATIONS IN INFLAMMATORY BOWEL DISEASE

Background

Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), may affect multiple organ systems. The extraintestinal manifestations (EIMs) occur frequently, considerably increase morbidity and mortality, and strongly influence the quality of life in IBD patients.

Aims

To establish the all-time prevalence of EIMs in a large cohort of IBD patients and assess risk factors contributing to their development.

Methods

We conducted a retrospective cohort study of IBD patients followed at the Division of Gastroenterology, University of Alberta, diagnosed between 1954 and 2019. We recorded demographic, clinical, and biochemical data. The EIMs included dermatological, musculoskeletal, ophthalmological, hepatobiliary, urogenital, and pulmonary manifestations. The chi-square and Mann-Whitney tests (median, IQR) were used to evaluate differences. Univariate logistic regression was used to determine the association of EIMs with demographic and disease-specific variables across CD and UC, with predictors (p≤0.05) further incorporated into multivariate regression models.

Results

We analyzed data of 4493 IBD patients: 2354 with CD and 2139 – with UC, aged 18–96 years. Males were underrepresented in the CD cohort compared to the UC (47.8% vs 52.8%; p=0.001), with longer disease duration (16.3, IQR 16.1 vs 12.3, IQR 12.4 years; p≤0.001). The EIMs were slightly more prevalent in the CD group compared to UC (22.2% vs 20.4%; p=0.134), along with a significantly higher proportion of patients with over two EIMs (4.1% vs 1.7%; p≤0.001). The EIMs’ pattern varied substantially between the IBD subtypes (Figure). In the CD cohort, the most common EIM was peripheral arthropathy (4.1%), followed by ankylosing spondylitis (4.0%) and nephrolithiasis (3.6%). Among CD patients, disease duration ≥20 years (OR 1.70, 95% CI 1.17–2.48; p=0.006), iron (OR 1.54, 95%CI 1.13–2.09; p=0.006) and calcium (OR 2.28, 95% CI 1.21–4.27; p=0.010) deficiencies were identified as risk factors for EIMs. The UC patients most frequently had primary sclerosing cholangitis (9.6%) with peripheral arthropathy and nephrolithiasis each being present in 2.2% of patients. In the UC cohort, three variables demonstrated the most significant associations with EIMs: male sex (OR 1.75, 95% CI 1.32–2.32; p≤0.001), disease duration ≥20 years (OR 1.93, 95% CI 1.35–2.74; p≤0.001), and pan-colonic disease extent (OR 2.12, 95% CI 1.03–4.36; p=0.041) (Table).

Conclusions

Our data demonstrate that over one-fifth of IBD patients had at least one EIM over the course of the disease and the EIMs pattern varies substantially across CD and UC. Identification of risk factors allowing prediction of EIMs would increase awareness, assist in their early recognition, and tailor further management.

Funding Agencies

AbbVie

How Do Contexts Affect Physicians' Clinical Reasoning? A Narrative Review

This article was migrated. The article was marked as recommended. Background Research about clinical reasoning has tended to focus on the individual, assessing their ability to perform clinical reasoning tasks. However, recent studies have noted that clinical reasoning varies with the clinical context. Objectives The purpose of this narrative review is to examine how the context can affect physicians clinical reasoning skills. Methods A narrative literature review was conducted by searching PubMed, PsycINFO and Embase via Ovid using the search terms clinical OR critical AND thinking OR judgement OR reasoning. Of 22,296 results found, 25 studies were found to be relevant to our review. Results Most studies focused on diagnostic skills. Contexts affecting clinical reasoning fell into three broad categories: patient, physician and environmental (the physical and social setting) factors. Patient contexts researched included factors both personal to the patient and their physical disease manifestations. Physician contexts included experience, age, exposure to similar diagnoses, incorrect diagnostic suggestion, emotions, and the use of reflection and checklists. Environmental contexts included time pressure, unfamiliarity with surroundings, dealing with uncertainty and high-stakes outcomes. The effect of applying more than one contextual factor increasing cognitive load, was explored. Conclusion This original review suggests that the context can affect a physician's clinical reasoning abilities. This review identifies areas for continued research, including which contexts have a negative or positive impact, and the effect of multiple contexts (cognitive loading) on clinical reasoning. Further empirical research is needed to investigate these areas in more depth and to establish how far these benefits have an impact in practice.

Evaluating latent tuberculosis testing and treatment programme for new migrants in South East England

Background

Tuberculosis (TB) cases in England often originate from high burden TB countries due to ’reactivation’ of the latent TB infection (LTBI), an asymptomatic and non-infectious phase lasting years. 5,137 TB cases were notified in England in 2017, and 71% of these patients were born outside the UK. This mixed-method study evaluated the implementation of the four LTBI testing and treatment programme for new migrants in South East (SE) England.

Methods

A retrospective database (May 2016-Feb 2018) review was undertaken to identify LTBI cases using multiple data sources; LTBI testing laboratories, LTBI programmes, and the national TB team at Public Health England. In addition, a survey questionnaire was emailed to 51 stakeholders (45% response rate) and five in-depth interviews were conducted with LTBI programme leads/TB nurses to explore the challenges of the programme. Quantitative data were analysed using descriptive summary statistics and qualitative interviews were analysed using thematic content analysis.

Results

Of the 5931 eligible patients, 40 % (n = 2391) accepted the LTBI test and 13.4% (n = 321) tested positive. 93.1% (n = 299) of the positive patients were referred for treatment and 63.8% (n = 191) of these accepted the treatment. The programme also picked up 18 active TB cases, an unexpected incidental finding. Results from the survey and the interviews identified laboratory arrangements, workforce, and data collection/management as the greatest challenges for the LTBI programme. Patient focused care, cultural understanding, success in testing/treating migrants, and raising awareness amongst professionals/communities were highlighted as achievements of the programme.

Conclusions

This study found that LTBI programmes in SE England are in line with national expectations and other LTBI programmes in England. The study recognises the achievements and good practice of the LTBI teams in SE England and identifies key barriers to improve the service for the future.

Key messages

Data collection and management is the biggest challenges of the LTBI programmes in SE England. The LTBI programmes in SE England are in line with national expectations.

Assessing Theoretical Conclusions With Blinded Inference to Investigate a Potential Inference Crisis

Scientific advances across a range of disciplines hinge on the ability to make inferences about unobservable theoretical entities on the basis of empirical data patterns. Accurate inferences rely on both discovering valid, replicable data patterns and accurately interpreting those patterns in terms of their implications for theoretical constructs. The replication crisis in science has led to widespread efforts to improve the reliability of research findings, but comparatively little attention has been devoted to the validity of inferences based on those findings. Using an example from cognitive psychology, we demonstrate a blinded-inference paradigm for assessing the quality of theoretical inferences from data. Our results reveal substantial variability in experts’ judgments on the very same data, hinting at a possible inference crisis.

27. A new presentation of interstitial lung disease

Introduction

Patients presenting with new onset interstitial lung disease (ILD) should be assessed for secondary, potentially treatable, causes. Some patients with rheumatic disease may present with ILD as the first manifestation of their condition. Early diagnosis and treatment of an underlying rheumatic disease can improve patient outcome. As autoimmune screening has evolved to include extended myositis and scleroderma panels, increasing numbers of patients with ILD are being referred for review by a rheumatologist. This case highlights one such patient diagnosed with new onset ILD during an acute hospital admission but subsequently found to have an underlying connective tissue disease (CTD).

Case description

A 54-year-old previously fit and well man presented to the Emergency Department with a three-month history of progressively worsening shortness of breath and dry cough. He denied any other symptoms, including those in keeping with a connective tissue disease (CTD). His past medical history was unremarkable. His father had a possible diagnosis of Sjögren’s syndrome and his sister had Sjögren’s syndrome with ILD. He had a 20 pack year smoking history.

On admission his could only walk ten meters before having to stop due to shortness of breath. On auscultation of his chest he had fine inspiratory crepitations in the mid and lower zones. Blood tests revealed an elevated c-reactive protein (CRP) of 96 and erythrocyte sedimentation rate (ESR) of 120. He failed to improve with intravenous antibiotics and his CRP rose to 122. Computer tomography (HRCT) of the chest, abdomen and pelvis revealed bilateral reticulation peripherally in the mid and lower zones and paraseptal/centrilobular emphysematous changes in the upper zones. Pulmonary function tests (PFTs) demonstrated normal spirometry but reduced gas transfer. Anti-cyclic citrullinated peptide (anti-CCP) antibodies, rheumatoid factor, anti-neutrophil cytoplasmic antibodies (ANCA) and HIV screen were negative. Creatine kinase was normal. ANA was positive, with positive anti-Ro-52 antibodies and positive anti-PL12 on an extended myositis panel.

A diagnosis of anti-synthetase syndrome was made. He was treated with three 1 gram doses of intravenous methylprednisolone on consecutive days then switched to 40mg of oral prednisolone daily. His inflammatory markers improved and he was discharged home. Monthly cyclophosphamide infusions were commenced and he has received two doses thus far. Although subjectively the patient does not report much improvement in his breathing as yet, he attends his appointments independently and is able to walk over 50 meters without stopping. Repeat PFTs and HRCT chest are scheduled.

Discussion

Patients presenting with ILD with no identifiable cause should be assessed and screened for CTDs. Evaluation should include a thorough history and examination, looking for associated conditions. ILD may be associated with rheumatoid arthritis, systemic sclerosis, polymyositis, dermatomyositis, anti-synthetase syndrome, sarcoidosis, Sjogren’s syndrome, mixed connective tissue disease and systemic lupus erythematous (SLE).

Pulmonary function tests may demonstrate a restrictive pattern on spirometry, although this can be normal. Gas transfer is often reduced and a carbon monoxide transfer factor of < 40% is indicative of advanced disease. Imaging, usually in the form of high-resolution CT (HRCT), can allow assessment of the pattern of ILD and the potential for reversibility. It can often help avoid the need for lung biopsy.

If no clear alternative cause of ILD (eg. drugs, occupational exposure, inhaled substances, infection, radiation) then physicians should consider sending bloods to help excludes CTDs, including creatine kinase, rheumatoid factor, anti-CCP antibodies, anti-nuclear antibodies (with extended myositis and scleroderma panels) and ANCA, even in asymptomatic patients. Case series have demonstrated that ILD may be the only presenting feature in a proportion of those with anti-synthetase syndrome, particularly in patients with anti-PL7 or PL-12. The classic triad of clinical features for anti-synthetase syndrome consists of ILD, myositis and arthritis (mechanic’s hands). Our patient had no CTD symptoms at presentation but has gone on to develop Raynaud’s and stiffness in his fingers over the last 6 months. He has not at any stage had evidence of myositis, either clinically or serologically, which is in keeping with case series of patients with ILD and PL-12 positivity reporting a proportion as being amyopathic. Particular factors that should prompt screening for anti-synthetase syndrome include female gender, middle age, clinical signs suggestive of a CTD and an NSIP pattern on HRCT.

Key learning points

Rheumatic conditions which can present with ILD include rheumatoid arthritis, systemic sclerosis, polymyositis, dermatomyositis, anti-synthetase syndrome, sarcoidosis, Sjögren’s syndrome, mixed connective tissue disease and SLE.Newly presenting ILD patients with no identifiable cause should be checked for rheumatoid factor, anti-CCP antibodies, anti-nuclear antibodies (with extended myositis and scleroderma panel) and ANCA.

ILD associated with anti-synthetase syndrome, polymyositis or dermatomyositis often warrants early treatment with steroid and cyclophosphamide or another immunosuppressive agent such as rituximab.

Patient characteristics which should prompt screening for anti-synthetase syndrome with extended myositis panel testing include clinical suspicion of CTD, female gender, middle age, CTD symptoms or signs and NSIP pattern on HRCT.

All patients presenting with ILD should have pulmonary function tests and imaging to assess severity of disease.

Conflicts of interest

The authors have declared no conflicts of interest.

Expected Value of Reward Predicts Episodic Memory for Incidentally Learnt Reward-Item Associations

In this paper, we draw connections between reward processing and cognition by behaviourally testing the implications of neurobiological theories of reward processing on memory. Single-cell neurophysiology in non-human primates and imaging work in humans suggests that the dopaminergic reward system responds to different components of reward: expected value; outcome or prediction error; and uncertainty of reward (Schultz et al., 2008). The literature on both incidental and motivated learning has focused on understanding how expected value and outcome—linked to increased activity in the reward system—lead to consolidation-related memory enhancements. In the current study, we additionally investigate the impact of reward uncertainty on human memory. The contribution of reward uncertainty—the spread of the reward probability distribution irrespective of the magnitude—has not been previously examined. To examine the effects of uncertainty on memory, a word-learning task was introduced, along with a surprise delayed recognition memory test. Using Bayesian model selection, we found evidence only for expected value as a predictor of memory performance. Our findings suggest that reward uncertainty does not enhance memory for individual items. This supports emerging evidence that an effect of uncertainty on memory is only observed in high compared to low risk environments.

Inflammation and dementia: Using rheumatoid arthritis as a model to develop treatments?

Dementia is a major international public health problem which looks set to grow as the ageing population increases. Despite large amounts of investment there has been relatively little progress in developing new therapies to combat this. There is a growing body of evidence that both local and systemic inflammation are important in dementia; with cerebral inflammation occurring secondarily to beta-amyloid plaques, raised levels of serum inflammatory molecules and cytokines being present in Alzheimer's disease patients and systemic inflammation being associated with cerebral microvasculature disease in vascular dementia. Observational studies had suggested that non-steroidal anti-inflammatory drugs may reduce the risk of dementia, but subsequent interventional studies have been disappointing. More recently some observational studies have suggested a protective effect from conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS) and tumour necrosis factor inhibiting (TNFi) biological therapies. Treatments for inflammatory rheumatic diseases have previously been repurposed and used successfully in other diseases, such as TNFi for inflammatory bowel disease. There are also studies looking at the use of csDMARDs such as methotrexate to improve outcomes after cardiovascular events. Ongoing interventional trials are currently looking at whether therapies designed to treat inflammatory and autoimmune diseases have the potential to be used to treat dementia.

UK Role 4 military infectious diseases and tropical medicine cases in 2005-2013

INTRODUCTION

Infectious diseases are a frequent cause of morbidity among British troops. The aim of this paper is to describe the spectrum of infectious diseases seen when UK service personnel are evacuated for definitive care to the Role 4 Medical Treatment Facility based at Birmingham Heartlands Hospital.

METHOD

A retrospective analysis of all military patients presenting with infectious diseases and treated at Birmingham Heartlands Hospital between 14 April 2005 and 31 December 2013 was undertaken.

RESULTS

During this period, 502 patients were identified. Infections originated in 49 countries, most commonly Afghanistan (46% cases), the UK (10% cases) and Belize (9% of cases). The most common presentations were dermatological conditions, gastroenterological illnesses and undifferentiated fevers.

CONCLUSION

UK service personnel in significant numbers continue to suffer a wide range of infectious diseases, acquired throughout the globe, which often require specialist tertiary infection services to diagnose and manage. Future prospective data collection is recommended to identify trends, which in turn will inform military training needs and future research priorities in the Defence Medical Services (DMS) and allows development of appropriate policies and clinical guidelines for management of DMS personnel with infectious diseases.

Adaptive scaling of reward in episodic memory: a replication study

Reward is thought to enhance episodic memory formation via dopaminergic consolidation. Bunzeck, Dayan, Dolan, and Duzel [(2010). A common mechanism for adaptive scaling of reward and novelty. Human Brain Mapping, 31, 1380–1394] provided functional magnetic resonance imaging (fMRI) and behavioural evidence that reward and episodic memory systems are sensitive to the contextual value of a reward—whether it is relatively higher or lower—as opposed to absolute value or prediction error. We carried out a direct replication of their behavioural study and did not replicate their finding that memory performance associated with reward follows this pattern of adaptive scaling. An effect of reward outcome was in the opposite direction to that in the original study, with lower reward outcomes leading to better memory than higher outcomes. There was a marginal effect of reward context, suggesting that expected value affected memory performance. We discuss the robustness of the reward memory relationship to variations in reward context, and whether other reward-related factors have a more reliable influence on episodic memory.

Noninvasive In-Situ Measurement of Blood Lactate Using Microwave Sensors

GOAL

This paper reports a novel electromagnetic sensor technique for real-time noninvasive monitoring of blood lactate in human subjects.

METHODS

The technique was demonstrated on 34 participants who undertook a cycling regime, with rest period before and after, to produce a rising and falling lactate response curve. Sensors attached to the arm and legs of participants gathered spectral data, blood samples were measured using a Lactate Pro V2; temperature and heart rate data was also collected.

RESULTS

Pointwise mutual information and neural networks are used to produce a predictive model. The model shows a good correlation between the standard invasive and novel noninvasive electromagnetic wave based blood lactate measurements, with an error of 13.4% in the range of 0-12 mmol/L.

CONCLUSION

The work demonstrates that electromagnetic wave sensors are capable of determining blood lactate level without the need for invasive blood sampling.

SIGNIFICANCE

Measurement of blood metabolites, such as blood lactate, in real-time and noninvasively in hospital environments will reduce the risk of infection, increase the frequency of measurement and ensure timely intervention only when necessary. In sports, such tools will enhance training of athletes, and enable more effecting training regimes to be prescribed.