Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting

BACKGROUND

In boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management.

OBJECTIVES

To audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management.

MATERIALS AND METHODS

Lateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate.

RESULTS

The term "fracture" was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively.

CONCLUSION

Only a third of radiology reports of spine imaging in DMD explicitly used the terminology "fracture". Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.

The Future of Decisions From Experience: Connecting Real-World Decision Problems to Cognitive Processes

In many important real-world decision domains, such as finance, the environment, and health, behavior is strongly influenced by experience. Renewed interest in studying this influence led to important advancements in the understanding of these decisions from experience (DfE) in the last 20 years. Building on this literature, we suggest ways the standard experimental design should be extended to better approach important real-world DfE. These extensions include, for example, introducing more complex choice situations, delaying feedback, and including social interactions. When acting upon experiences in these richer and more complicated environments, extensive cognitive processes go into making a decision. Therefore, we argue for integrating cognitive processes more explicitly into experimental research in DfE. These cognitive processes include attention to and perception of numeric and nonnumeric experiences, the influence of episodic and semantic memory, and the mental models involved in learning processes. Understanding these basic cognitive processes can advance the modeling, understanding and prediction of DfE in the laboratory and in the real world. We highlight the potential of experimental research in DfE for theory integration across the behavioral, decision, and cognitive sciences. Furthermore, this research could lead to new methodology that better informs decision-making and policy interventions.

The role of episodic memory sampling in evaluation

Many models of choice assume that people retrieve memories of past experiences and use them to guide evaluation and choice. In this paper, we examine whether samples of recalled past experiences do indeed underpin our evaluations of options. We showed participants sequences of numerical values and asked them to recall as many of those values as possible and also to state how much they would be willing to pay for another draw from the sequence. Using Bayesian mixed effects modeling, we predicted participants' evaluation of the sequences at the group level from either the average of the values they recalled or the average of the values they saw. Contrary to the predictions of recall-based models, people's evaluations appear to be sensitive to information beyond what was actually recalled. Moreover, we did not find consistent evidence that memory for specific items is sufficient to predict evaluation of sequences. We discuss the implications for sampling models of memory and decision-making and alternative explanations.

Rare and extreme outcomes in risky choice

Many real-world decisions involving rare events also involve extreme outcomes. Despite this confluence, decisions-from-experience research has only examined the impact of rarity and extremity in isolation. With rare events, people typically choose as if they underestimate the probability of a rare outcome happening. Separately, people typically overestimate the probability of an extreme outcome happening. Here, for the first time, we examine the confluence of these two biases in decisions-from-experience. In a between-groups behavioural experiment, we examine people's risk preferences for rare extreme outcomes and for rare non-extreme outcomes. When outcomes are both rare and extreme, people's risk preferences shift away from traditional risk patterns for rare events: they show reduced underweighting for events that are both rare and extreme. We simulate these results using a small-sample model of decision-making that accounts for both the underweighting of rare events and the overweighting of extreme events. These separable influences on risk preferences suggest that to understand real-world risk for rare events we must also consider the extremity of the outcomes.

Dual biologic therapy for the treatment of rheumatic diseases and asthma: a case series

Objective

Combination biological therapies are being considered increasingly for patients with multiple co-morbidities requiring biologics. There are limited data available on this approach, and concerns remain about the possible risk of adverse events, particularly infection.

Methods

We present three patients on dual biologics for rheumatic disease and asthma. The biologic combinations used were etanercept and mepolizumab, infliximab and omalizumab, and etanercept and omalizumab. The time on combination biologic therapies ranged from 24 to 36 months. Patients were monitored for any serious adverse events.

Results

All three patients were able to tolerate combined biologic therapies, with no serious adverse events. All three patients gained improvement in their rheumatic and asthma disease control, with reduction in disease activity scores and reduction in steroid usage.

Conclusion

The decision to start dual biologic therapy should be considered carefully, on a case-by-case basis. The number of patients who are on combination biological therapy is small, and data are sparse. Real-world data are needed to examine the long-term benefits and risks of different forms of combination biologic therapies.

Biased confabulation in risky choice

When people make risky decisions based on past experience, they must rely on memory. The nature of the memory representations that support these decisions is not yet well understood. A key question concerns the extent to which people recall specific past episodes or whether they have learned a more abstract rule from their past experience. To address this question, we examined the precision of the memories used in risky decisions-from-experience. In three pre-registered experiments, we presented people with risky options, where the outcomes were drawn from continuous ranges (e.g., 100-190 or 500-590), and then assessed their memories for the outcomes experienced. In two preferential tasks, people were more risk seeking for high-value than low-value options, choosing as though they overweighted the outcomes from more extreme ranges. Moreover, in two preferential tasks and a parallel evaluation task, people were very poor at recalling the exact outcomes encountered, but rather confabulated outcomes that were consistent with the outcomes they had seen and were biased towards the more extreme ranges encountered. This common pattern suggests that the observed decision bias in the preferential task reflects a basic cognitive process to overweight extreme outcomes in memory. These results highlight the importance of the edges of the distribution in providing the encoding context for memory recall. They also suggest that episodic memory influences decision-making through gist memory and not through direct recall of specific instances.

P024 Real-world experience of Tocilizumab withdrawal in GCA

Background/Aims

Part 2 of the GIACTA trial explored the maintenance of efficacy in giant cell arteritis (GCA) patients. It showed that nearly half the patients treated with weekly tocilizumab (TCZ) maintained remission, though flares did still occur in the remaining half when TCZ was discontinued. Currently, NHS England has approved the use of TCZ in GCA for only 1 year as this duration was agreed upon by clinical experts to be sufficient to sustain remission. However, this remains a point of concern amongst clinicians as to whether data from real-life patients confirms that 1 year of TCZ can achieve sustainable remission.

Methods

Our objective is to assess the real-world experience of TCZ withdrawal in GCA patients and how different centres are trying to mitigate risk of relapse after its cessation. We are conducting a patient survey across six hospitals in Wessex, United Kingdom. Our aim is to assess the change in clinical features, acute phase reactants and the rate of sustained remission and relapse.

Results

53 patients with GCA were included in the survey. Average age of patients was 73.5 years. 36 patients had cranial GCA, five had large vessel vasculitis and no sub-type was mentioned for the 12 remaining patients. Temporal artery biopsy was the most common diagnostic tool used for 21 patients, followed by PET scan for 14 patients. Eight patients had a clinical diagnosis only, while seven were diagnosed with GCA based on findings of Anterior Ischaemic Optic Neuropathy. Only three patients had their diagnosis confirmed via ultrasound temporal arteries. Out of these 53 patients, 45 started Tocilizumab. 15 patients stopped treatment due to side effects. Of the remaining 30 patients, only 17 have completed their 1 year of TCZ so far. Two patients relapsed 6 months after stopping TCZ. One of them was on methotrexate (MTX) and low dose prednisolone, while other was on mycophenolate mofetil only. Of those who are currently stable since completing TCZ, five patients are on MTX with prednisolone, one patient on leflunomide and prednisolone, four patients on prednisolone only and three patients on MTX only. Two patients are on no treatment currently.

Conclusion

This is an ongoing study. Our figures so far show that most patients are still on treatment with steroids and MTX, either alone or in combination, after completing 1 year of TCZ. This could be due to clinicians trying to mitigate against relapse once TCZ is withdrawn. This study highlights that real-world data on relapse/remission rates following TCZ withdrawal is essential as it will help shape future GCA treatment and guidelines.

Disclosure

S. Khalid: None. B. Davidson: None. N. Hopkinson: None. A. Mason: None. M. Malik: None. F. Laskou: None. L. Parker: None.

P244 The use of anti-malarial therapy in UK Rheumatology practice. A UK-based pilot survey for the BILAG group

Background/Aims

Antimalarials have an important role in the management of autoimmune rheumatic disease, especially lupus (SLE) and other connective tissue diseases (CTD). A large North American study demonstrated a risk of retinopathy with hydroxychloroquine, increasing at doses above 5mg/kg and after 10 years or more of continuous therapy. This has influenced the development of specific monitoring ocular guidance for hydroxychloroquine although there has been less attention to potential side effects in routine use. Our aim was to examine hydroxychloroquine use including the effect of changes in ophthalmology guidance

Methods

We designed a 21-question internet-based survey. This requested information on antimalarials including hydroxychloroquine brand, dosing, monitoring and concerns about use. We requested information about alternatives to hydroxychloroquine including mepacrine and chloroquine, barriers to and indications for prescribing these alternative antimalarials.

Results

We received 69 responses, 59 (86%) Consultants, 10 (14%) ST’s from across the United Kingdom of which 51% worked in a district general hospital (DGH) setting. Of the Consultants, 28 (47%) ran dedicated CTD clinics. Regarding hydroxychloroquine, 39 respondents (57%) used a defined local pathway for Hydroxychloroquine retinopathy screening. While 59/69 (86%) did not know which hydroxychloroquine brand their pharmacy dispensed, of the remainder, 14/19 (74%) used Quinoric. Regarding hydroxychloroquine dosing, 83% targeted weight-based maintenance dosing with most of these (77%) maintaining at the currently recommended 5mg/kg body weight or less, while 23% used 6.5mg/Kg. No participants measured hydroxychloroquine drug levels. Potential ocular toxicity, cardiac arrythmias and skin hyperpigmentation were reported as the most significant concerns with hydroxychloroquine usage. Of the alternatives, mepacrine was never used by 39%, (77% for chloroquine) while only 4% used either often or very often. Barriers to prescription of these alternative antimalarials were most commonly GP or local Pharmacy unavailability (39% and 17 retrospectively). However, mepacrine/ hydroxychloroquine combination was used by 32% of respondents, most often for refractory skin disease (21 respondents), refractory joint disease (five respondents) and as a steroid sparing drug (six respondents).

Conclusion

Our results suggest several aspects in which hydroxychloroquine use could be improved. Although recent evidence demonstrates the potential for significant ocular toxicity with Hydroxychloroquine in those taking > 5mg/kg body weight and for >10 years we found practice still varied with 43% Rheumatologists not using a dedicated ocular screening pathway making monitoring long term potentially hazardous. Alternatives to hydroxychloroquine are not considered by 39% perhaps reflecting paucity of data for mepacrine and chloroquine, especially in circumstances including pregnancy but also cost and lack of availability. Our results suggest a need for standardised hydroxychloroquine monitoring processes including improved ophthalmic screening with Optical Coherence Tomography, a need for more evidence about the potential benefits and hazards of hydroxychloroquine and alternative antimalarials and availability of prescribing guidelines.

Disclosure

A. Kaul: Consultancies; Dr Kaul has received fees for Advisory Boards for AbbVie, Janssen, Novartis, Lilly. Member of speakers’ bureau; r Kaul has received speaker fees from AbbVie, Novartis, Janssen, Leo, Pfizer. A. Mason: None. C. Edwards: None. E. Vital: None.

A208 ASSESSING FEASIBILITY AND ACCEPTABILITY OF AN ONLINE MIND-BODY WELLNESS PROGRAM FOR PRIMARY BILIARY CHOLANGITIS

Background

Persons with primary biliary cholangitis (PBC) experience significantly higher rates of fatigue, stress, anxiety, depression, and impaired health related quality of life (HRQOL) as compared to the general population. While online wellness programming has been shown to be effective in decreasing fatigue and improving mental wellness in a variety of chronic disease populations, limited data is available for PBC.

Aims

This pilot study aimed to assess the hypothesis that a 12-week, online, mind-body wellness program would be feasible (assessed through adherence and retention) and acceptable in people with PBC. We also aimed to explore indicators of impact on measures of wellbeing.

Methods

Persons with PBC were recruited across Alberta and British Columbia in January 2021. The program included a 20–30 minute video containing low intensity mindful movement, meditation, and breathwork (goal 2–3 times/week) as well as a weekly behaviour change tip, PBC tip from a physician, and PBC nutrition tip. The online programming was accompanied by brief (10-minute) once weekly phone check-ins from a member of the study team, and optional once monthly zoom group sessions hosted by the Canadian PBC Society. Satisfaction and adherence were assessed at the end of the study using a survey. The pre-post exploratory efficacy assessment included: fatigue (Modified Fatigue Impact Scale), perceived stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and HRQOL (PBC-40). Using a qualitative descriptive approach, we conducted semi-structured interviews at the end of the study to explore experiences with the intervention, and gather feedback for improvement.

Results

Participants (N = 32) completed baseline surveys and 29 (91%) were retained to end-of-study. Twenty-five (86%) adhered to the program goal of carrying out the mind-body practice at least 2–3 days per week. Comparing baseline to end-of-study, significant reductions were observed in fatigue (13%, p=0.004), anxiety (30%, p=0.005), and depression (28%, p=0.022), and significant improvements were observed in the PBC-40 itch (22%, 0.043), fatigue (13%, 0.005), cognitive (17%, 0.006), and emotional (18%, 0.001) domains. Eleven individuals participated in qualitative interviews, reporting an increase in energy, a more positive outlook, and increased knowledge of PBC. Feedback supported acceptability (satisfaction score of 90%), with fatigue cited as the primary barrier to increased program participation.

Conclusions

These findings suggest that a 12-week online mind-body intervention is feasible and acceptable to persons with PBC and has promising impact on efficacy. Recognizing the limitations of a single-arm study with a small sample size, a future RCT will be designed using this feedback.

Funding Agencies

MITACS Accelerate, Canadian PBC Society

Giant cell arteritis complicated by tongue necrosis and bilateral cerebellar ischaemic stroke

Giant cell arteritis (GCA) typically presents with headache, scalp tenderness or visual disturbance. Other symptoms include orofacial pain, constitutional symptoms and ischaemic stroke. An 81-year-old woman with a background of type-2 diabetes and hypertension presented with headache, oral pain and right visual loss. Examination showed hypertension, nodular temporal arteries, reduced visual acuity and suspected oral candida. Inflammatory markers were raised and she was diagnosed with GCA and commenced on corticosteroids. During treatment she developed tongue ulceration, then acute vertigo and incoordination with nystagmus and ataxia. Neuroimaging confirmed bilateral, cerebellar ischaemic strokes and temporal artery biopsy was consistent with GCA. With corticosteroids and secondary prevention of stroke measures she is now functionally independent. Oral pain is an uncommon symptom of GCA and delays in recognition may lead to catastrophic consequences. Clinicians should be aware of uncommon presentations and to optimise additional ischaemic stroke risk-factors.

P30 A case of recurrent orbital myositis

Case report - Introduction

An interesting case of an 11-year recurrent isolated lateral rectus myositis. Initially responsive to short courses of oral steroids; however, this has more recently become refractory and now the patient is unable to wean off steroids. The use of biologics in these patients is uncommon and there are very few case reports of this and the outcomes. We present a case of refractory orbital myositis treated with rituximab.

Case report - Case description

A 38-year-old female presented in 2009 with ocular pain, swelling and diplopia. After review by the ophthalmology team an MRI orbits was requested which showed swelling and enhancement of the right lateral rectus muscle, consistent with orbital myositis. She had no other symptoms of myositis elsewhere, and no other symptoms suggestive of a connective tissue disease. Her ANA, ENA and extended myositis panel were negative and therefore aetiology was uncertain. She had no past medical history, but was later diagnosed with hypothyroidism with positive TPO antibodies. Throughout the 11 years since diagnosis her thyroid disease has been well controlled, and she has had normal free T3/T4 and TSH. It was felt that thyroid eye disease was unlikely to present with a single muscle.

She was initially treated with a course of 40mg oral prednisolone reducing over 6 weeks and symptoms resolved. In 2013 she had her first relapse, which was treated with prednisolone reducing over the course of 12months, and again symptoms resolved. Her third relapse in 2019 was treated with steroids, but patient was unable to wean off this, requiring 60mg of prednisolone, and at this point was referred to rheumatology for steroid sparing agents. Between 2013 and 2019 there was MRI progression with volumetric enlargement of the right lateral rectus with intra-orbital space reduction.

Under the care of rheumatology, she had repeat connective tissue disorders and myositis screen. She was started on azathioprine as a steroid sparing agent. This had little effect and she was still debilitated by orbital pain and diplopia, and unable to reduce her prednisolone below 30mg daily. She trialled intra-orbital steroid injections with little benefit. She has now been started on rituximab infusions to allow us to wean steroids. Thus far she has had two doses and we await the outcome from this treatment.

Case report - Discussion

Orbital myositis can be a debilitating condition causing diplopia and pain, as in the case of this 38-year-old female who has been off work for the past year due to the condition. It can affect single muscles or multiple muscles and may be unilateral or bilateral. The major differential diagnosis is thyroid eye disease which would not usually cause an isolated myopathy, is usually painless and slowly progressive and as such was felt unlikely to be the underlying pathology in this case.

From a literature review into idiopathic orbital inflammation, including myositis, 75% of patients are found to have a good response to corticosteroids. Second-line treatments include radiotherapy, methotrexate/azathioprine and other biologic agents.

A case report in 2014 of 10 patients with orbital myositis refractory to steroids and at least one other immunosuppressant, demonstrated that rituximab was safe and effective, with 7/10 patients noting improvement of their symptoms. Out of those seven patients, four had been on steroids at induction of rituximab and all of the patients were able to reduce their steroid dose. The patients in this trial received two initial doses of rituximab and were permitted to have a further dose at 24 weeks if there were recurrence of symptoms. Four out of the seven patients required a further infusion after 24 weeks.

In a review of the literature, we have noted a further two case reports of the use of rituximab in orbital myositis from 2008 and 2012 with good response. Both patients were unable to wean from corticosteroids and had tried other DMARDs such as methotrexate. Other case reports of biologics therapy include a case report of two patients in which adalimumab was used and allowed steroid reduction with good results for at least 9 months.

Case report - Key learning points

Lupus, vaccinations and COVID-19: What we know now

Severe acute respiratory syndrome coronavirus-2 (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. Patients with systemic lupus erythematosus (SLE) are at increased risk of viral infections, and recent data suggests they may be at an increased risk of poor outcomes with COVID-19. This may be particularly true for those on rituximab or high dose steroids. A huge international effort from the scientific community has so far resulted in the temporary authorisation of three vaccines which offer protection against SARS-CoV-2, with over 30 other vaccines being evaluated in ongoing trials. Although there has historically been concern that vaccines may trigger disease flares of SLE, there is little convincing evidence to show this. In general lupus patients appear to gain good protection from vaccination, although there may be reduced efficacy in those with high disease activity or those on immunosuppressive therapies, such as rituximab or high dose steroids. Recent concerns have been raised regarding rare clotting events with the AstraZeneca/Oxford vaccine and it is currently unknown whether this risk is higher for those patients with secondary antiphospholipid syndrome. With the possibility of annual COVID vaccination programmes in the future, prospective data collection and registries looking at the effect of vaccination on SLE disease control, the incidence of COVID-19 in SLE patients and severity of COVID-19 disease course would all be useful. As mass vaccination programmes begin to roll out across the world, we assess the evidence of the use of vaccines in SLE patients and in particular vaccines targeting SARS-CoV-2.

African immigrant child health: A scoping review

The health of migrant children is a pressing issue. While most African migration takes place within Africa, a significant number of African migrants travel to outside of the continent. This article reports findings from a scoping review on the health of African immigrant children from sub-Saharan Africa now living outside of Africa. A systematic search for studies published between 2000 and 2019 resulted in only 20 studies reporting on the health of children up to 18 years of age migrating from sub-Saharan Africa. Data from these articles were thematically analyzed, highlighting concerns related to the children's nutrition status (n = 8), mental health (n = 7), and physical health (n = 5). Study participants were primarily from Somali and Ethiopia, and most studies were conducted in Australia or Israel. The review highlights several gaps related to the scope, range, and nature of evidence on the health of African immigrant children living outside of Africa. In particular, most focus on children's nutritional and mental health, but pay little attention to other health concerns this specific population may encounter or to the benefits associated with effective responses.

AB0298 PREGNANCY IN RHEUMATIC DISEASE: A REGION WIDE SURVEY OF CURRENT PRACTICE AMONGST CLINICIANS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Rheumatic diseases frequently affect females of child-bearing age, with implications for foetal and maternal outcomes.

Two-thirds (66%) of the women who died in the 2016-18 MBRRACE report were known to have pre-existing medical problems1. The NHS long-term plan supports creation of Maternal Medicine Networks to facilitate access to specialist care and advice in pregnancy.

Guidelines exist for use of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy but other aspects of pregnancy related care in rheumatic disease remain less well defined. The Wessex wide connective tissue disease (CTD) network provides a multi-disciplinary forum to discuss cases, to obtain approval for high cost drugs, to compare practice in multiple hospitals but does not specifically discuss pregnancy related uncertainties.

Objectives:

To survey variations in clinical practice relating to rheumatic disease in pregnancy

Methods:

Following careful project planning with the tertiary referral centre obstetric lead consultant for maternal medicine, several areas of care were identified which were prone to local and individual variation. An anonymous online survey relating to these specific areas of pregnancy related care was circulated amongst members of the CTD network, including rheumatology consultants, rheumatology practitioners and specialist trainees.

Results:

16 responses were obtained across 7 hospital sites; 56% were from rheumatology consultants. 12/16 (75%) reported routinely offering contraceptive advice when prescribing DMARDs. Only 4/16 (25%) were aware of a specific pre-natal obstetric clinic available in their hospital. There was major variation in planned frequency of clinical review. 10/16 would increase frequency of review during pregnancy if a patient’s disease became active or unstable; 6/16 would aim to review patients approximately 3 monthly; 3/16 would not routinely increase frequency of review during pregnancy. Planned post-natal care was equally varied. 3/16 would routinely prescribe aspirin to all lupus women during pregnancy despite this being recommended for all women with SLE for prevention of pre-eclampsia2. Prescription of low molecular weight heparin was variable, and several responses were at odds with the current RCOG guidance on the subject3. 8/16 (50%) would prescribe corticosteroids judiciously in case of an acute disease flare.

Conclusion:

This survey has revealed significant variation in practice relating to rheumatic disease in pregnancy. Integrated care with colleagues from the regional referral centre for maternal medicine is required, in keeping with the recently published NICE guidance on the subject4. Adopting a hub and spoke model, with local centres working closely alongside a tertiary centre, will help optimise peri-partum care and outcome for patients with long-term rheumatic conditions.

References:

[1]Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) Saving Lives, Improving Mothers’ Care Maternal Report (December 2020). Available at https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10.pdf [Accessed 28 January 2021]

[2]National Institute for Health and Care Excellence (2019) Hypertension in pregnancy: diagnosis and management (NICE guideline 133) Available at https://www.nice.org.uk/guidance/ng133 [Accessed 28 January 2021]

[3]Royal College of Obstetricians and Gynaecologists (2015) Reducing the risk of venous thromboembolism during pregnancy and the puerperium (Green-top Guideline Number 37a) Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf [Accessed 5 January 2021]

[4]National Institute for Health and Care Excellence (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies (NICE guideline 121) Available at https://www.nice.org.uk/guidance/ng121 [Accessed 5 January 2021]

Disclosure of Interests:

None declared

AB0409 INTRAVENOUS ILOPROST: A REGION WIDE SURVEY OF CURRENT PRESCRIBING AMONGST HOSPITALS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Digital ulceration in systemic sclerosis is a severe and disabling aspect of this complex, multi-system disease. Traditionally, intravenous (IV) iloprost has been prescribed to treat the problem. Alternative oral medications including sildenafil and bosentan are now readily available, although NHS clinical commissioning policy is yet to be updated to reflect changes in drug costs. Use of IV iloprost across Wessex was audited to review current practice across the region.

Objectives:

To compare use of IV iloprost across 7 different hospital rheumatology departments

Methods:

Data was collected across 7 different NHS hospital sites using rheumatology specific pharmacy records for high cost drug prescribing and a single uniform data collection proforma, which was then analysed by 1 person to ensure uniformity of results. Case notes were reviewed retrospectively to determine diagnosis, frequency and duration of iloprost treatment, if patients had been considered for sildenafil treatment (including if sildenafil was prescribed, any cautions or contra-indications to treatment, dose and any reason for discontinuation of treatment) and if patients had been considered for bosentan treatment and if it was prescribed.

Results:

45 patients were identified currently receiving IV iloprost. 32/45 (71%) had a diagnosis of systemic sclerosis, mixed connective tissue disease (CTD) or undifferentiated CTD (to be called scleroderma group). 13/45 had other miscellaneous diagnoses which had resulted in digital ulceration. These 13 patients were excluded from further analysis relating to sildenafil or bosentan prescribing as these medications were not indicated for other causes of digital ulceration. In the scleroderma group, 27/32 (84%) had been considered for sildenafil treatment. Of these, 8/27 started and discontinued due to intolerance and 17/27 remained on sildenafil. In the scleroderma group, 9/32 had been considered for bosentan treatment, and of these 7/9 remained on bosentan.

Conclusion:

The authors have identified that IV iloprost is still widely used for management of digital ulceration in rheumatology departments across seven different hospitals in Wessex. Most of this group of patients would likely be eligible for treatment with sildenafil or bosentan. Sildenafil intolerance is a challenge to management. Consideration of bosentan as a treatment option was limited in this group, and may be a cost-effective alternative to IV iloprost which would also eliminate the risk of infection associated with IV access in a potentially immunosuppressed group of patients.

Disclosure of Interests:

None declared

POS0295 NO CAUSAL EFFECTS OF GENETICALLY DETERMINED SERUM URATE LEVELS ON THE RISK OF ALL-CAUSE AND SITE-SPECIFIC CANCER: A MENDELIAN RANDOMIZATION STUDY

Background:

Positive associations between urate levels and gout and the risk of some cancer types (urogenital, prostate, gastrointestinal and lung) have been reported in a number of observational studies; however, whether the relationship is causal remains uncertain.

Objectives:

The study aim was to evaluate a causal effect of genetically determined serum urate (SU) concentrations on cancer risks (overall and major cancer types) in individuals with European ancestry using Mendelian randomization (MR) analyses design.

Methods:

We used the individual-level data from two population-based Swedish cohorts including middle-aged subjects (mean follow-up = 21.2 years), Malmö Diet Cancer and Malmö Preventive Project (MDC/MPP), for one-sample MR setting. Data from a total of 17,597 individuals (n = 17,597 for SU at baseline, diagnoses during follow-up: 5659 for all-cause, 516 for bladder, 545 for lung, 791 for bowel, 1521 for prostate and 729 for breast cancer) was included. For two-sample MR, summary-statistic data for SU was obtained from Global Urate Genetic Consortium (GUGC: n = 110,347), while UK-Biobank data was employed for several major cancer outcomes (n = 36,815 for all-cause, 2,245 for bladder, 2,590 for lung, 4,488 for bowel, 6,474 for prostate and 10,274 for breast cancer). The definitions for cancer endpoints were matched for ICD9 and 10 codes between MDC/MPP and UK-Biobank cohorts. For both MR settings, a set of 26 urate-associated single nucleotide variants was selected to build-up the SU instrument (SU-instr) to test for a causal effect of SU on cancer outcomes. Statistical analysis, adjusted for age and sex, was done using multiple conventional MR methodologies and MR package in R (v4.0.2). A p < 0.05 was designated as statistically significant.

Results:

We found no causal effect of our SU-instr on neither all-cause nor site-specific cancer across all MR analyses (all p > 0.05). In MDC/MPP, SU-instr did not show a causal effect on the risk of all-cause [OR = 1.06, p = 0.32], bladder [OR = 0.96, p = 0.84], lung [OR = 1.26, p = 0.17], bowel [OR = 0.96, p = 0.81], prostate [OR = 1.05, p = 0.62], and breast [OR = 0.99, p = 0.98] cancer. Similar findings were made in the two-sample settings. Detailed results are provided in Table 1.

Conclusion:

Our MR study, using a series of causal inference approaches, does not support a causal effect of genetically determined SU for major cancer outcomes. There is no evidence to support changing SU levels by lifestyle or pharmacological intervention to attenuate the risk of major cancer types.

Table 1.

Results from a range of MR analyses for causal effect of SU on cancer risk in MDC/MPP (one-sample MR) and GUGC and UK-Biobank (two-sample MR) cohorts

One-sample MRCancer typeIVW2SLSGRSOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder0.96(0.68; 1.36)0.840.550.99(0.70; 1.42)0.990.94(0.67; 1.34)0.76Lung1.26(0.90; 1.77)0.170.891.29(0.91; 1.82)0.141.26(0.90; 1.77)0.17Bowel0.96(0.72; 1.28)0.810.440.95(0.72; 1.27)0.770.97(0.73; 1.28)0.83Prostate1.05(0.84; 1.31)0.620.841.04(0.83; 1.30)0.721.04(0.83; 1.30)0.69Breast0.99(0.74; 1.33)0.980.110.98(0.73; 1.32)0.920.98(0.73; 1.32)0.94All-cause1.06(0.93; 1.21)0.320.61.07(0.94; 1.21)0.281.07(0.94; 1.21)0.29Two-sample MRCancer typeIVWWeighted medianMR-EggerOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder1.02(0.88; 2.16)0.770.361.03(0.86; 2.10)0.71.03(0.83; 2.13)0.75Lung0.86(0.73; 1.08)0.070.040.86(0.73; 1.09)0.090.84(0.66; 1.16)0.15Bowel0.82(0.69; 1.02)0.03< 0.00010.89(0.78; 1.06)0.060.92(0.72;1.67)0.52Prostate1.00(0.91; 2.64)0.970.720.98(0.88; 2.17)0.770.94(0.83; 1.45)0.37Breast0.97(0.88; 1.95)0.670.00021.00(0.91; 2.70)0.990.95(0.81; 1.59)0.46All-cause0.96(0.90; 1.20)0.18< 0.00010.97(0.92; 1.23)0.210.93(0.86; 1.12)0.11

OR; odds ratio, 95% CI; 95% confidence interval, IVW; Inverse variance weighted method, 2SLS; two-stage least square, GRS; genetic risk score, p-Het; p-value for heterogeneity.

Disclosure of Interests:

None declared

Encoding Context Determines Risky Choice

Both memory and choice are influenced by context: Memory is enhanced when encoding and retrieval contexts match, and choice is swayed by available options. Here, we assessed how context influences risky choice in an experience-based task in two main experiments (119 and 98 participants retained, respectively) and two additional experiments reported in the Supplemental Material available online (152 and 106 participants retained, respectively). Within a single session, we created two separate contexts by presenting blocks of trials in distinct backgrounds. Risky choices were context dependent; given the same choice, people chose differently depending on other outcomes experienced in that context. Choices reflected an overweighting of the most extreme outcomes within each local context rather than the global context of all outcomes. When tested in the nontrained context, people chose according to the context at encoding and not retrieval. In subsequent memory tests, people displayed biases specific to distinct contexts: Extreme outcomes from each context were more accessible and judged as more frequent. These results pose a challenge for theories of choice that rely on retrieval as guiding choice.

P035 Inflammatory myopathy and metabolic disorders causing myopathies

Background/Aims 

Myopathies due to inborn errors of metabolism can be difficult to differentiate from inflammatory myopathies. Careful history, examination and laboratory tests are required to establish the diagnosis. We present a case of Riboflavin Transport Deficiency (Brown-Vialetto-Van Laere syndrome) masquerading as an inflammatory myopathy.

Methods 

A 37-year-old lady presented with severe proximal muscle weakness. She had background of sensory neuropathy and chronic anaemia. Notably, her sister had a history of similar symptoms. Creatine Kinase (CK) was 360 IU/L and lactate dehydrogenase (LDH) was 1700 IU/L. Inflammatory markers were normal. The Ro52 antibody was weakly positive. Electromyography showed evidence of a sensory neuropathy with myopathic features. There was symmetrical fatty infiltration and atrophy of the thigh muscles on magnetic resonance imaging (MRI). Positron emission tomography (PET-CT) scan showed widespread intense uptake in skeletal muscle groups. She was given 3 pulses of IV methyprednisolone followed by oral prednisolone which did not provide clinical benefit. Intravenous immune globulin was given when she developed bulbar weakness, with difficulty swallowing and breathing. She required non-invasive ventilation and nasogastric feed. There were necrotic and regenerative muscle fibres on the muscle biopsy, in keeping with rhabdomyolysis. Electron microscopy showed abundant lipid accumulation, suggestive of a metabolic disorder. Urinary organic acids were raised, triggering an acylcarnitines blood spot test, which were increased. This was compatible with riboflavin transport 'Brown-Vialetto-Van-Laere syndrome'. Riboflavin 500mg TDS was started resulting in significant clinical improvement. Prednisolone was weaned, genetic testing sent, and she was transferred for neurorehabilitation.

Results 

Riboflavin Transport Deficiency (Brown-Vialetto-Van Laere syndrome) is an autosomal recessive neurodegenerative genetic disorder. It affects females and males equally. Symptoms can appear in infants as well as adults. These include hearing and visual loss, bulbar palsy leading to dysphagia and speech problems. Paralysis of diaphragm may cause breathing difficulty. Initially it affects the proximal muscles and then generalized muscle weakness. Molecular genetic testing is required to confirm diagnosis. Patients may have abnormal plasma levels of flavin or acylcarnitine. Acylcarnitines are biological intermediates, used in the diagnosis of fatty acid oxidation disorders. Treatment includes riboflavin supplementation and supportive measures. Response to treatment is variable.

Conclusion 

This lady was initially managed as inflammatory myopathy but did not respond to high dose methylprednisolone. There were atypical features including normal inflammatory markers, MRI thighs showing predominantly fatty infiltration and muscle atrophy and the muscle biopsy with abundant lipid accumulation suggestive of a metabolic disorder. We are awaiting full results of genetic testing. This case is a reminder of the importance of tissue diagnosis and reassessing the initial diagnosis if the clinical picture changes or patients do not respond as expected to treatment.

Disclosure 

M. Malik: None. A. Mason: None. B. Davidson: None. J. Furby: None.

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.