Strategies to enhance physical activity in people with Rheumatoid Arthritis: A Delphi survey

INTRODUCTION

Managing symptoms, resisting functional decline and maintaining health and independence are key motivators for people with Rheumatoid Arthritis (RA) who successfully engage with physical activity (PA). To inform PA support for people with RA the aim was to determine whether the broader RA population share similar beliefs and strategies regarding PA to those who report successful engagement.

METHODS

A modified two-stage Delphi approach. 200 patients from four National Health Service rheumatology departments received a postal questionnaire containing statements relating to engagement with PA derived from prior interview data from physically active individuals with RA. Statements rated as agree or strongly agree by >50% of respondents were retained and the same respondents asked to rate and prioritize potential PA intervention components. Ethical approval: Oxford C Research Ethics Committee (ref 13/SC/0418).

RESULTS

Questionnaire one received 49 responses (11 males, 37 females, 1 unknown), mean age 65 years (range 29-82). Low levels of PA were reported by 60% of respondents. Questionnaire two responses (n = 36) indicated that a PA intervention should include information about prevention of RA symptoms worsening and benefits of PA for joints; help participants to achieve improved pain management and a feeling of being in control of their RA. For PA maintenance it was important that medication controlled symptoms, and PA instructors understood RA to ensure safety.

CONCLUSIONS

A key factor to consider when designing a PA intervention for people with RA is that education from a knowledgeable instructor should underpin programme delivery alongside effective medication. Programmes may need tailoring based on demographics; this should be explored in future studies.

Health professionals' perspectives on psychological distress and meeting patients' support needs in rheumatology care settings: A qualitative study

BACKGROUND

Patients with inflammatory rheumatic diseases (IRDs) face challenges including pain, fatigue and disease flares. Evidence suggests their levels of anxiety and depression are higher compared to the general population. Rheumatology teams report psychologically distressed patients have additional support needs and require more clinical time. Little is currently known about models of support and their integration into care pathways.

AIM

To understand rheumatology health professionals' perspectives on patients' psychological distress and ways to meet support needs.

METHODS

The study used a qualitative design, with data collected in telephone semi-structured interviews. Inductive thematic analysis was used to analyse the data.

RESULTS

Fifteen interviews were conducted. Two main themes with sub-themes represent the data: Theme 1: 'No one shoe fits all'-the many manifestations of distress in patients (sub-themes: recognising distress, dealing with distress, dealing with life events alongside an IRD) and Theme 2: 'If rheumatology could be interwoven with psychological principles'-the need to attend to the psychological impact of IRDs, alongside the physical impact (sub-themes: priority given to physical health, working together to help patients in distress, how should patient distress be measured?, the need for extra time and resources).

CONCLUSION

Distress can be obvious or hidden, cause issues for patients and health professionals and lead to poor engagement with care provision. Health professionals described the powerful link between physical and mental distress. This study suggests psychological support provision should be embedded within the rheumatology team and that patients' emotional wellbeing should be given equal priority to their physical wellbeing.

725 Experience of Implementing Diversity Teaching into University of Oxford

Background

Medical education should equip students with the necessary skills to support the diverse population they treat and work with and be confident to act as an ally for patients and colleagues. We found there to be a gap for a diversity module in the curriculum at Oxford University.

Method

We created a diversity training session for over 300 medical students aiming to;

The course consisted of a series of talks conducted by a senior lecturer on diversity, doctors, patients, and students, followed by small-group case-based teaching facilitated by a final-year medical student and a junior doctor. All facilitators underwent training by a senior lecturer on diversity. The cases encouraged students to reflect on their own personal biases and enact how they would confront discrimination on the wards. Students completed a survey before and after the session, rating self-confidence on six key learning points.

Results

91.4% students agreed the session was useful to their medical training. There was a significant increase in students who felt confident implementing all learning points: defining key terms (post-session: 95.4%, pre-session: 82.3%); understanding health inequalities (post-session: 93%, pre-session: 54.6%); awareness of personal bias (post-session: 87.9%, pre-session: 70%); partaking in allyship (post-session: 95%, pre-session: 89.5%); and being an active bystander (post-session: 91.4%, pre-session: 45.9%). 79.3% felt confident to challenge acts of discrimination (33.6% pre-session).

Conclusions

This session educates and empowers students to challenge acts of discrimination. We recommend the implementation of similar sessions at all medical schools.

POS1472-HPR CLINICIANS’ PERSPECTIVES ON PSYCHOLOGICAL DISTRESS AND MEETING PATIENTS’ SUPPORT NEEDS IN RHEUMATOLOGY CARE SETTINGS

Background:

People with inflammatory rheumatic diseases (IRDs) face challenges that include fluctuations in pain, fatigue and flares of disease activity, complex medical regimens, and decisions about when to seek clinical help with symptoms [1,2]. Evidence suggests levels of anxiety and depression are higher in people with IRDs compared to the general population [3]. Rheumatology teams report that psychologically distressed patients can have additional support needs and require more time. Patients’ concerns include health-related anxiety and difficulty accepting the diagnosis. This group can have poor outcomes and poor adherence to treatments. However, little is currently known about optimal ways to meet these patients’ support needs.

Objectives:

To understand rheumatology clinicians’ perspectives on psychological distress in care settings with the long-term aim to develop a proposed model/pathway of support.

Methods:

Telephone interviews were conducted with members of UK rheumatology teams who have clinical experience with patients experiencing distress. The semi-structured interviews explored both ‘what happens now’ (current clinical practice) and ‘what should happen’ (acceptable models of future psychological support provision). The semi-structured format provided flexibility to probe more deeply and develop new lines of enquiry based on participants’ responses.

Results:

Fourteen interviews were conducted with rheumatology clinicians including 2 consultants, 4 nurses, 1 physiotherapist, 4 occupational therapists, 2 clinical psychologists and 1 podiatrist. Inductive thematic analysis was used to analyse the data. Two main themes represent the data (Table 1).

Table 1.Main ThemeSub-themes1. ‘No one shoe fits all’ – the many manifestations of distress in patients.‘I pick up on distress as increased emotion…tearfulness and sadness I suppose, but also frustration, anger...A lot of helplessness comments’1. ‘Distress can be quite emotive and quite obvious, but then it can also hide away’2. ‘They’re [patients] trying to manage their own conditions, but they’re also trying to manage life’2. ‘If Rheumatology could be interwoven with psychological principles’ – the need to attend to the psychological impact of IRDs, alongside the physical impact.‘The physical and mental health side of things are so closely linked because one affects the other…after a while they [patients] don’t really know what’s affecting what’1. ‘Prioritising physical health…sometimes the stress gets not thought about’2. ‘Make best use of everyone in the team to work with patients who are struggling’3. ‘For the psychological side of things we don’t measure anything about that at all’

Conclusion:

Distress can be obvious or hidden and cause issues for both patient and clinician. It can lead to poor engagement with care provision. Clinicians differ in their perceptions of distress and in their thresholds for dealing with distress and have described the inconsistency of support offered for distressed patients. They described the powerful link between physical and mental distress, the vicious cycle that can develop, and the benefits of incorporating a psychological approach to treatment. This study suggests psychological support should be embedded within the team as it is felt there is a need for speciality understanding and for patients’ emotional wellbeing to consistently be given equal priority to their physical wellbeing.

References:

[1]Gettings L. Psychological well-being in rheumatoid arthritis: a review of the literature. Musculoskeletal care 2010;8(2):99-106. doi: 10.1002/msc.171 [published Online First: 2010/03/17]

[2]Homer D. Addressing psychological and social issues of rheumatoid arthritis within the consultation: a case report. Musculoskeletal care 2005;3(1):54-9. doi: 10.1002/msc.26 [published Online First: 2006/10/17]

[3]Isik A, Koca SS, Ozturk A, et al. Anxiety and depression in patients with rheumatoid arthritis. Clinical rheumatology 2007;26(6):872-8. doi: 10.1007/s10067-006-0407-y [published Online First: 2006/08/31]

Disclosure of Interests:

None declared

Promoting engagement in physical activity in early rheumatoid arthritis: A proof-of-concept intervention study

OBJECTIVE(S)

The aim of this study is to test the feasibility and acceptability of promoting engagement in physical activity in early rheumatoid arthritis (PEPA-RA) to inform a future trial.

DESIGN

A 'proof of concept' study was carried out.

SETTING

This study was conducted in community hospitals delivered by musculoskeletal primary care physiotherapists.

PARTICIPANTS

Participants were 12 adults with rheumatoid arthritis (RA) diagnosed 6-24 months previously (nine females, three males; mean age 58 years, range 23-79).

INTERVENTION

The intervention consisted of five sessions, that is, four group sessions and one individual session facilitated by a physiotherapist over 12 weeks including patient education and support for behaviour change as well as supervised practical exercise.

MAIN OUTCOMES

The main outcomes were attendance, completion of outcome measures, adverse events, and participant and physiotherapist feedback views relating to the intervention.

RESULTS

Overall attendance was 85%, with sessions missed due to illness or RA flare. Outcome measure completion ranged from 83% to 100%. There were no clinically meaningful changes in pain or function at 12 weeks, but mean 6-min walk distance improved from 394 to 440 m. No serious adverse events were reported, and participants were generally positive about the intervention. Suggested minor modifications for the group sessions included venue accessibility and ensuring that physical activity time was protected. Several participants indicated that they would have liked to receive the intervention earlier following diagnosis.

CONCLUSIONS

PEPA-RA and the outcomes appear feasible and acceptable. Overall, small beneficial effects were noted at 12 weeks for most outcomes. Challenges to recruitment resulted in a smaller than anticipated sample size, and the majority of participants were active at baseline indicating that future recruitment needs to target less active individuals.

Keeping physically active with rheumatoid arthritis: semi-structured interviews to explore patient perspectives, experiences and strategies

BACKGROUND

Regular physical activity is safe and beneficial for people with rheumatoid arthritis (RA) but the majority of people with RA are less active than the general population and have a higher risk of co-morbidities. Exploring strategies used by physically active people with RA could inform effective methods to support those who are less active.

OBJECTIVE

To explore the perspectives, experiences and strategies employed by people with RA who successfully engage with regular physical activity.

DESIGN

Individual semi-structured interviews and thematic analysis.

PARTICIPANTS

A purposive sample of physically active people with RA.

RESULTS

Twelve females and three males participated (mean age 56, range 29 to 80; mean disease duration 13 years, range 10 months to 46 years). Analysis revealed eight constructs clustered into three themes. Theme 1: 'the individual' incorporated constructs of symptoms, feelings and role; theme 2: 'management' incorporated medical and self-management; theme 3: 'physical activity' incorporated constructs of type of physical activity, including barriers or facilitators. Participants reported a long history of physical activity prior to diagnosis and good support networks. All participants recognised that physical activity was key to their RA management, acknowledged the benefits from engaging in physical activity and were able to overcome barriers. Participants had strong beliefs that physical function would decline without regular physical activity.

CONCLUSIONS

People with RA who successfully maintain physical activity are motivated by a desire to manage symptoms, resist functional decline and maintain health and independence. These findings should be explored with a wider range of people with RA.

Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?

BACKGROUND AND STUDY AIM

Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting.

METHODS

Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05.

RESULTS

368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores.

CONCLUSIONS

Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.

Occupational asthma caused by cellulase and lipase in the detergent industry

Three employees from two different detergent companies were investigated for occupational asthma, using skin prick tests, serum specific IgE, and specific bronchial challenge. Two were challenged with lipase and one with cellulase. All three cases had immunological evidence of sensitisation to the detergent enzymes with which they worked. Bronchial challenge in each provoked a reproducible dual asthmatic response, which reproduced their work related symptoms. These are the first reported cases of occupational asthma attributable to cellulase and lipase in the detergent industry. Four of the most common enzymes used in this industry have now been reported to cause occupational asthma; continued vigilance and caution are needed when working with these or other enzymes.

Maternal and fetal immune responses of cattle inoculated with Neospora caninum at mid-gestation

The humoral and cell-mediated immune responses of pregnant cattle and their fetuses were examined at intervals after infection with Neospora caninum tachyzoites at mid-gestation (day 140). All cattle seroconverted and interferon gamma was detected in supernatants of peripheral blood mononuclear cells stimulated with specific antigen. At day 14 post-inoculation (pi), specific cell proliferation responses were detected in the lymph node draining the site of inoculation and in the uterine lymph node. The peak response was recorded in the majority of maternal lymph nodes by day 28 pi and cells from the maternal retropharyngeal lymph node, which in part drains the central nervous system, showed no specific activity to N. caninum until day 42 pi. This changing pattern of immune responsiveness may reflect parasite invasion and development within different host tissues. Fetal lymph node cells showed mitogen responsiveness from day 14 pi (day 154 of gestation) and also showed N. caninum-specific cell proliferation and interferon-gamma responses by day 28 pi (day 168 of gestation). At day 42 pi, specific cell-mediated immune responses were not apparent; however, N. caninum-specific fetal IgG and IgM antibodies were detected.

The pathogenesis of neosporosis in pregnant cattle: inoculation at mid-gestation

To investigate the pathogenesis of bovine neosporosis, 14 pregnant cattle were each inoculated subcutaneously with either 10(7) or 5 x 10(8) Neospora caninum (strain NC1) tachyzoites at 140 days' gestation. Serial necropsies were then carried out over an 8-week period. In the placenta, Neospora DNA and histopathological changes were observed in samples taken 14 days post-inoculation (dpi), with focal necrosis of maternal caruncular septa and fetal placental villi, serum leakage, and a maternal and fetal inflammatory response. At subsequent samplings, pathological changes in the placenta showed signs of resolution. No parasitaemia was detected in the dams in the two weeks following inoculation. In the fetus, Neospora DNA was detected at 14 dpi, and histopathological changes in the fetal central nervous system at 28 and 42 dpi consisted of small foci of necrosis and inflammation. Resolution of placental lesions during the experiment indicated that the disease was being controlled, and fetal infection, although established, did not appear to be progressing to a fatal outcome. The two doses of tachyzoites produced similar results, but the higher dose elicited earlier and more extensive lesions in the placenta and fetus. Control animals remained negative for all parameters recorded. It is concluded that in bovine neosporosis the placenta plays a central role in the pathogenesis and epidemiology of the infection, and that while primary tissue destruction by the parasite may endanger the fetus, the maternal and fetal inflammatory responses may also be damaging.

Surveillance of occupational skin disease: EPIDERM and OPRA

Consultant dermatologists in the U.K. have been reporting to EPIDERM, a voluntary surveillance scheme for occupational skin disease, since February 1993; reporting by occupational physicians to the scheme began in May 1994 and was superseded in January 1996 by OPRA (Occupational Physicians Reporting Activity). Currently 244 dermatologists and 790 occupational physicians report incident cases to these schemes. During the 6 years to January 1999 a total of 12, 574 new cases of occupational skin disease was estimated from reports by consultant dermatologists and 10,136 cases estimated from occupational physicians (since May 1994). The annual incidence of occupational contact dermatitis using data from both schemes was 12. 9 per 100,000 workers. The incidence of contact dermatitis per 100, 000 workers increased with age in men from 4.9 (age 16-29 years) to 6.6 (age 45-60 years); in women a higher rate (9.5) was apparent in the younger age group, with lower rates in older female workers. High rates in young workers were associated with wet work and in older workers with exposure to oils. For men, high rates of contact dermatitis were seen in reports from both schemes for chemical operatives, machine tool setters and operatives, coach and spray painters and metal workers. For women, high rates were found for hairdressers, biological scientists and laboratory workers, nurses and those working in catering. The most frequent agents for contact dermatitis were rubber chemicals and materials (14.1% of cases reported by dermatologists), soaps and cleaners (12.7%), nickel (11. 9%), wet work (11.1%), personal protective equipment (6.2%), petroleum products (6.3%), cutting oils and coolants (5.6%), and epoxy and other resins (6.1%). In the 1608 estimated cases of skin cancer all but 4% were attributed to ultraviolet radiation. Cases of contact urticaria attributed to latex peaked in 1996, with a decline in cases since that time.