Feasibility and acceptability of multidisciplinary team training in health coaching: Case study in adolescent rheumatology

The central importance of the biopsychosocial model of chronic disease is increasingly recognised in the management of long-term conditions (LTC), which are often associated with chronic pain, fatigue and disability. Despite the physical and mental health impact, 'struggle' to maintain self-efficacy, gap in effective transition to adult pathways and long term consequences of poor disease control and lifestyle choices in young people with LTCs, innovation in this age range is rarely reported in generic journals. This paper explores the feasibility and acceptability of health coaching with young service users to increase engagement and self-management, achieved through multidisciplinary team (MDT) training in Adolescent Rheumatology.

A simple, clinically usable whole-body MRI system of joint assessment in adolescents and young people with juvenile idiopathic arthritis

OBJECTIVES

To introduce and evaluate a simple method for assessing joint inflammation and structural damage on whole-body MRI (WBMRI) in juvenile idiopathic arthritis (JIA), which is usable in clinical practice.

METHODS

The proposed system utilises post-contrast Dixon WBMRI scans. Joints are assessed for synovitis (grade 0-2) and structural damage (present/absent) at 81 sites. The synovitis grading is based on features including above-normal intensity synovial enhancement, synovial hypertrophy, joint effusion, subarticular bone marrow oedema and peri-articular soft tissue oedema.This system was evaluated in a prospective study of 60 young people (47 patients with JIA and 13 controls with non-inflammatory musculoskeletal pain) who underwent a WBMRI. Three readers (blinded to diagnosis) independently reviewed all images and re-reviewed 20 individual scans. The intra- and inter-reader overall agreement (OA) and the intra- and inter-reader Gwet's agreement coefficients 2 (GAC2) were measured for the detection of a) participants with ≥1 joint with inflammation or structural damage and b) joint inflammation or structural damage for each joint.

RESULTS

The inter-reader OA for detecting patients with ≥1 joint with inflammation, defined as grade 2 synovitis (G2), and ≥1 joint with structural damage were 80% and 73%, respectively. The intra-reader OA for readers 1-3 were 80-90% and 75-90% respectively. The inter-reader OA and GAC2 for joint inflammation (G2) at each joint were both ≥85% for all joints but were lower if grade 1 synovitis was included as positive.

CONCLUSION

The intra- and inter-reader agreements of this WBMRI assessment system are adequate for assessing objective joint inflammation and damage in JIA.

Detection of inflammation by whole-body MRI in young people with juvenile idiopathic arthritis

OBJECTIVES

To assess the frequency of joint inflammation detected by whole-body MRI (WBMRI) in young people (YP) with JIA and controls, and to determine the relationship between WBMRI-detected inflammation and clinical findings.

METHODS

YP aged 14-24 years, with JIA (patients) or arthralgia without JIA (controls), recruited from one centre, underwent a WBMRI scan after formal clinical assessment. Consensus between at least two of the three independent radiologists was required to define inflammation and damage on WBMRI, according to predefined criteria. YP with JIA were deemed clinically active as per accepted definitions. The proportions of YP with positive WBMRI scans for joint inflammation (≥1 inflamed joint) as well as serum biomarkers were compared between active vs inactive JIA patients and controls.

RESULTS

Forty-seven YP with JIA (25 active and 22 inactive patients) and 13 controls were included. WBMRI detected joint inflammation in 60% (28/47) patients with JIA vs 15% (2/13) controls (difference: 44%, 95% CI 20%, 68%). More active than inactive JIA patients had WBMRI-detected inflammation [76% (19/25) vs 41% (9/22), difference: 35% (95% CI 9%, 62%)], and this was associated with a specific biomarker signature. WBMRI identified inflammation in ≥ 1 clinically inactive joint in 23/47 (49%) patients (14/25 active vs 9/22 inactive JIA patients).

CONCLUSIONS

WBMRI's validity in joint assessment was demonstrated by the higher frequency of inflammation in JIA patients vs controls, and in active vs inactive JIA patients. WBMRI found unsuspected joint inflammation in 49% YP with JIA, which needs further investigation of potential clinical implications.

Prevalence of chronic pain or analgesic use in children and young people and its long-term impact on substance misuse, mental illness, and prescription opioid use: a retrospective longitudinal cohort study

Background

Epidemiological studies suggest chronic and recurrent pain affects around a quarter of children, while 8% report intense and frequent pain. The long-term implications of chronic pain in childhood are uncertain. Using electronic health records (EHRs) we used both disease codes and medicines prescription records to investigate the scale of chronic pain and long-term analgesic use in children and young people (CYP), and if chronic pain and/or use of analgesic medicines at an early age is associated with substance misuse, use of prescription opioids, and poor mental health in adulthood.

Methods

We conducted a cohort study using data from IQVIA Medical Research Data UK. We identified individuals aged 2-24 with exposure to either a diagnostic code indicating chronic pain (diagnosis-exposed), repeat prescription for medicines commonly used to treat pain (prescription-exposed), or both. Follow-up began at 25, and the unexposed population acted as comparators. We calculated hazard ratios (HR) for mental health and substance misuse outcomes, and rate ratios (RR) for opioid prescriptions in adulthood. Additionally, we investigated which diagnoses, if any, were over-represented in the prescription-exposed subgroup.

Findings

The cohort constituted 853,625 individuals; 146,431 had one or more of the exposures of interest (diagnosis-exposed = 115,101, prescription-exposed = 20,298, both-exposed = 11,032), leaving 707,194 as comparators. Median age at index exposure was 18.7 years (IQR 14.7-22.3). On average during follow-up, the pooled exposed group had, respectively, a 31% and 17% higher risk of adverse mental health and substance misuse outcomes (adjusted HR [95% CI] of 1.31 [1.29-1.32] and 1.17 [1.11-1.24]). Exposed individuals also received prescription opioids at double the rate of unexposed individuals on average during follow-up (adjusted RR 2.01 [95% CI 1.95-2.10]). Outcomes varied between exposure subgroups, with prescription- and both-exposure tending to have worse outcomes. Unlike these two subgroups, in the diagnosis-exposed subgroup we did not detect a greater risk of substance misuse.

Interpretation

Chronic pain in CYP is associated with increased prescription opioid use and adverse mental health outcomes in adulthood, as is repeat prescription for analgesic medicines, but only the latter is also associated with substance misuse in adulthood. It is essential to avoid the harms of under-treating pain in CYP while giving due consideration to the risks posed by analgesic medicines. Early recognition of chronic pain in CYP and utilising non-pharmacological management options may help minimise overprescribing, and long-term reliance on dependence-forming-drugs.

Funding

AL is an NIHR funded academic clinical fellow, and was supported by funding from UCLH Charities while carrying out this work. RS and DS are part of the Advanced Pain Discovery Platform and were supported by a UKRI and Versus Arthritis grant (MR/W002566/1) as part of the Consortium Against Pain Inequality. AW was supported by the Wellcome Trust (220558/Z/20/Z).

Relationship between ethnicity and multidisciplinary intervention for young people with rheumatic and musculoskeletal diseases

Introduction

There is growing recognition of the impact of societal factors on health throughout a patient's lifespan. The COVID-19 pandemic has exposed the impact of racial disparity on health outcomes.

Aims

We aimed to investigate the association between ethnicity and the multidisciplinary team (MDT) interventions for young people (YP) with complex care needs.

Method

This retrospective, single-centre, cross-sectional study was conducted within the department of adolescent and young adult rheumatology at University College Hospital, London, between August 2019 and August 2021. We extracted demographic, clinical and laboratory data. The index of multiple deprivation was extracted from the Office for National Statistics database. R software was used for analysis.

Results

We identified 310 YP referred to the MDT with a median age of 18 years (interquartile range 17-19). The female patient to male patient ratio was 2.4. Over a third of our cohort were from deprived areas. Comparison between Black, Asian and minority ethnic (BAME) and White ethnic groups revealed significant differences in terms of referral for pain optimisation (p=0.006), social support (p<0.00001), and adherence and non-clinic attendance (p=0.0004).

Conclusion

Our findings reveal the importance of quality data for early identification and support of vulnerable YP, particularly those from BAME communities.

AB1566-HPR SHIFTING THE MINDSET: USING A HEALTH COACHING APPROACH FOR HEALTH PROMOTING CONSULTATION IN ADOLESCENT RHEUMATOLOGY

Background

Juvenile rheumatic diseases have a significant negative impact on health early in life which may affect later health outcomes. The Adolescent and Young Adult Rheumatology Department (AYAD) at University College London Hospitals (UCLH) looks after over 2,000 young people with a variety of rheumatological conditions and provides developmentally appropriate interdisciplinary (ID) approach to healthcare.

Health coaching (HC) is “a behavioural intervention that facilitates participants in establishing and attaining health promoting goals in order to change lifestyle-related behaviour, with the intent of reducing health risks, improving self-management of chronic conditions, and increasing health related quality of life”.[1] Evidence shows that health coaching can improve health related behaviours including medication adherence, patient activation, and use of healthcare resources. [2-4]

Objectives

The aim of this project is to enable young people attending the AYAD to establish and achieve their own health-promoting goals and thereby change behaviour and increase confidence in self-management. As a first stage the aim was to develop health coaching capabilities within our ID Team by March 2022.

Methods

The strategy to deliver this project included commissioning a recognised core skills health coaching course for multidisciplinary team (MDT) members. Pre and post course surveys were completed by participants.

Results

All the AYA team members comprising 3 physiotherapists, 2 nurse specialists, a transition pathway coordinator, 4 consultants and 2 senior registrars took part in the health coaching workshops.

A pre course survey (10/ 12 responded) revealed that 70% of MDT members felt their consultations focused solely on young people’s medical/clinical care. 80% reported they discuss lifestyle choices such as sleep, and weight management. 40 % felt that their consultation times were long enough to discuss resources that would support long-term management. 30% reported they felt effective in facilitating Young people and their families to self-manage and/or had sufficient health coaching awareness to facilitate behaviour change.

The course was delivered over 2 separate days, one week apart, and included educational material, presentations, group discussion and skills development delivered in a coaching style.

A post course survey (11/12 responses) demonstrated 100% of participants were satisfied with the course content, delivery, facilitation and opportunities to work and learn with colleagues, and felt that the skills were applicable to their work. They reported that the skills learned could be applied beyond healthcare, for example, with colleagues or in leadership roles, the course helped to raise self-awareness of behaviours that can negatively and positively impact patient and family engagement in their care, and that using some techniques and small changes to practice could potentially have a big impact on quality of care and outcomes as well as patient and staff experience.

Conclusion

Health coaching skills were considered as a useful tool by all AYAD team members.

Skills gained on the course were considered useful in managing young people and applicable in settings beyond clinical care.

The next stage of this project will include embedding the techniques learned into clinical practice and measuring qualitative and quantitative outcomes over time

References

[1]van Ryn, M., & Heaney, C. A. (1997). Developing effective helping relationships in health education practice. Health Education & Behavior, 24(6), 683–702

[2]https://www.health.org.uk/publications/reducing-emergency-admissions-unlocking-the-potential-of-people-to-better-manage-their-long-term-conditions

[3]Newman P, McDowell A, Life changing conversations: clinicians experience of health coaching in the east of England, 3-2-147 Future Hosp J June 1, 2016

[4]https://www.england.nhs.uk/wp-content/uploads/2020/03/health-coaching-implementation-and-quality-summary-guide.pdf

Disclosure of Interests

None declared

P159 The potential impact of whole-body MRI on the rheumatologists’ disease activity assessment and treatment plan for patients with juvenile idiopathic arthritis

Background/Aims

To assess the potential for whole-body MRI (WBMRI) to modify rheumatologists’ impression of disease activity and treatment management in adolescent patients with JIA.

Methods

Two rheumatology consultants experienced in managing people with JIA reviewed anonymised clinical data from an opportunistic sample of 30 patients with JIA (aged 15-24), not under their care. The cohort were clinically assessed by a senior rheumatology fellow before undergoing a research WBMRI scan, reported for musculoskeletal inflammation by a radiologist blinded to clinical information. The clinical findings and patient-reported outcomes recorded on that visit, alongside the patients’ present and past treatments, imaging and laboratory results were included in the clinical summaries examined by each rheumatologist. They then independently rated their impression of disease activity (See Table 1) and documented their resulting treatment recommendations per patient, in a two-stage approach. The first stage data analysis did not include the WBMRI reports. In stage two, the rheumatologists re-rated disease activity and treatment suggestions in light of WBMRI findings. The responses without and with the WBMRI findings were compared for each consultant and between them.

Results

Disease activity ratings were changed after reviewing the WBMRI reports in 16/30 and 17/30 patients by the rheumatologist A and B respectively. The activity category (‘active’ to ‘inactive’ or vice versa) changed in 7/16 and 4/17 cases, respectively. The certainty in the activity status increased for both rating clinicians (from ‘likely’ to ‘definitely’ in the same category or from ‘not sure’ to any other category) in 7/16 and 11/17 cases, respectively, whilst decreased for both in two cases. Disease activity assessments and treatment recommendations with and without WBMRI, are summarised in Table 1. Inter-rater agreement without and with WBMRI regarding disease activity (active/inactive) was 84.00% and 82.1% respectively, and regarding the intention to change treatment (yes/no) was 63.3% and 83.3%, respectively.

Conclusion

WBMRI scan findings changed the rheumatologists’ impression or level of certainty regarding disease activity in about half the patients and treatment plan in about one-third. Therefore, a larger study involving a greater number of rheumatologists across the country, should be considered to validate these results.

Disclosure

V. Choida: None. R.S. Tattersall: None. J.J. Manson: None. D. Sen: None. C. Ciurtin: None. M.A. Hall-Craggs: None.

P174 HLA B27 status and disease phenotype: a cohort study of 223 patients with enthesitis-related arthritis

Background/Aims

Enthesitis-related arthritis (ERA) is a subtype of juvenile idiopathic arthritis (JIA) accounting for 10-20% of patients with JIA. ERA is associated with a poor prognosis compared to other JIA subtypes. Whilst a high proportion of patients with ERA are HLA-B27 positive, the correlation between HLA-B27 status and disease phenotype is not well described. The aim of our study was to investigate the influence of HLA-B27 status on ERA phenotype.

Methods

Demographic and clinical data were collected and HLA-B27 positive and negative patients were compared. All subjects included met ILAR classification criteria. The data were analysed using R software (R version 4.0.4). Median and interquartile range (IQR) were calculated for continuous variables and frequency and percentage for categorical variables. Subgroup comparison was performed using the chi-squared test for qualitative variables, and Wilcoxon rank-sum for quantitative variables. P values less than 0.05 were considered significant.

Results

223 patients were included in this study. The median age of symptom onset was 12 years (IQR: 9-14). The median disease duration was 11 years (IQR: 7-14). 18% of patients had family history of HLA-B27-related disease and 67% had positive HLA-B27. 54% of patients were on conventional disease modifying anti-rheumatic drugs (cDMARDs). 80% were on biologic DMARDs (bDMARD). HLA-B27 positive patients (n = 148) and negative patients (n = 68) were compared. Our analysis revealed a higher proportion of male patients in the HLA-B27 positive cohort (74% [n = 111] versus 59% [n = 39], p = 0.02). HLA-B27 positive subjects developed ERA at an older age compared to the HLA-B27 negative group at 12 versus 11 years, respectively (p = 0.02). HLA-B27 positive patients also had a higher probability of an axial phenotype within 12 months of disease onset 51% (n = 75) in the HLA-B27 positive group versus 32% (n = 22) in the HLA-B27 negative group (p = 0.01). At any point of disease course, sacroiliitis was also more common in the HLA-B27 positive group (78% [n = 116] versus 63% [n = 43], p = 0.01), who also had a higher usage of bDMARDS (74% [n = 110] versus 56% [n = 38], p = 0.006). There was no significant difference between the two groups in terms of ethnicity, family history of HLA-B27 disease or the prevalence of extra-articular manifestations, including uveitis.

Conclusion

Our study revealed that patients with ERA who were HLA-B27 positive, were more likely to be male, developed disease at an older age and had a higher probability of axial phenotype at onset and later in disease. They also had an increased bDMARD requirement. These data suggest that HLA-B27 confers a worse prognosis clinically which is consistent with findings from other studies.

Disclosure

A. Bouraoui: None. C. Fisher: None. J. Glanville: None. D. Sen: None.

P167 COVID-19 perniosis, a differential diagnosis to consider in adolescent patients presenting with chilblain-like lesions

Background/Aims

Chilblain-like lesions (perniosis) have been reported frequently during COVID-19 pandemic in children and adolescents with no history of exposure to cold temperatures or underlying autoimmune conditions. Patients with these skin changes reported mild COVID-19 symptoms or previous contact with confirmed COVID-19 cases before they became symptomatic. In the majority of cases, a causal relationship between SARS-CoV-2 infection and chilblain-like lesion has not been proven.

Methods

Retrospective review of patients with chilblain-like lesions, possibly secondary to SARS-CoV-2 infection, presenting to a tertiary Adolescent Rheumatology service between January and August 2021.

Results

We identified five, male, adolescent patients (mean age, 16 years old) who presented with new onset of chilblain-like lesions affecting fingers, toes and heels in December 2020, which coincided with the peak of second wave of COVID-19 infection. One month prior to skin changes occurrence, 3 out of 5 patients experienced mild respiratory COVID-19-like symptoms and the rest of the patients were asymptomatic but were in contact with COVID-19 positive cases following outbreaks in schools. 1 of 3 symptomatic patients had a positive COVID-19 PCR test prior to skin manifestations. 2 out of 4 patients with heel lesions had deep, full thickness skin loss heel ulcers and 2 of 5 patients had superficially ulcerated lesions on a finger and toes, respectively, resulting in inability to attend school. None of the patients had any other symptoms or signs to suggest an underlying autoimmune connective tissue disorder. Demographics, clinical features and serological data are summarised in Table 1. One patient underwent a biopsy of heel ulcer which was histologically consistent with perniosis. In two patients (40%) chilblain like lesions resolved spontaneously within 2 months. Three patients (60%), with progressive ulcerated lesions, required various combinations of treatments with aspirin, calcium channel blockers (nifedipine), topical or oral steroids and hydroxychloroquine with complete resolution of symptoms within 6 months.

Conclusion

Chilblain-like lesions, including heel involvement associated with mildly symptomatic COVID-19 infection, have been reported before. Our mini-case series raises awareness of ulcerating chilblain like lesions possibly secondary to COVID-19 in adolescent patients, which require early recognition and instigation of treatment leading to better patient’s outcomes.

Disclosure

N. Gak: None. V. Choida: None. M. Leandro: None. D. Sen: None. C. Ciurtin: None. C. Fisher: None.

P027 Challenges and opportunities in embedding quality data into routine clinical practice using electronic health record systems

Background/Aims

The emergence of the electronic health record system (EHRS) creates opportunities for standardising clinical data which can be used for service improvement and research. However, there are also challenges related to EHRS use particularly with respect to data quality and availability. In this project, our goal is to enhance the use of EHRS to enable timely access to reliable high quality clinical data which can be used for research and Quality Improvement. We aimed to improve the entry of structured clinical data starting with problem list, medication list and core outcome variables by 70% within 12 months.

Methods

We audited our current practice and developed an improvement strategy to incorporate standardized documentation into our adolescent and young adult (AYA) rheumatology clinics. We initially extracted a baseline report for AYA patients to establish our baseline data quality and availability. We also compared structured data to narrative data. Then we organised meetings to develop a shared understanding of the challenges. Subsequent departmental meetings were organised to prioritise and then agree on actions which were summarised in a driver diagram. Then we ran 5 cycles of change and measured data over time including the weekly proportion of clinic encounters using standardised problem lists, medication lists, core outcomes variables. We also measured the use of Smart tools built within our EHRS. Smart-Tools are processes that enable efficiency through easier ordering, navigation and documentation in an EHRS. Using the patient interface ‘MyCare’, we engaged with our patients to encourage them to prepare for their appointment including updating their medication list and completing health questionnaires.

Results

Initial audit comparing structured and narrative data, revealed poor quality data with 50% of problem lists documented in a structured manner. Of those, 20% were not entered correctly. 70% of medication lists were entered in a non-structured manner. 80% of those with structured medication lists were entered inaccurately. There was no structured documentation of core outcomes variables or joint examination in all encounters which was also inconsistently entered in the free text. Over the last 12 months, 5 cycles of change were implemented testing a number of interventions including developing clinic encounters templates and smart tools within EHRS. The weekly entry of structured problem list improved from 50% to 98%. The Smart-Phrase use and AYA template weekly use rate improved from 0% to 70% and the entry of core outcome variables has improved from 0% to 30% of cases.

Conclusion

This project supports the feasibility of implementing standardized data into routine clinical practice that can be used for research and service improvement. This has created an opportunity to improve data quality and accuracy. Most importantly, this work has facilitated a standardisation of clinical practice and better engagement between clinicians and patients.

Disclosure

A. Bouraoui: None. C. Fisher: None. D. Sen: None.

The role of whole-body MRI in musculoskeletal inflammation detection and treatment response evaluation in inflammatory arthritis across age: A systematic review

OBJECTIVE

To evaluate the relation between whole-body MRI (WBMRI) outcomes and disease activity measures, including clinical examination, composite scores, and other imaging outcomes, and the ability of WBMRI to detect treatment response in patients with inflammatory arthritis (IA) across age.

METHODS

Human studies published as full text or abstract in the PubMed and MEDLINE and Cochrane databases from inception to 11th April 2021 were systematically and independently searched by two reviewers. Studies including patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA) or unclassified inflammatory arthritis (UA) who underwent WBMRI and which reported on disease outcomes were included.

RESULTS

Nineteen full-text studies were eligible for inclusion: 2 interventional, 7 retrospective and 10 prospective observational studies, comprising 540 participants (SpA 38.7%, RA 24.8%, JIA 17.8%, PsA 11.5%, healthy controls 5.9%, UA 1.3%). Abstracts of 6 conference papers were reported separately. Five studies in PsA and SpA and 4 in RA measured the frequency of WBMRI-detected and clinically-detected synovitis, and all found the former to be more frequent. Less enthesitis was detected by WBMRI than clinical examination in 5/8 studies. After biologic treatment, the WBMRI inflammation scores declined in 3 studies in SpA and 2 in RA, whilst in 3 studies the results were equivocal.

CONCLUSION

The ability of WBMRI to assess disease activity and treatment response in IA was adequate overall. Further studies are needed to corroborate WBMRI findings with IA outcomes and investigate the clinical value of subclinical inflammation.

Occupational health management of work-related stress: guidelines versus practice

BACKGROUND

Work-related stress, anxiety and depression (WRSAD) are common, overlapping mental health problems burdened with major medical, occupational, institutional and societal implications. Current occupational health (OH) management of WRSAD is based on clinical and managerial guidelines and individual risk assessment.

AIMS

The study sought to identify patterns of OH advice in WRSAD and the relationships between the OH advice, available evidence, experience and expertise of the OH doctors (OHDs).

METHODS

A retrospective cross-sectional analysis of 101 first-time OH consultations for WRSAD by nine OHDs.

RESULTS

The three most common OH interventions included follow-up OH consultations, adjusted duties and referrals for counselling. All OHDs preferred a light-touch approach but the less experienced and qualified OHDs were more proactive and prescriptive.

CONCLUSIONS

In the absence of a specific occupational medical guideline for the management of WRSAD, the OH interventions may be guided by clinical guidelines, individual risk assessment, the client's circumstances or the experience, expertise and preferences of the OHDs. In the study group, OH interventions were under-utilized and not consistently applied. Our findings support the argument for OH guideline for WRSAD to improve the consistency and effectiveness of OH interventions. This is important given the scale of the problem and the recent increase in WRSAD during the COVID-19 pandemic.

Similarities and Differences Between Juvenile and Adult Spondyloarthropathies

Spondyloarthritis (SpA) encompasses a broad spectrum of conditions occurring from childhood to middle age. Key features of SpA include axial and peripheral arthritis, enthesitis, extra-articular manifestations, and a strong association with HLA-B27. These features are common across the ages but there are important differences between juvenile and adult onset disease. Juvenile SpA predominantly affects the peripheral joints and the incidence of axial arthritis increases with age. Enthesitis is important in early disease. This review article highlights the similarities and differences between juvenile and adult SpA including classification, pathogenesis, clinical features, imaging, therapeutic strategies, and disease outcomes. In addition, the impact of the biological transition from childhood to adulthood is explored including the importance of musculoskeletal and immunological maturation. We discuss how the changes associated with adolescence may be important in explaining age-related differences in the clinical phenotype between juvenile and adult SpA and their implications for the treatment of juvenile SpA.

O14 Frequency and site of clinically unsuspected synovitis on whole-body MRI in juvenile idiopathic arthritis

Background/Aims 

Magnetic resonance imaging can facilitate the diagnosis of JIA, but is also increasingly used for monitoring disease activity in individual joints. This prospective study aims to measure the frequency of subclinical synovitis on whole-body MRI, in adolescent patients with JIA.

Methods 

JIA patients were recruited from a tertiary adolescent and young adult rheumatology clinic, between September 2019 and August 2020. All patients were examined by a senior rheumatology registrar, before undergoing a contrast enhanced whole-body MRI scan. Patients were assigned to a clinically active or inactive group, depending on their active joint count (AJC); active patients had AJC≥ 1, while the clinically inactive patients had an AJC =0. The post-contrast, water-only mDixon images were assessed for synovitis by one radiologist, blinded to clinical information. Only joints that were definitely abnormal were counted as synovitic. Eighty-one joints per patient were examined with both methods. The presence of subclinical synovitis in a patient was defined as synovitis in one or more joints on MRI, which were not active clinically.

Results 

Thirty-two patients aged 15 to 24 were included in the analysis. The patient characteristics and the frequency of subclinical synovitis are summarised in the table. Subclinical synovitis was detected in a similar proportion of JIA patients in both active and inactive groups (46.7% vs. 41.2%, P = 0.76). The most frequent region with subclinical synovitis was the hindfoot, detected in 22% (7/32) of JIA patients and 17.2% (11/64) of hindfoot joints assessed by MRI. The second most common joint with clinically unsuspected inflammation was the knee, found in 19% (6/32) of JIA patients and 14% (9/64) knee joints. Similarly, 16% (5/32) of the adolescent patients had active disease in the hip, ankle or midfoot joints. The frequency of elbow involvement was also considerable, with 12% (7/58) of joints with subclinical synovitis in 14% (4/29) of JIA patients.

Conclusion 

In conclusion, 43.8% of JIA patients had subclinical synovitis on whole-body MRI scan with no significant difference between the clinically active vs. inactive JIA patients. Large joints were predominantly affected. Further research is required to validate our findings in a larger cohort of JIA patients.

Disclosure 

V. Choida: None. C. Ciurtin: None. T.J.P. Bray: None. D. Sen: None. C. Fisher: None. M. Leandro: None. M.A. Hall-Craggs: None.

Role of free volumes and segmental dynamics on ion conductivity of PEO/LiTFSI solid polymer electrolytes filled with SiO2 nanoparticles: a positron annihilation and broadband dielectric spectroscopy study

The limited ionic conductivity of polymer electrolytes is a major issue for their industrial application. Enhancement of ionic conductivity in the poly(ethylene oxide), PEO, based electrolyte has been achieved by loading passive nanofillers such as SiO₂ nanoparticles (NPs). To investigate the role of modifications in free volume characteristics and the polymer chain dynamics induced by the loading of passive fillers on the ionic conductivity of the PEO based ternary electrolyte, a systematic investigation has been carried out using positron annihilation and broadband dielectric spectroscopy. As a result of interfacial interactions, the loading of SiO₂ NPs alters the semi-crystalline morphology of PEO resulting in a higher crystallinity at lower loadings due to the surface confinement of PEO chains, and the formation of smaller PEO crystallites at higher loadings due to interparticle nanoconfinement. These modifications are accompanied by a decrease in free volume fraction at the lowest loading (0.5 wt%) followed by an increase at higher loadings (≥2.0 wt%). The Almond-West formalism considering two different universalities in different temperature and frequency ranges has been used to explain the ion-conduction process at different NP loadings. The Li ion conductivity is observed to be maximum for a 5.0 wt% loading of SiO₂ NPs. The enhancement in ionic conductivity is observed to be directly correlated with the free volume characteristics and segmental dynamics of the PEO matrix, confirming their role in ion transport in polymer electrolytes.

Chest X-Ray image and pathological data based artificial intelligence enabled dual diagnostic method for multi-stage classification of COVID-19 patients

<abstract> <p>The use of Artificial Intelligence (AI) in combination with Internet of Things (IoT) drastically reduces the need to test the COVID samples manually, saving not only time but money and ultimately lives. In this paper, the authors have proposed a novel methodology to identify the COVID-19 patients with an annotated stage to enable the medical staff to manually activate a geo-fence around the subject thus ensuring early detection and isolation. The use of radiography images with pathology data used for COVID-19 identification forms the first-ever contribution by any research group globally. The novelty lies in the correct stage classification of COVID-19 subjects as well. The present analysis would bring this AI Model on the edge to make the facility an IoT-enabled unit. The developed system has been compared and extensively verified thoroughly with those of clinical observations. The significance of radiography imaging for detecting and identification of COVID-19 subjects with severity score tag for stage classification is mathematically established. In a Nutshell, this entire algorithmic workflow can be used not only for predictive analytics but also for prescriptive analytics to complete the entire pipeline from the diagnostic viewpoint of a doctor. As a matter of fact, the authors have used a supervised based learning approach aided by a multiple hypothesis based decision fusion based technique to increase the overall system's accuracy and prediction. The end to end value chain has been put under an IoT based ecosystem to leverage the combined power of AI and IoT to not only detect but also to isolate the coronavirus affected individuals. To emphasize further, the developed AI model predicts the respective categories of a coronavirus affected patients and the IoT system helps the point of care facilities to isolate and prescribe the need of hospitalization for the COVID patients.</p> </abstract>

Association of Anxiety With Pain and Disability but Not With Increased Measures of Inflammation in Adolescent Patients With Juvenile Idiopathic Arthritis

Objective

To explore whether anxiety and depression are associated with clinical measures of disease for adolescent patients with juvenile idiopathic arthritis (JIA) and whether anxiety and depression are associated with increased peripheral proinflammatory cytokine levels in adolescent patients with JIA and in healthy adolescent controls.

Methods

A total of 136 patients with JIA and 88 healthy controls ages 13–18 years completed questionnaires on anxiety and depressive symptoms. For patients with JIA, pain, disability, physician global assessment (using a visual analog scale [VAS]), and number of joints with active inflammation (active joint count) were recorded. In a subsample, we assessed lipopolysaccharide‐stimulated interleukin 6 (IL‐6) production from peripheral blood mononuclear cells, serum IL‐6, cortisol, and C‐reactive protein levels. Data were analyzed by linear regression analysis.

Results

Levels of anxiety and depressive symptoms in patients with JIA were not significantly different than those in healthy controls. For patients with JIA, anxiety was significantly associated with disability (β = 0.009, P = 0.002), pain (β = 0.029, P = 0.011), and physician global assessment VAS (β = 0.019, P = 0.012), but not with active joint count (β = 0.014, P = 0.120). Anxiety was not associated with any laboratory measures of inflammation for JIA patients. These relationships were also true for depressive symptoms. For healthy controls, there was a trend toward an association of anxiety (but not depressive symptoms) with stimulated IL‐6 (β = 0.004, P = 0.052).

Conclusion

Adolescent patients with JIA experience equivalent levels of anxiety and depressive symptoms as healthy adolescents. For adolescent patients with JIA, anxiety and depressive symptoms are associated with pain, disability, and physician global assessment VAS, but not with inflammation.

AB1084 A SYSTEMATIC REVIEW OF THE ABILITY OF WHOLE BODY MRI TO ASSESS DISEASE ACTIVITY AND TREATMENT RESPONSE IN INFLAMMATORY ARTHRITIS

Background:

Whole body MRI (WBMRI) is an imaging technique that allows the assessment of the spine and peripheral joints in patients with inflammatory arthritis (IA) in a single examination. Depending on the protocol, it can potentially identify synovitis, enthesitis, spondyloarthritis and chronic structural changes.

Objectives:

To evaluate the performance of WBMRI in patients with IA for detecting inflammation compared with clinical assessments and to show changes in response to treatment.

Methods:

We conducted a systematic search of the electronic databases MEDLINE, EMBASE and Cochrane Library. Two authors selected independently the eligible studies, extracted the predefined data and assessed the quality using the QUADAS2 tool. Studies that reported a)disease activity scores, b)patient or physician reported outcomes or c)results from other imaging tests in IA patients who underwent WBMRI were included.

Results:

Fourteen studies out of 471 met our inclusion criteria. The majority of the studies were performed in Spondyloarthritis [SpA] (n=9), followed by Rheumatoid Arthritis [RA] (n=4) and Psoriatic Arthritis [PsA] patients (n=3). Nine studies provided clinical and MRI outcome measures. There was great heterogeneity in the quality of studies, disease specific outcomes reported and methodology used to compare with MRI findings. One study documented low correlation between 28 swollen/tender joint count and MRI bone marrow oedema (BME)/synovitis in RA patients, whereas another reported that 31% of MRI negative joints (other than hand joints) exhibited tenderness. In PsA, one study demonstrated correlation between 28 swollen joint count and BME (r=0.54,p=0.03). Superiority of WBMRI in the detection of synovitis and enthesitis over clinical examination was documented in two studies with SpA patients. A third study in SpA showed a ranging agreement of 49 to 100% between clinical and WBMRI enthesitis.

Treatment response to biologics was assessed by WBMRI in 7 studies (5 in SpA, 2 in RA). In RA, one study showed numerical (but not statistically significant) reduction of WBMRI joint count at week 16 and 52 of Adalimumab treatment, whereas the reduction was statistically significant for the subset of patients achieving good EULAR response at week 16. The other study demonstrated a reduction in WBMRI synovitis and bone oedema scores after 1 year of anti-TNF or Tocilizumab treatment (median DAS28 score decreased from 5.1 to 2.1). A multicentre open label study reported a reduction in the number of MRI enthesitis lesions, spinal and sacroiliac joint scores at week 48, year 2 and 3 of Etanercept treatment in SpA patients. The mean BASDAI score decreased from 5.4 at baseline to 1.5 at year 2 and 2.2 at year 3. Improvement in WBMRI scores in SpA was also documented in one Adalimumab and one further Etanercept study.

Conclusion:

There was a variable level of correlation between clinical and WBMRI outcome measures across the included studies. The clinical significance of inflammation detected by WBMRI in some studies remains unclear. Many of the devised WBMRI scores appear to decrease after biologic treatment. Further studies are needed to determine the accuracy of WBMRI in detecting inflammation and its potential utility for clinical practice.

Disclosure of Interests:

Varvara Choida: None declared, Anastasia-Vasiliki Madenidou: None declared, Debajit Sen: None declared, Margaret Hall-Craggs: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences

The pain trajectory of juvenile idiopathic arthritis (JIA): translating from adolescent patient report to behavioural sensitivity in a juvenile animal model

BACKGROUND

While pain is a common symptom in JIA patients, it remains unclear why some JIA patients develop ongoing or persistent pain. Complex clinical and social settings confound analysis of individual factors that may contribute to this pain. To address this, we first undertook a retrospective analysis of pain reports in a JIA patient cohort with the aim of identifying potential factors contributing to persistent pain. We then carried out an experimental laboratory study, using joint inflammatory pain behaviour in rodents, to validate the role of these factors in the onset of persistent pain under controlled conditions.

METHODS

Patients: Retrospective analysis of anonymised pain visual analogue scale (VAS) scores and accompanying clinical scores from 97 JIA patients aged 13-19 (mean: 16.40 ± 1.21) collected over 50 weeks. Rats: Experimental study of pain behaviour following intra-articular microinjection of complete Freund's adjuvant (CFA) in adolescents (n = 25) and young adults (n = 43). Some animals (n = 21) had been previously exposed to joint inflammation in infancy or adolescence.

RESULTS

Patients: Cluster analysis of patient pain VAS scores revealed three trajectories over 50 weeks: consistently low pain (n = 45), variable pain (n = 30) and persistently high pain (n = 22). Number of actively inflamed joints did not differ in the three groups. High pain at a single visit correlated with greater physician global assessment of disease activity, while a high pain trajectory over 50 weeks was associated with more limited joints but fewer actively inflamed joints. Rats: Rodents administered ankle joint CFA also exhibit low, medium and high joint pain sensitivities, independent of joint inflammation. Prolonged inflammatory pain behaviour was associated with high background pain sensitivity, following joint inflammation at an earlier stage in life.

CONCLUSIONS

Both JIA patients and rodents differ in their individual pain sensitivity independent of the concurrent joint inflammation. Using experimental animal models allows us to isolate physiological factors underlying these differences, independently of social or clinical factors. The results suggest that a history of prior arthritic activity/joint inflammation may contribute to high pain sensitivity in adolescents with JIA.

Aquaporin-4 IgG antibody-related disorders in patients with juvenile systemic lupus erythematosus

OBJECTIVE

The aim of this study was to: (a) screen a large group of unselected patients with juvenile systemic lupus erythematosus for anti-aquaporin 4 antibodies (AQP4-Ab); (b) identify clinical and laboratory predictors of the presence of AQP4-Ab positivity in juvenile systemic lupus erythematosus.

METHODS

Sera from 90 patients with juvenile systemic lupus erythematosus were tested for the presence of AQP4-Ab using a cell-based assay. Demographics, clinical and immunological features, treatment received were summarized. Fisher's exact test was used to identify clinical predictors of positivity for AQP4-Ab.

RESULTS

Five of 90 (5.5%) patients tested positive for AQP4-Ab, all of which had neurological involvement, mainly transverse myelitis and optic neuritis. AQP4-Ab-positive patients were more likely to have neurological symptoms (P = 0.002), less likely to experience dermatological manifestations (P = 0.045), and less likely to have detectable anti-dsDNA antibodies (P = 0.022). These patients were also more likely to have received anti-epileptic (P = 0.023) and anti-coagulant (P = 0.007) drugs.

CONCLUSIONS

The findings of this study indicate that some patients with juvenile systemic lupus erythematosus develop antibodies against aquaporin-4 and may be at risk of developing a neurological clinical phenotype. We suggest that all juvenile systemic lupus erythematosus patients should be systematically screened for the presence of AQP4-Ab and this may help identify a high risk for neurological involvement in juvenile systemic lupus erythematosus.

Development of a benchmarking toolkit for adolescent and young adult rheumatology services (BeTAR)

BACKGROUND

Young people (YP; 12-24 years old) with rheumatic diseases face many challenges associated with chronic illness in addition to the physiological and psychosocial changes of adolescence. Timely access to developmentally appropriate multidisciplinary care is key to successfully managing rheumatic diseases, but gaps in the care of this vulnerable age group still exist. This study aimed to develop a benchmarking toolkit to enable comparative evaluation of YP rheumatology services in order to promote best practice and reduce variations in service delivery.

METHODS

A staged and consultative method was used across a broad group of stakeholders in the UK (YP, parents/other carers, and healthcare professionals, HCPs) to develop this toolkit, with reference to pre-existing standards of YP-friendly healthcare. Eighty-seven YP (median age 19 years, range 12-24 years) and 26 rheumatology HCPs with 1-34 years of experience caring for YP have participated.

RESULTS

Thirty quality criteria were identified, which were grouped into four main domains: assessment and treatment, information and involvement, accessibility and environment, and continuity of care. Two toolkit versions, one to be completed by HCPs and one to be completed by patients, were developed. These were further refined by relevant groups and face validity was confirmed.

CONCLUSIONS

A toolkit has been developed to systematically evaluate and benchmark YP rheumatology services, which is key in setting standards of care, identifying targets for improvement and facilitating research. Engagement from YP, clinical teams, and commissioners with this tool should facilitate investigation of variability in levels of care and drive quality improvement.

Sacroiliac Joint Ankylosis in Young Spondyloarthritis Patients Receiving Biologic Therapy: Observation of Serial Magnetic Resonance Imaging Scans

OBJECTIVE

To assess the temporal relationship between initiating biologic therapy and magnetic resonance imaging (MRI) scores of inflammation and structural damage in young patients with spondyloarthritis.

METHODS

A local adolescent/young adult patient rheumatology database was searched for patients ages 12-24 years who had evidence of sacroiliitis on MRI and a clinical diagnosis of enthesitis-related arthritis (ERA) with axial involvement or nonradiographic axial spondyloarthritis. Patients treated with tumor necrosis factor inhibitor (TNFi) therapy who had undergone a minimum of 1 MRI scan before and 2 MRI scans after starting TNFi therapy (over ≥2 years) were included. Images of the sacroiliac joints were scored for inflammation and structural abnormalities (including erosions, fat metaplasia, and fusion). The effects of TNFi therapy and of time since initiation of TNFi therapy on inflammation and structural abnormalities were assessed using a mixed-effects regression analysis.

RESULTS

Twenty-nine patients (ages 12-23 years) with ERA or nonradiographic axial spondyloarthritis who underwent TNFi therapy were included. Inflammation scores were significantly lower in patients receiving TNFi treatment (P = 0.013), but there was no significant effect of time from TNFi initiation on inflammation (P = 0.125). Conversely, there was no significant effect of active TNFi treatment on fusion scores (P = 0.308), but fusion scores significantly increased with time from TNFi initiation (P < 0.001); a similar positive relationship between time since biologic start and fat metaplasia scores was observed.

CONCLUSION

TNFi therapy failed to prevent the eventual development of joint ankylosis in this cohort of young patients with spondyloarthritis, despite a substantial reduction in inflammation with TNFi therapy.

Depressive symptoms, pain and disability for adolescent patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study

Objectives

To determine if depressive symptoms assessed near diagnosis associate with future measures of pain, disability and disease for adolescent patients diagnosed with JIA.

Methods

Data were analysed from JIA patients aged 11–16 years recruited to the Childhood Arthritis Prospective Study, a UK-based inception cohort of childhood-onset arthritis. Depressive symptoms (using the Mood and Feelings Questionnaire; MFQ), active and limited joint count, disability score (Childhood Health Assessment Questionnaire), pain visual analogue scale and patient’s general evaluation visual analogue scale were collected. Associations between baseline measures (first visit to paediatric rheumatologist) were analysed using multiple linear regression. Linear mixed-effect models for change in the clinical measures of disease over 48 months were estimated including MFQ as an explanatory variable.

Results

Data from 102 patients were analysed. At baseline, median (IQR) age was 13.2 years (11.9–14.2 years) and 14.7% scored over the MFQ cut-off for major depressive disorder. At baseline, depressive symptoms significantly associated with all clinical measures of disease (P ⩽ 0.01). High baseline depressive symptoms scores predicted worse pain (P ⩽ 0.005) and disability (P ⩽ 0.001) 12 months later but not active and limited joint counts.

Conclusions

Adolescent patients with JIA and depressive symptoms had more active joints, pain and disability at the time of their first specialist appointment. The associations between baseline depression and both pain and disability continued for at least one year, however, this was not the case for active joint count.

An Artificial Intelligence Platform for Asset Management Contributes to Better Decision-making Tools for Operations, Maintenance, and Utility Management

  An Artificial Intelligence system was developed and implemented for water, wastewater, and reuse plants to improve management of sensors, short and long-term maintenance plans, asset and investment management plans. It is based on an integrated approach to capture data from different computer systems and files. It adds a layer of intelligence to the data. It serves as a repository of key current and future operations and maintenance conditions that a plant needs have knowledge of. With this information, it can simulate the configuration of processes and assets for those conditions to improve or optimize operations, maintenance and asset management, using the IViewOps (Intelligent View of Operations) model. Based on the optimization through model runs, it is able to create output files that can feed data to other systems and inform the staff regarding optimal solutions to the conditions experienced or anticipated in the future.

Developing and Evaluating JIApp: Acceptability and Usability of a Smartphone App System to Improve Self-Management in Young People With Juvenile Idiopathic Arthritis

BACKGROUND

Flare-ups in juvenile idiopathic arthritis (JIA) are characterized by joint pain and swelling and often accompanied with fatigue, negative emotions, and reduced participation in activities. To minimize the impact of JIA on the physical and psychosocial development and well-being of young people (YP), it is essential to regularly monitor disease activity and side effects, as well as to support self-management such as adherence to treatment plans and engagement in general health-promoting behaviors. Smartphone technology has the potential to engage YP with their health care through convenient self-monitoring and easy access to information. In addition, having a more accurate summary of self-reported fluctuations in symptoms, behaviors, and psychosocial problems can help both YP and health care professionals (HCPs) better understand the patient's condition, identify barriers to self-management, and assess treatment effectiveness and additional health care needs. No comprehensive smartphone app has yet been developed in collaboration with YP with JIA, their parents, and HCPs involved in their care.

OBJECTIVES

The objective of this study was to design, develop, and evaluate the acceptability and usability of JIApp, a self-management smartphone app system for YP with JIA and HCPs.

METHODS

We used a qualitative, user-centered design approach involving YP, parents, and HCPs from the rheumatology team. The study was conducted in three phases: (1) phase I focused on developing consensus on the features, content, and design of the app; (2) phase II was used for further refining and evaluating the app prototype; and (3) phase III focused on usability testing of the app. The interview transcripts were analyzed using qualitative content analysis.

RESULTS

A total of 29 YP (aged 10-23, median age 17) with JIA, 7 parents, and 21 HCPs were interviewed. Major themes identified as the ones that helped inform app development in phase I were: (1) remote monitoring of symptoms, well-being, and activities; (2) treatment adherence; and (3) education and support. During phase II, three more themes emerged that informed further refinement of the app prototype. These included (4) adapting a reward system to motivate end users for using the app; (5) design of the app interface; and (6) clinical practice integration. The usability testing during phase III demonstrated high rates of overall satisfaction and further affirmed the content validity of the app.

CONCLUSIONS

We present the development and evaluation of a smartphone app to encourage self-management and engagement with health care for YP with JIA. The app was found to have high levels of acceptability and usability among YP and HCPs and has the potential to improve health care and outcomes for this age group. Future feasibility testing in a prospective study will firmly establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with arthritis.