Reducing diagnostic delay in hypophosphatasia: a case series of 14 patients presenting to general rheumatology

OBJECTIVES

Hypophosphatasia (HPP) is a rare genetic metabolic bone disease that can cause chronic pain and fractures. Its hallmark is a persistently low serum ALP. HPP is now recognised by many osteoporosis specialists, but other specialists, such as rheumatologists and primary care physicians, may be less aware of this condition, causing diagnostic delay and possible harm to these patients. Our objective was to highlight features that can reduce this delay.

METHODS

We retrospectively analysed 14 patients that presented with musculoskeletal pain to general rheumatology clinic at St. George's Hospital and were subsequently diagnosed with HPP.

RESULTS

Median diagnostic delay was 13 years. All patients had an ALP below reference range for age and gender, with lowest mean ALP of 16 IU/L. All but one patient were women with median age of 51 years. Most common presentation was peripheral joint pain in 85.7% of patients. This was due to early-onset CPPD (calcium pyrophosphate deposition disease) in 71.4% of patients, osteoarthritis in 50%, or bursitis in 50%. Axial pain was reported in 64% of patients due to osteoarthritis or spinal stenosis. Fifty percent of patients had a history of long bone pain. Fifty percent had previous fracture(s). A total of 28.6% of patients had psoriatic arthritis, of which 1 patient had spondyloarthropathy, and 4 patients also had enthesitis.

CONCLUSION

Patients with HPP can present to rheumatology with musculoskeletal pain, and if a persistently low ALP is confirmed, this may reduce the diagnostic delay of this rare disease. Similar to other rheumatologic patients, musculoskeletal pain in HPP was noted in peripheral joints and in the spine with almost a third of patients having psoriatic arthritis. Pain was also noted in the long bones, a feature consistent with metabolic bone disease. The diagnosis of HPP was also more likely in those patients with a personal or family history of dental disease or arthritis.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The Safety of Continued Oral Anticoagulation Therapy in Joint Injections and Aspirations: A Qualitative Review of the Current Evidence

ABSTRACT

Performing joint aspirations and injections on patients taking long-term oral anticoagulants poses a clinical conundrum. This review aimed to quantify the safety of performing joint procedures in these patients in terms of bleeding risk. In addition, it aimed to identify, in those receiving vitamin K antagonists, what level of international normalized ratio (INR) is the safest.A review of the medical literature was performed (electronic searches in Ovid [MEDLINE], EMBASE, and the Cochrane Library). English language original reports of patients undergoing joint injections or aspirations performed on anticoagulant therapy, published within the last 10 years, were included.Seven studies met the inclusion criteria. Patients were taking a variety of anticoagulants: warfarin, acenocoumarol, and direct oral anticoagulants. Four cases of hemorrhage were reported after 5427 procedures, over a pooled 32-year period, across 9 centers. The INR values were available for 3 cases with bleeding complications: values were 1.9, 2.3, and 3.4.Authors of all studies concluded that joint injection is safe in patients on anticoagulants. A variety of joints and approaches, reversal, or withholding of anticoagulation and bridging with low molecular weight heparin did not seem to alter bleeding risk. Bleeding complications remained low even in those with renal or hepatic impairment or those taking concomitant antiplatelets.In conclusion, joint aspiration and injection are safe in patients taking anticoagulants. Anticoagulation should not be routinely discontinued in these patients; decisions should be made on a case-by-case basis. Because of low event numbers, a recommended safe maximum INR value for joint procedures cannot be determined.

O01 Hypophosphatasia in adults at a specialist centre in the UK: the spectrum of musculoskeletal disease

Background

Hypophosphatasia (HPP) is a condition arising due to mutations in the gene encoding the tissue-non-specific alkaline phosphatase (TNSALP) isoenzyme (ALPL), leading to deficient activity of TNSALP. It can be inherited as an autosomal dominant or recessive disorder. There are over 300 known mutations in the ALPL gene associated with HPP, leading to varying degrees of deficiency in the activity of TNSALP. There are six clinical forms of HPP, with a great degree of heterogeneity in clinical presentation. The adult form is generally milder than perinatal and infantile forms, which may be fatal. Estimates of the prevalence of HPP range from 0.3/100,000 (more severe forms), to 1/6370 (less severe forms). Diagnosis is based on clinical features, biochemical abnormalities (low serum alkaline phosphatase (ALP), raised serum pyridoxal-5’-phosphate and raised urinary phosphoethanolamine), and genetic testing. The dentition and musculoskeletal system are often affected. Low trauma, metatarsal and atypical subtrochanteric femoral fractures may be seen, often with poor healing. However in some cases, individuals may present with calcium pyrophosphate deposition disease (CPPD) or non-specific musculoskeletal features. Under-recognition of HPP and diagnostic delay are therefore common. This retrospective observational study, performed at a specialist centre, aimed to characterise the spectrum of musculoskeletal manifestations in adults with HPP.

Methods

Patient records of adults with a confirmed diagnosis of HPP seen in the Rheumatology department at St George’s Hospital, London, were consulted. Clinical features at presentation and those developed subsequently were recorded, with a focus on musculoskeletal manifestations. Biochemical, genetic and radiographic data were also obtained.

Results

Fifteen individuals (two male, thirteen female) with a confirmed diagnosis of HPP were identified. Average delay to diagnosis was 21 years. The commonest presenting feature for the whole cohort was joint pain or swelling, followed by dental caries. The commonest presenting musculoskeletal feature in childhood was fracture (often low trauma and recurrent); in adults it was joint pain followed by poor mobility. There were eight diagnoses of osteoarthritis, five cases of tendinopathy and three of bursitis. Four patients had previously been diagnosed with psoriatic arthritis and three with pseudogout. Other musculoskeletal diagnoses included patellofemoral dysfunction, hypermobility and musculoskeletal tumours (two individuals). The upper limb joints were most commonly affected; some individuals reported back and knee pain. Musculoskeletal morbidity was high: eight individuals had poor mobility or abnormal gait, and three were unable to work through ill health.

Conclusion

There is a long delay to diagnosis of HPP. The condition may present in adults with non-specific musculoskeletal or dental features. It is therefore important to consider the diagnosis in individuals with a low ALP and musculoskeletal features which may suggest HPP, such as fractures or CPPD. Earlier recognition may avoid potential harm through inappropriate bisphosphonate or high-dose vitamin D therapy.

Disclosures

J. Kotecha None. S. Mansour None. C. Hall None. K.E. Moss None.

Resolution of adhesive small bowel obstruction with a protocol based on Gastrografin administration

The use of Gastrografin may have a therapeutic effect on resolving adhesive small bowel obstruction.

Adhesive Small Bowel obstruction (ASBO) accounts for the majority of patients with small bowel obstruction. Most patients are managed conservatively; frequent admissions create a considerable burden. We sought to examine the adherence to the Bologna guidelines for the management of ASBO in a high volume tertiary center and whether or not Gastrografin had a therapeutic effect.

A comparison was made between an initial retrospective audit looking at ASBO and a prospective re-audit after applying standards derived from the Bologna guidelines. During re-audit it was found that more patients underwent conservative management and fewer patients had surgery as first line management. In the re-audit, those who had to undergo surgery within/after a period of 72h of conservative management were also fewer. Whether they were managed surgically primarily or after a period of conservative management, the average length of stay was also shorter. In comparison to the preliminary audit, there appeared to be no change in the way that medical history and physical examination was documented during the re-audit. However, there was a marked difference in the use of appropriate blood tests and CT scans.

Changes were made successfully following the initial audit results and have been implemented, thus closing the audit loop. This study shows that the use of Gastrografin has decreased the need for surgical intervention in a group of patients with small bowel obstruction.

Radiology examination as a diagnostic aid in presentations with wide differential diagnoses: Case report of new Hodgkin's lymphoma on a background of poorly controlled HIV

Hodgkin's lymphoma and disseminated Mycobacterium avium complex (MAC) infection share similar clinical features; both may affect human immunodeficiency virus (HIV)-positive individuals. We discuss a patient with poorly controlled HIV-infection presenting with chest sepsis, dyspnoea and weight loss. Whilst the initial working diagnosis was that of MAC infection, pathology results had not met diagnostic criteria. Lymph node biopsy instead revealed classical Hodgkin's lymphoma. We discuss the role of radiological examination in cases of diagnostic uncertainty.

Patient confidence and quality of life in idiopathic pulmonary fibrosis and sarcoidosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) and sarcoidosis impact significantly on health-related quality of life (HRQOL). There are few studies on the impact of patient confidence on HRQOL in these conditions.

OBJECTIVES

1. To investigate whether patient confidence is associated with HRQOL, anxiety, depression, dyspnoea or fatigue. 2. To assess if patient confidence is associated with inpatient admissions, access to community healthcare and, for IPF patients, mortality and disease severity.

METHODS

Study participants self-completed seven questionnaires: Hospital Anxiety and Depression Scale, EuroQol 5D (EQ5D), King's Brief Interstitial Lung Disease questionnaire, St George's Respiratory Questionnaire, MRC dyspnoea scale, Fatigue Assessment Scale and a non-validated questionnaire assessing patient confidence, symptom duration and access to community healthcare. Lung function and follow-up data were collected from hospital electronic databases. Spearman's rank correlation coefficients were calculated to assess for correlation between patient confidence, questionnaire variables and inpatient admissions. Chi-square tests were performed to assess for association between patient confidence, mortality and disease severity.

RESULTS

75 IPF patients and 69 sarcoidosis patients were recruited to the study. Patient confidence in IPF was significantly negatively correlated with depression and fatigue, and significantly positively correlated with EQ5D scores, but not healthcare outcomes. No associations were found between confidence and any of the variables assessed in sarcoidosis.

CONCLUSIONS

Lower levels of confidence in IPF patients are associated with higher levels of depression and fatigue and worse HRQOL. Efforts should be made to improve patient confidence to assess the impact on HRQOL.

Plasma Vascular Endothelial Growth Factor Concentration and Alveolar Nitric Oxide as Potential Predictors of Disease Progression and Mortality in Idiopathic Pulmonary Fibrosis

Background: Declining lung function signifies disease progression in idiopathic pulmonary fibrosis (IPF). Vascular endothelial growth factor (VEGF) concentration is associated with declining lung function in 6 and 12-month studies. Alveolar nitric oxide concentration (CANO) is increased in patients with IPF, however its significance is unclear. This study investigated whether baseline plasma VEGF concentration and CANO are associated with disease progression or mortality in IPF. Methods: 27 IPF patients were studied (maximum follow-up 65 months). Baseline plasma VEGF concentration, CANO and pulmonary function tests (PFTs) were measured. PFTs were performed the preceding year and subsequent PFTs and data regarding mortality were collected. Disease progression was defined as one of: death, relative decrease of ≥10% in baseline forced vital capacity (FVC) % predicted, or relative decrease of ≥15% in baseline single breath diffusion capacity of carbon monoxide (TLCO-SB) % predicted. Results: Plasma VEGF concentration was not associated with progression-free survival or mortality. There was a trend towards shorter time to disease progression and death with higher CANO. CANO was significantly higher in patients with previous declining versus stable lung function. Conclusion: The role of VEGF in IPF remains uncertain. It may be of value to further investigate CANO in IPF.

Behçet's pulmonary artery aneurysms treated with infliximab and monitored with the 6-min walk test

Pulmonary involvement in Behçet's disease (BD) is uncommon; however, it is potentially fatal due to the risk of massive haemoptysis. We describe the case of a 36-year-old male presenting with a 2-month history of worsening dyspnoea, weight loss, haemoptysis, oral ulceration, erythema nodosum and superficial thrombophlebitis. He was diagnosed with pulmonary vasculitis secondary to BD; however, his symptoms were refractory to initial treatment with cyclophosphamide, azathioprine and prednisolone. We therefore trialled infliximab alongside methotrexate, which led to a remarkable improvement in his condition, enabling eventual discontinuation of prednisolone. Whilst not being one of the treatments currently recommended for managing pulmonary involvement in BD, infliximab has previously been successfully used in cases refractory to conventional therapy. We used the 6-min walk test (distance covered and lowest oxygen saturations) to monitor his progress, which correlated with his symptoms. This may represent a useful adjunct in monitoring the activity of pulmonary vasculitis.

Can Biometric Measures Predict TORS Feasibility?

Objective: 1) Investigate whether subjective evaluation of patient suitability for Transoral Robotic Surgery (TORS) is reliable. 2) Establish if TORS feasibility can be assessed using anthropometric measures and Mallampatti grade. 3) Determine which biometric characteristics warrant further clinical evaluation.

Method: Cadaver study (n = 42) conducted between April 2010-2012. Seven anthropometric measurements and Mallampati grade were recorded. Three head and neck surgeons assessed TORS feasibility. Adequate visualization of tonsil, tongue base, vallecula, and epiglottis were recorded using 2 TORS mouth gags. Significant anthropometric differences between full and suboptimal visualisation groups were identified.

Results: There was a negative correlation between subjective difficulty impression and actual transoral visualization for all anatomical regions ( R2 = 0.32, P < .05). Six anthropometric measures were identified whose mean values were significantly different between full and suboptimal transoral visualization groups. Suboptimal visualization of the tongue base was associated with shorter mean sterno-mental ( P < .01) and cricoid-mental ( P = .02) lengths and greater mean neck circumference ( P = .04). Suboptimal visualization of the vallecula and epiglottis were associated with a short ramus width ( P = .03) and long ramus length ( P = .05). The mean Mallampati grade was higher in the suboptimal visualization group for tongue base ( P < .01), vallecula ( P < .03), and epiglottis ( P < .04).

Conclusion: Subjective assessment is an unreliable predictor of TORS feasibility. Anthropometric measures of the neck, mandible, and Mallampati grade are valuable indicators which can potentially be used to devise a weighted predictive scale. Further clinical evaluation is warranted to determine the true predictive value of these anthropometric measures and Mallampati grade.