A manifestation of severe sarcoid arthropathy in the distal interphalangeal joint

In 2011 a gentleman in his 50s presented with nasal blockage and bloody discharge. He was diagnosed with sarcoidosis and after 9 years of failed strategies to control his disease, he developed dactylitis. X-ray of the hands showed severe arthropathy in the distal interphalangeal joints. This case demonstrates an uncommon extrapulmonary manifestation of sarcoidosis. Although most of his follow up was with a respiratory clinic, his main symptoms were not due to interstitial lung disease, highlighting the importance of a multidisciplinary approach. To reduce the need for steroids, several DMARDs were tried illustrating that there are limited treatment options

Identifying factors that predict fracture risk in polymyalgia rheumatica

Background/Aims  Polymyalgia rheumatica (PMR) is a chronic inflammatory condition that commonly affects the elderly and may be treated with long-term steroids. In these patients, fracture risk is higher than the general population and can lead to increased morbidity and mortality. This retrospective observational cohort study aimed to identify factors which help predict fracture risk in PMR patients. Methods  Data were collected from June 2004 to October 2010 on patients with PMR at a District General Hospital. This included dexa scan data: bone mineral density (BMD), Z score, T score, fat mass, lean mass, percentage body fat, BMI and average tissue thickness. Demographic data, steroid use, alcohol consumption, smoking, secondary osteoporosis and presence of fracture was also recorded for each patient. Fracture risk was predicted by a series of binomial logistic regression models, which were adjusted for age and sex. Odds ratios with 95% confidence intervals and area under ROC curve (AUC) were calculated. Results  714 patients with PMR were studied of whom 532 were female, the mean age was 70.5. Steroid use, secondary osteoporosis, lean mass, fat mass, BMI, average tissue thickness, average percentage fat and alcohol consumption were not significant predictors of fracture in regression models. BMD, T score and Z score predicted fracture risk. AUC of BMD was lower than that of T and Z score for each level. The AUC for L2 models were higher than other levels in BMD, T and Z score. Odds ratios, 95% confidence intervals and AUC of the significant predictors of fracture are shown in the table. Conclusion  These data suggest that BMD, T and Z score help predict fracture in PMR patients. Lifestyle factors and other body composition data from dexa scans do not predict fracture risk. Strongest predictor models were at the level of L2. FRAX could therefore underestimate the fracture risk as it uses femoral measurings. Limitations of the study are that it was retrospective and only studied patients who underwent DEXA scans. Steroid data were binary, not reflecting dose and duration of use. The study may have been underpowered to detect the impact of some factors predicting fracture risk

POS0511 USING HIP STRUCTURAL ANALYSIS MEASUREMENTS TO PREDICT FRACTURE IN RHEUMATOID ARTHRITIS

Background: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease and increases the risk of developing osteoporosis. Incidence of fracture is higher in this group of patients compared to the general population and can lead to increased morbidity (1). Bone strength of the proximal femur is not only linked to bone mineral density; it also depends on the geometric properties of the bone mass (2). Hip structural analysis (HSA) is a technique used to assess hip bone structure that takes geometric measurements of the femur from dual-energy X-ray absorptiometry (DEXA) images (3). Objectives: To determine whether HSA measurements help predict fracture in patients with RA. Methods: Data were collected from June 2004 to August 2017 from RA patients who underwent a DEXA scan at a District General Hospital. This included hip axis length (HAL), cross-sectional area (CSA), cross-sectional moment

DO HIP STRUCTURAL ANALYSIS MEASUREMENTS PREDICT FRACTURE RISK IN PATIENTS WITH POLYMYALGIA RHEUMATICA?

Background: Polymyalgia Rheumatica (PMR) is an inflammatory condition which commonly affects the elderly. Risk of fracture is higher in this group of patients compared to the general population and can lead to increased morbidity and mortality (1). Hip structural analysis (HSA) is a technique that uses dual-energy X-ray absorptiometry (DEXA) images to assess hip bone structure (2). Objectives: To identify whether HSA measurements help predict fracture in patients with PMR. Methods: Data were collected from June 2004 to October 2010 from PMR patients who had a DEXA scan at a District General Hospital. This included hip axis length (HAL), cross-sectional area (CSA), cross-sectional moment of inertia (CSMI), distance from centre of femoral head to centre of femoral neck (D1) and to inter-trochanteric line (D2), mean femoral neck diameter (D3), shaft angle (A) neck/shaft angle (Θ) and proximal femur strengt

AB1010 FACTORS ASSOCIATED WITH LONGITUDINAL BONE MINERAL DENSITY CHANGES IN RHEUMATOID ARTHRITIS

Background Rheumatoid Arthritis (RA) is a long-term inflammatory disorder affecting the joints. It is associated with osteoporosis, possibly linked to inflammation around affected joints and glucocorticoid medication. To our knowledge, longitudinal analysis of a UK based cohort of patients with RA has not been carried out. The impact of average tissue thickness on bone mineral density (BMD) has not been studied longitudinally in RA. Objectives This study aimed to identify factors that affect the rate of BMD change in patients with RA in a UK based cohort. Methods RA patients referred for multiple routine DEXA scans at the Royal Lancaster Infirmary from 2004-2019 were studied. Demographic and physical data such as age, sex, weight and height were collected. BMD in grams/centimetre2 and average tissue thickness were collected from DEXA images of the left and right hip (femoral neck and total femur), and the spine (L1-L4). BMD was modelled at the regions of the hip and spine using mixed-effects linear models. Age, sex, average tissue thickness and weight were used as explanatory variables. Results:1135 scans from 496 patients (80.4% female) with more than one scan were included, mean age was 64.1 (standard deviation 12.5). Fixed effect size and confidence intervals for each variable are shown in the Table 1. Female sex had a negative fixed effect at the hip but no significant effect on BMD change at the spine. Average tissue thickness had a significant positive fixed effect at all regions of the left and right hip, but no significant effect at the spine. Weight showed a significant positive fixed effect with BMD at the hip but no significant effect at the spine. Conclusion This study demonstrates that in RA patients, sex is associated with an increased rate of BMD loss at the hip but not at the spine. It also shows that weight and average tissue thickness are associated with lower BMD loss over time. This could be due to increased inflammation at the hip compared to the spine leading to osteoporosis. This study supports longitudinal data from other countries suggesting that factors associated with the rate of BMD change are different at the hip and the spine in RA (1). Average tissue thickness is associated with a reduced rate of BMD loss at the hip in RA patients, which is a novel finding. Average tissue thickness could be used in conjunction with other risk factors to help identify RA patients at risk of osteoporosis. This study may have been underpowered to detect changes at the spine. There may have been selection bias not all patients were routinely referred for repeat DEXA scans

Retrospective Analysis of Factors Associated with Fracture in 714 Patients with Polymyalgia Rheumatica

Introduction. Polymyalgia rheumatica (PMR) is a disease of the elderly, associated with increased fracture risk due to glucocorticosteroid (GC) treatment with the additional possible influence of chronic inflammation. Risk factors for fracture in PMR have not been extensively studied. Hip structure analysis (HSA) is a way to measure bone morphology in the hip using dual X-ray absorptiometry (DEXA). It has been used as a predictor of fracture in epidemiological settings. HSA has not been studied in PMR before. Objectives. The object of this retrospective study was to determine if fracture risk in PMR was associated with densitometry data and to determine the influence, if any, of HSA on that association. Methods. 714 patients with PMR referred for a bone density estimate at a district general hospital from June 2004 to October 2010 were studied. Demographic data, GC use, alcohol consumption, smoking status, secondary osteoporosis, and fracture history were recorded. Bone mineral density (BMD), Z score, T score, body composition data, and HSA measurements were collected. These were geometric measurements taken from 2-dimensional DEXA images of the hip. Fracture was modelled as an outcome variable using logistic regression models, adjusted for age and sex. And the fit of the model was assessed by comparing the area under the curve (AUC). Results. 714 patients were studied, 532 (75%) were female, and mean age was 70.5 with SD of 8.8. 703 (98%) had been treated with GCs. Lumbar and femoral BMD models were significantly associated with fracture. Right femur OR 0.062 (0.014-0.285), left femur OR 0.098 (0.023-0.412), right femoral neck 0.078 (0.014-0.43), left femoral neck 0.104 (0.022- 0.492), L1 0.192 (0.066-0.56), L2 OR 0.138 (0.053-0.358), L3 0.192 (0.079-0.463), and L4 0.243 (0.108-0.544). Cross-sectional area was the only HSA parameter that was associated with fracture OR 0.988 (0.980–0.997). Conclusion. L2 association models were strongest. Prospective studies are needed to elucidate whether these factors predict future fracture. GC data were binary, not reflecting dose and duration

A closed loop audit of clerking psychiatric histories in an acute psychiatric inpatient unit

Abstract Aims An accurate and complete history is a key component of a medical consultation. Evidence suggests that up to 80% of diagnosis may be made entirely off the patient history. The aim of this closed loop audit was to examine the effects of a clerking pro forma on the quality of doctors clerking histories of new patients admitted to an acute psychiatric inpatient unit, against standards suggested in the New Oxford Textbook of Psychiatry. Method Data for this audit were gathered by finding the initial clerking history for inpatients at The Orchard on ECR and RIO. The clerking histories of the 18 inpatients present on 12.10.20 were initially audited. These standards recommend in the in the New Oxford Textbook of Psychiatry include; Patient Identification (ID), Presenting Complaint (PC), History of Presenting Complaint (HPC), Psychiatric history, Medical history, Family history, Forensic history, Social history, Personal history, Premorbid personality, Mental state exam (MSE). After analysis of the results of the first loop, a clerking pro forma was created and distributed to junior doctors to implement. The clerking histories for the subsequent 18 patients to be admitted were then audited and compared. Result The results of the first audit cycle were poor. Only patient identification and presenting complaint were present in 100% of clerked histories. Concerningly, only 72% of the histories included the patients’ medical histories, forensic histories were included 44% of the time, and social history just 39% of the time. The implementation of a clerking history proforma showed improvements in all areas of clerking. Patient ID, PC, HPC, psychiatric history and MSE were now present in 100% of clerked histories. Forensic history showed a statistically significant improvement from 44% to 73% [X2(1) = 5.9; p = 0.015]. Social history showed a statistically significant improvement from 39% to 78% [X2(1) = 5.6; p = 0.018]. Premorbid personality showed a statistically significant improvement from 44% to 89% [X2(1) = 8.0; p = 0.005]. Personal history showed a non-statistically significant improvement from 39% to 56%, as did medical history from 72% to 94%, and family history from 39% to 61%. Conclusion In conclusion, the implementation of a clerking history pro-forma has significantly improved the quality and completeness of clerking histories gathered by doctors at The Orchard. This is hopefully increase diagnostic accuracy and improve the quality of care of patients in the hospital

Evaluating the long-term impact of an antimicrobial stewardship programme in a central London mixed medical and surgical intensive care unit

BACKGROUND: Antimicrobial overuse causes increased antimicrobial resistance in ICUs; antimicrobial stewardship programmes (ASPs) aim to optimize usage. Following an MDR Acinetobacter baumannii (MRAb) outbreak in 2008, an ASP was implemented at a London ICU, and then continued as a long-term programme. This study aimed to determine long-term changes in antimicrobial prescribing 9 years on. METHODS: Data were collected from ICU patients in 2008 immediately before ASP implementation, and thereafter for 6 month cohort periods in 2010–2011, 2012 and 2017. Antimicrobial usage in DDD per 1000 occupied bed days (OBD) were compared. Multivariate linear regression models for antimicrobial days were fitted, adjusting for APACHE II score and patient days. Antimicrobial resistance in Pseudomonas aeruginosa (as an indicator organism) was compared across cohort periods. FINDINGS: Across 400 patients over 9 years, antimicrobial use changed significantly (P < 0.011) and remained lower in all post-ASP cohorts compared with pre-ASP [(2008; 1827 DDD/1000 OBD), (2010; 1264 DDD/1000 OBD), (2012; 1270 DDD/1000 OBD) and (2017; 1566 DDD/1000 OBD)]. There was reduction in usage of all antimicrobial classes except β-lactams (where there was no significant increase nor decrease, P = 0.178) and aminoglycosides (where there was a significant increase in usage, P < 0.0001). The latter was temporally associated with restrictions on specific carbapenems. There was an increase in carbapenem-resistant P. aeruginosa in 2012 only (P = 0.028) but not subsequently. CONCLUSIONS: Following ASP implementation after an outbreak of MRAb, reduced antimicrobial prescribing was maintained 9 years on. We identify several factors influencing successful long-term maintenance of ASPs in ICUs