Rheumatoid arthritis patients with fibromyalgic clinical features have significantly less synovitis as defined by power Doppler ultrasound

BACKGROUND: In patients with rheumatoid arthritis (RA) clinical measures of disease activity may not reliably discriminate between patients with active inflammatory disease and those with concomitant fibromyalgia (FM). Recent work has shown RA patients with a 28 tender joint count (TJC) minus swollen joint count (SJC) of 7 or more (joint count criteria) are more likely to meet classification criteria for FM. This study aimed to determine whether RA patients meeting clinical criteria for FM had lower levels of joint inflammation as determined by ultrasound (US). METHODS: RA patients with DAS28 > 2.6 were recruited. Patients underwent clinical assessment including ultrasound examination of the hands and wrists with quantification of grey scale (GS) and power Doppler (PD) synovitis. Patients completed questionnaires to assess pain, fatigue, disability and psychological comorbidity. RESULTS: Patients meeting either of the FM criteria had higher scores for disease activity, depression, disability and fatigue. Those meeting both the joint count and classification FM criteria had significantly lower levels of GS and PD inflammation on US. CONCLUSIONS: RA patients with concomitant FM, as determined by widespread soft tissue tenderness but fewer clinically inflamed joints, have higher disease activity scores but may have lower levels of synovial inflammation on US. This has implications for the identification and management of these patients who may not respond to conventional therapy and hence be more suitable for alternative approaches to treatment

Retroperitoneal haemorrhage in renal angiomyolipoma causing hepatic functional decompensation: a case report

Renal angiomyolipomata usually present as incidental findings on routine imaging, but rarely they may give rise to significant haemorrhage. If bleeding occurs, first-line treatment is currently angiography with selective embolisation. Prophylactic embolisation may be considered in some cases, depending on lesion size and patient co-morbidities

Oral abstracts 1: SpondyloarthropathiesO1. Detecting axial spondyloarthritis amongst primary care back pain referrals

Background: Inflammatory back pain (IBP) is an early feature of ankylosing spondylitis (AS) and its detection offers the prospect of early diagnosis of AS. However, since back pain is very common but only a very small minority of back pain sufferers have ASpA or AS, screening of back pain sufferers for AS is problematic. In early disease radiographs are often normal so that fulfilment of diagnostic criteria for AS is impossible though a diagnosis of axial SpA can be made if MRI evidence of sacroiliitis is present. This pilot study was designed to indicate whether a cost-effective pick up rate for ASpA/early AS could be achieved by identifying adults with IBP stratified on the basis of age. Methods: Patients aged between 18 and 45 years who were referred to a hospital physiotherapy service with back pain of more than 3 months duration were assessed for IBP. All were asked to complete a questionnaire based on the Berlin IBP criteria. Those who fulfilled IBP criteria were also asked to complete a second short questionnaire enquiring about SpA comorbidities, to have a blood test for HLA-B27 and CRP level and to undergo an MRI scan of the sacroiliac joints. This was a limited scan, using STIR, diffusion-weighted, T1 and T2 sequences of the sacroiliac joints to minimize time in the scanner and cost. The study was funded by a research grant from Abbott Laboratories Ltd. Results: 50 sequential patients agreed to participate in the study and completed the IBP questionnaire. Of these 27 (54%) fulfilled criteria for IBP. Of these, 2 patients reported a history of an SpA comorbidity - 1 psoriasis; 1 ulcerative colitis - and 3 reported a family history of an SpA comorbidity - 2 psoriasis; 1 Crohn's disease. 4 were HLA-B27 positive, though results were not available for 7. Two patients had marginally raised CRP levels (6, 10 -NR ≤ 5). 19 agreed to undergo MRI scanning of the sacroiliac joints and lumbar spine; 4 scans were abnormal, showing evidence of bilateral sacroiliitis on STIR sequences. In all cases the changes met ASAS criteria but were limited. Of these 4 patients 3 were HLA-B27 positive but none gave a personal or family history of an SpA-associated comorbidity and all had normal CRP levels. Conclusions: This was a pilot study yielding only limited conclusions. However, it is clear that: Screening of patients referred for physiotherapy for IBP is straightforward, inexpensive and quick. It appears that IBP is more prevalent in young adults than overall population data suggest so that targeting this population may be efficient. IBP questionnaires could be administered routinely during a physiotherapy assessment. HLA-B27 testing in this group of patients with IBP is a suitable screening tool. The sacroiliac joint changes identified were mild and their prognostic significance is not yet clear so that the value of early screening needs further evaluation. Disclosure statement: C.H. received research funding for this study from Abbott. A.K. received research funding for this study, and speaker and consultancy fees, from Abbott. All other authors have declared no conflicts of interes

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

P046 Pointing the finger: an unusual presentation of dactylitis

Abstract Background/Aims  Dactylitis is commonly associated with psoriatic arthritis, and regularly presents at Rheumatology clinics. We discuss a case where progressive systemic symptoms lead to the consideration of alternate diagnoses. Methods  A 46-year-old Nepalese woman presented to the Rheumatology department with a 3 month history of diffuse swelling of the right middle finger proximal interphalangeal joint, with the appearance of dactylitis. There was pain on movement, but no other joint involvement. Simultaneously she noticed blurred and decreased vision, which on review by the ophthalmologists, was diagnosed with bilateral uveitis. There was no history of psoriasis, inflammatory bowel disease, or other past medical history of note. There was no travel history in the past 12 months. A diagnosis of a presumed inflammatory arthritis was made. Results  Blood tests showed elevated c-reactive protein 55 (normal &amp;lt;4 mg/l), erythrocyte sedimentation rate 138 (normal 0-22 mm/hr) and an iron deficiency anaemia. Rheumatoid factor and Anti-CCP antibody were negative. Hand radiographs were reported as normal. MRI of the third digit confirmed an enhancing soft tissue collection at the proximal phalanx of the right middle finger. She was referred for a biopsy of this lesion. Interestingly over the subsequent few months, she developed progressive breathlessness. Chest radiograph showed a left pleural effusion. Further tests showed negative serum ACE, Lyme and Toxoplasma screen. Quantiferon test was negative. Pleural aspirate showed a transudate with negative Acid-fast bacillus (AFB) test and culture. CT chest and abdomen showed a persistent pleural effusion, inflammatory changes in the small bowel and thickening of the peritoneum and omentum. In view of the systemic involvement, a peritoneal tissue biopsy was performed. This confirmed chronic granulomatous inflammation with positive AFB stain for mycobacterium tuberculosis. Our patient was started on quadruple anti- TB antibiotics for 6 months. Her systemic symptoms and dactylitis have improved, although there is on-going treatment for her ocular involvement. Conclusion  Approximately 10% of all cases of extrapulmonary TB have osteoarticular involvement. Dactylitis is a variant of tuberculous osteomyelitis affecting the long bones of the hands and feet. It occurs mainly in young children; however adults may be affected also. The first manifestation is usually painless swelling of the diaphysis of the affected bone followed by trophic changes in the skin. The radiographic changes are known as spina ventosa, because of the ballooned out appearance of the bone, although this was not seen in our case. Fibrous dysplasia, congenital syphilis, sarcoidosis and sickle cell anaemia may induce similar radiographic changes in the metaphysis of long bones of hands and feet, but do not cause soft tissue swelling or periosteal reaction. This case highlights the importance of testing for TB, especially in atypical cases of dactylitis, with other systemic features. Disclosure  N. Cernovschi - Feasey: None. J. Wajed: None.</jats:p

P038 Is it all in the eyes?

Abstract Background/Aims  The ocular manifestations of giant cell arteritis (GCA) and ocular myasthenia gravis (OMG) have significant overlap, which can lead to clinical uncertainty in the absence of awareness and routine diagnostic testing. Methods  We present the case of a 63-year-old male patient with a strong family history of autoimmune disease. He presented to the Rheumatology department in 2009 with symptoms of polymyalgia rheumatica (PMR) and was treated successfully with a reducing regime of Prednisolone. In 2013, he presented to the Ophthalmology department with blurred vision and diplopia. Giant cell arteritis was suspected and a high dose of Prednisolone was started. His temporal artery biopsy was normal and inflammatory markers were not raised, but there was a complete resolution of his symptoms since starting steroids. Under the care of the Rheumatology department, reducing regimes of Prednisolone were attempted and a steroid sparing agent, Methotrexate was introduced. Unfortunately, he continued to have recurring symptoms of blurred vision and diplopia, particularly at Prednisolone doses less than 20mg. Over the course of a few years, there was a progression of his ocular symptoms. He developed a horizontal diplopia, monocular ptosis and a 4th nerve palsy. He was referred back to the Ophthalmology department, where alternate diagnoses were investigated. Anti-acetylcholine receptor antibodies (AChR) were strongly positive at 35 mU/L (normal &amp;lt;0.44 mU/L). MRI head was normal, and CT chest showed no thymoma. Single fibre EMG confirmed severe OMG. Our patient was subsequently commenced on Pyridostigmine, with which symptoms improved. Results  The literature on OMG mimicking GCA is sparse. The prevalence of an exclusively ophthalmic presentation in patients with GCA is 1 in 5. Ocular signs and symptoms in GCA can vary drastically due to the propensity of the disease to affect different structures within the eye. Transient and permanent visual loss, affects 10-30% of GCA patients due to anterior ischemic optic neuropathy. Diplopia affects 5% of GCA patients. In comparison, OMG can be the only presenting feature in 15% of patients with Myasthenia Gravis, and is characterised by unilateral ptosis, oculomotor paresis and binocular diplopia. Conclusion  This case highlights the clinical similarities of OMG and GCA, and that OMG should be considered as a differential diagnosis when the clinical picture of GCA does not truly fit. In patients presenting with GCA with ocular symptoms, normal inflammatory markers and no systemic features, OMG should be considered and AChR antibody testing be performed. More awareness of OMG is needed. We also propose that OMG should be included as a differential diagnosis, in the British Society of Rheumatology guidelines for GCA. Disclosure  A. Gharatya: None. J. Wajed: None. N. Cernovschi: None. D. Christidis: None.</jats:p

P078 Delivering far reaching patient education in rheumatological conditions and treatments: RadioRheumatology podcasts

Abstract Background/Aims  There is a need for accessible rheumatic patient education . Podcasts can be accessed globally, are simple and cheap to produce and enable access by patients who may have reading difficulties. They also allow local patients to connect personally with their rheumatology department staff. Hospital radio departments offer access to high quality recording equipment and often have spare capacity to facilitate recordings Methods  RadioRheumatology podcasts are recorded by our rheumatology clinical team with technical support from RadioFrimleyPark volunteers.Hospital radio departments are often under-utilised and have enthusiastic volunteers. The podcasts are uploaded to our podcast hosting website Buzzsprout (accessible at www.rheumatology.buzzsprout.com) and then propagated to Spotify, Apple Podcasts, Android Podcasts and other podcasts sites. Listeners can find our episodes via social media platforms or by searching their podcast provider of choice. We offer a 'QR' link to the podcasts for our patients in clinic and can send the link in a letter or email. In the last 11 months we have recorded podcasts on 'Steroids in Rheumatology', 'Methotrexate Overview' 'Early Inflammatory Arthritis' and 'Rheumatoid Arthritis'. Results  RadioRheumatology has been received well both locally and internationally with listeners in 62 different countries. Statistical data is sent from the podcast website on a monthly basis including 'top episodes', 'top apps', listener locations and devices used (to listen to the podcasts): The 'Methotrexate' episode has been the most popular to date and has had over 550 listeners at the time of writing.The United Kingdom has had the most 'listens' (570) followed by The United States (428). We have had listeners as far afield as New Zealand and Malaysia. Within the UK Islington,had the most listens (105), followed by Blackheath (91) Apple iPhone is the most commonly used device used to access (with 694 listens). Feedback so far has been positive.We have have had 5 star reviews and positive feedback from both patients and healthcare professionals. 5* review: A very easy to understand guide to RA: “Fantastic podcast which really explains rheumatoid arthritis but more importantly the help and support available to patients. As a Biologic Specialist Nurse I will certainly be directing my patients and families to this podcast to help them manage their conditions effectively" Conclusion  Podcasts can be an effective and cost-effective way to deliver patient education They enable both local and wider patient contact. Podcasts are an increasingly popular medium, particularly since the advent of COVID-19; listener number feedback and reviews enable us to assess the popularity of our episodes and tailor future podcasts accordingly. Hospital radio volunteers have been central to the success of this project by offering their time and championing the use of hospital radio to support clinical teams in delivering patient education. Disclosure  R.M. Killick: None. J. Cameron: None. S. Smith: None. M. Lloyd: None. J. Wajed: None.</jats:p

Clinical Study Quantitative Sensory Testing in Painful Hand Osteoarthritis Demonstrates Features of Peripheral Sensitisation

Hand osteoarthritis (HOA) is a prevalent condition for which treatments are based on analgesia and physical therapies. Our primary objective was to evaluate pain perception in participants with HOA by assessing the characteristics of nodal involvement, pain threshold in each hand joint, and radiological severity. We hypothesised that inflammation in hand osteoarthritis joints enhances sensitivity and firing of peripheral nociceptors, thereby causing chronic pain. Participants with proximal and distal interphalangeal (PIP and DIP) joint HOA and non-OA controls were recruited. Clinical parameters of joint involvement were measured including clinical nodes, VAS (visual analogue score) for pain (0-100 mm scale), HAQ (health assessment questionnaire), and Kellgren-Lawrence scores for radiological severity and pain threshold measurement were performed. The mean VAS in HOA participants was 59.3 mm ± 8.19 compared with 4.0 mm ± 1.89 in the control group (P &lt; 0.0001). Quantitative sensory testing (QST) demonstrated lower pain thresholds in DIP/PIP joints and other subgroups in the OA group including the thumb, metacarpophalangeal (MCPs), joints, and wrists (P &lt; 0.008) but not in controls (P = 0.348). Our data demonstrate that HOA subjects are sensitised to pain due to increased firing of peripheral nociceptors. Future work to evaluate mechanisms of peripheral sensitisation warrants further investigation