In-Office Lens Repositioning for Anterior Crystalline Lens Dislocation

BACKGROUND AND OBJECTIVE

We describe an in-office lens repositioning technique for anterior crystalline lens dislocation.

PATIENTS AND METHODS

We present a case series of four patients with spontaneous or traumatic anterior crystalline lens dislocation.

RESULTS

The technique included supine patient positioning, gentle pressure with a cotton swab on the peripheral cornea to guide the lens into the posterior chamber, and the use of a miotic agent afterward to prevent subsequent subluxation. In the four cases described, the in-office technique successfully restored the lens to the posterior chamber, improved vision, and decreased intraocular pressure in most instances by resolving the angle closure secondary to pupillary block.

CONCLUSIONS

The in-office lens repositioning technique is appropriate as an acute non-surgical intervention or temporizing measure for anterior crystalline lens dislocation. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Genetic liability to gastro-esophageal reflux disease, obesity, and risk of idiopathic pulmonary fibrosis

BACKGROUND

Gastro-esophageal reflux disease (GORD) has been associated with a greater risk of idiopathic pulmonary fibrosis (IPF) in observational studies, but results are limited by confounding. We used multivariable Mendelian randomization to examine their causal relationship, adjusting for BMI.

METHODS

We selected genetic instruments for GORD from genome-wide association studies of 80,265 cases and 305,011 controls. Genetic association data for IPF were obtained from 2668 cases and 8591 controls, and BMI from 694,649 individuals. We used the inverse-variance weighted method and a series of sensitivity analyses including weak instrument robust methods.

RESULTS

Although genetic liability to GORD increased IPF risk (OR 1.58; 95% CI 1.10-2.25), this result was attenuated to include the null after adjusting for BMI (OR 1.14; 95% CI 0.85-1.52).

CONCLUSION

Intervention for GORD alone is unlikely to reduce the risk of IPF, whereas reducing obesity may be a better approach.

Management of systemic sclerosis: British Society for Rheumatology guideline scope

This guideline will provide a practical roadmap for management of SSc that builds upon the previous treatment guideline to incorporate advances in evidence-based treatment and increased knowledge about assessment, classification and management. General approaches to management as well as treatment of specific complications will be covered, including lung, cardiac, renal and gastrointestinal tract disease, as well as RP, digital vasculopathy, skin manifestations, calcinosis and impact on quality of life. It will include guidance related to emerging approved therapies for interstitial lung disease and account for National Health Service England prescribing policies and national guidance relevant to SSc. The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol. This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence accreditation.

P221 Autoantibodies are common in patients with idiopathic interstitial lung disease, suggesting a high prevalence of undiagnosed autoimmune connective tissue disease

Background/Aims

In some patients, interstitial lung disease (ILD) may be the dominant or even sole manifestation of an otherwise unrecognised autoimmune connective tissue disease (CTD). Accurate diagnosis can be challenging given considerable overlap of the clinical, radiological and histological disease features. Distinguishing CTD related ILD (CTD-ILD) from idiopathic ILD, enables appropriate immunosuppressive treatment, informs prognosis and facilitates monitoring for other CTD associated complications. Occasionally a lung biopsy may be necessary to ensure accurate diagnosis. Autoantibodies are a hallmark feature of CTD, are highly disease specific and their presence is strongly suggestive of covert CTD-ILD. We investigated patients with idiopathic ILD for the presence of autoantibodies that may suggest misdiagnosis.

Methods

The serum from three subgroups of patients recruited to UK Biomarkers of Interstitial Lung Disease (BILD) were analysed: 171 with a diagnosis of idiopathic ILD and non-specific organising pneumonia on HRCT and 27 with a diagnosis of idiopathic ILD and cryptogenic organising pneumonia on HRCT. Autoantibody status was determined by radio-immunoprecipitation.

Results

Results are summarised in Table 1. Overall CTD-autoantibodies were identified in 15.6% of patients with idiopathic ILD, and were more common in those with NSIP, see table. Autoantibodies identified included those readily detectable e.g. anti-Jo1, in addition to rarer antibodies not included in standard assays e.g. anti-EIF3. Nearly half of all autoantibodies detected were anti-synthetase autoantibodies.

Conclusion

Covert-CTD is likely to be common amongst patients diagnosed with idiopathic ILD, particularly idiopathic NSIP. More specific guidance on autoantibody testing could improve diagnosis and ensure patients receive appropriate immunosuppressive treatment.

Disclosure

S. Tansley: None. C. Cotton: None. F.K. McMorrow: None. H. Lu: None. R.P. New: None. L.G. Spencer: None. N.J. McHugh: None. R.G. Cooper: None.

P299 What happens if the rheumatologist is no longer the gatekeeper to temporal artery ultrasound in giant cell arteritis?

Background/Aims

Prior to 2019, temporal artery ultrasound (TAUS) was introduced under close supervision of rheumatology consultants to support the diagnosis of giant cell arteritis (GCA). Evaluation of these early scans highlighted how the majority of patients presented via the acute medical unit (AMU). In 2019 a GCA fast-track pathway (GCA-FTP) was introduced at our centre in collaboration with AMU colleagues. The aim was to promote early utilisation of TAUS by expanding access of this test to physicians working across acute care prior to specialist rheumatology input, in contrast to many other units. This evaluation sought to establish if the new GCA-FTP led to improved presentation to scan times, as well as assessing the impact on availability of TAUS.

Methods

A retrospective analysis of data was carried out on all patients referred with suspected GCA for TAUS during a 4-month period in 2020. Results were compared with those from the 2019 evaluation and benchmarked against BSR GCA guidelines. An ultrasound was considered positive if a definite halo sign, or irregular thickening consistent with arteritis, was reported. Clinical records were reviewed to identify the final diagnosis made following the rheumatology consult. The rheumatologist’s intention to treat for GCA was considered the ‘gold standard’.

Results

We identified 58 patients (39 female, 19 male) with a mean age of 68 years (range 40-90). A positive TAUS was reported in 7/58 cases, with 4/58 reported as inconclusive and 47/58 as negative. A positive ultrasound in our cohort carried a sensitivity of 64% and specificity of 100%. A total of 50 patients were referred to a rheumatologist, of which 17/50 (34%) were reviewed on the same day. 8 patients were given an alternative diagnosis without rheumatology input and were deemed to have low clinical probability of GCA. The average number of scans per week was 2.2, compared to 0.4 pre pathway. The scans were requested by rheumatologists (21/58, 36%), acute physicians (15/58, 26%), ophthalmologists (13/58, 22%), emergency department physicians (1/58, 2%), other (5/58, 9%) and unknown source (3/58, 5%). Median time from initial review to scan request was <1 working day compared to 2 days pre-pathway. Median time from scan request to performance was 1 working day (previously 2 days). All scans were performed within 4 days of the request.

Conclusion

Despite reservations that enabling the non-specialist physician to access TAUS might overwhelm TAUS capacity, we have shown the opposite. Despite the higher volume of requests, the scans were requested earlier in the patient journey and performed more quickly. Diagnostic specificity remained high, despite more than 50% of the TAUS studies being requested by non-rheumatologists. We have shown that acute care physicians were able to successfully initiate diagnostic work-up in a collaborative GCA pathway.

Disclosure

A. Redfern: None. R. Benson: None. C. Cotton: None. C. Amoasii: None. D. Mewar: None.

Clinicoserological features of antisynthetase syndrome (ASyS)-associated interstitial lung disease presenting to respiratory services: comparison with idiopathic pulmonary fibrosis and ASyS diagnosed in rheumatology services

INTRODUCTION

Antisynthetase syndrome (ASyS) is a rare autoimmune connective tissue disease (CTD), associated with autoantibodies targeting tRNA synthetase enzymes, that can present to respiratory (interstitial lung disease (ILD)) or rheumatology (myositis, inflammatory arthritis and systemic features) services. The therapeutic management of CTD-associated ILD and idiopathic pulmonary fibrosis (IPF) differs widely, thus accurate diagnosis is essential.

METHODS

We undertook a retrospective, multicentre observational cohort study designed to (1) evaluate differences between ASyS-associated ILD with IPF, (2) phenotypic differences in patients with ASyS-ILD presenting to respiratory versus rheumatology services, (3) differences in outcomes between ASySassociated with Jo-1 versus non-Jo-1 autoantibodies and (4) compare long-term outcomes between these groups.

RESULTS

We identified 76 patients with ASyS-ILD and 78 with IPF. Patients with ASyS were younger at presentation (57 vs 77 years, p<0.001) with a female predominance (57% vs 33%, p=0.006) compared with IPF. Cytoplasmic staining on indirect immunofluorescence was a differentiating factor between ASyS and IPF (71% vs 0%, p<0.0001). Patients with ASyS presenting initially to respiratory services (n=52) had a higher prevalence of ASyS non-Jo-1 antibodies and significantly fewer musculoskeletal symptoms/biochemical evidence of myositis, compared with those presenting to rheumatology services (p<0.05), although lung physiology was similar in both groups. There were no differences in high-resolution CT appearances or outcomes in those with Jo-1 versus non-Jo-1 ASyS-ILD.

CONCLUSIONS

Extended autoimmune serology is needed to evaluate for ASyS autoantibodies in patients presenting with ILD, particularly in younger female patients. Musculoskeletal involvement is common in ASyS (typically Jo-1 autoantibodies) presenting to rheumatology but the burden of ILD is similar to those presenting to respiratory medicine.

P141 Young Ambassadors Project: engaging patients attending a specialised young adult clinic

Background

Emerging literature has highlighted that transition to adult services is a challenging time where many young patients are lost to follow up and disengage with health services. Furthermore, developmentally appropriate healthcare improves adherence and empowers young people. This recognises the changing biopsychosocial development needs of young people and advocates for a ‘young-person-friendly’ service. Aintree Hospital runs a young adult clinic based on the EULAR guidelines. Attending patients suggested that their positive experience could support and improve engagement of peers ready for transition. At the same time, they raised that the existing shared clinical area did not feel tailored to them given the lack of age-appropriate literature and lack of representation in the existing displays. This feedback led the team to a review of the service with the ultimate aim to improve patient engagement and satisfaction.

Methods

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary healthcare team alongside a group of willing young adult patients (Young Ambassadors) identified a strategy to improve the young adult clinical area and facilitate transition peer support. Pilot funding was obtained from the Trust, with the aim to expand the methods to other specialities if successful.

Results

The team worked with the Young Ambassadors and a professional media company to produce ‘pop-ups’ featuring photographs of our young adult patients with positive inspirational messages. These were purposefully produced as mobile units rather than static posters to increase flexibility of use. We also improved the availability of age-appropriate literature in the waiting room (e.g. literature from Arthur’s Place, a magazine and social network for young adults with arthritis). Additionally, we developed a set of videos featuring three of our Young Ambassadors talking about their transition experience and how this affected their day-to-day lives. The videos will be available to patients ready to enter transition while still in children’s services. We envisage that this initiative will provide a patient perspective of living with chronic conditions, empower young people to take control of their health needs and therefore increase adherence, independence and promote positive career and life goals. Lastly, through the project and focus group sessions, our patients have already started a support network for young patients with rheumatic diseases.

Conclusion

Our young patients are keen to be involved in service development and wish to raise awareness of their life with chronic rheumatic diseases. We will measure the impact of our interventions through patient satisfaction questionnaires, group feedback sessions and by auditing patient attendance rates pre- and post-project. By working with our Young Ambassadors, we have successfully developed patient-led initiatives, tailored to young adult patients with the aim of improving future engagement and empowerment.

Disclosures

I. Soares None. C. Cotton None. L. Brinkley None. C. Estrach None.

Muscle glycogen utilisation during Rugby match play: Effects of pre-game carbohydrate

OBJECTIVES

Although the physical demands of Rugby League (RL) match-play are well-known, the fuel sources supporting energy-production are poorly understood. We therefore assessed muscle glycogen utilisation and plasma metabolite responses to RL match-play after a relatively high (HCHO) or relatively low CHO (LCHO) diet.

DESIGN

Sixteen (mean±SD age; 18±1 years, body-mass; 88±12kg, height 180±8cm) professional players completed a RL match after 36-h consuming a non-isocaloric high carbohydrate (n=8; 6gkgday^-1) or low carbohydrate (n=8; 3gkgday^-1) diet.

METHODS

Muscle biopsies and blood samples were obtained pre- and post-match, alongside external and internal loads quantified using Global Positioning System technology and heart rate, respectively. Data were analysed using effects sizes ±90% CI and magnitude-based inferences.

RESULTS

Differences in pre-match muscle glycogen between high and low carbohydrate conditions (449±51 and 444±81mmolkg^-1d.w.) were unclear. High (243±43mmolkg^-1d.w.) and low carbohydrate groups (298±130mmolkg^-1d.w.) were most and very likely reduced post-match, respectively. For both groups, differences in pre-match NEFA and glycerol were unclear, with a most likely increase in NEFA and glycerol post-match. NEFA was likely lower in the high compared with low carbohydrate group post-match (0.95±0.39mmoll^-1 and 1.45±0.51mmoll^-1, respectively), whereas differences between the 2 groups for glycerol were unclear (98.1±33.6mmoll^-1 and 123.1±39.6mmoll^-1) in the high and low carbohydrate groups, respectively.

CONCLUSIONS

Professional RL players can utilise ∼40% of their muscle glycogen during a competitive match regardless of their carbohydrate consumption in the preceding 36-h.

Airtraq vs standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation

Two consecutive, randomised, cross-over trials compared intubation success rates in third-year paramedic students and experienced prehospital practitioners using the Airtraq or a Macintosh laryngoscope with flexible stylet in a manikin model of a Cormack and Lehane grade III/IV laryngoscopic view. First-time intubation rates for the Macintosh and Airtraq for students were 0/23 (0%) vs 10/23 (44%) (44% difference, 95% CI 26-63%, p < 0.001) and for experienced laryngoscopists were 14/56 (25%) vs 47/56 (84%) (59% difference, 95% CI 42-72%, p < 0.0001), respectively. First-time oesophageal intubation rates for students were 15/23 (65%) vs 3/23 (13%) (-52% difference, 95% CI -25 to -72%, p < 0.001) and for experienced practitioners 9/56 (16%) vs 0/56 (0%) (-16% difference, 95% CI -9 to -28%, p = 0.0014). Student paramedics and experienced prehospital laryngoscopists managing a manikin model of a grade III/IV view had increased first-time intubation rates and had lower rates of oesophageal intubation with the Airtraq compared with a standard laryngoscope.

Use of the Airtraq laryngoscope in a model of difficult intubation by prehospital providers not previously trained in laryngoscopy

This study evaluated the ability of prehospital providers who had no previous training in intubation, to use an Airtraq laryngoscope to intubate a manikin model of a Cormack and Lehane grade III/IV view. Volunteers attending the Australian College of Ambulance Professionals conference, Adelaide, in November 2006 received approximately 5 min of Airtraq training. First-time intubation success rate was 26/33 (79%) (95% CI 61-91%); oesophageal intubation rate was 0/33 (0%) (95% CI 0-11%); median time to intubation was 17 s (IQR 10-25 s (range 5-30 s)); and median subject-rated difficulty of use score was 21 out of a maximum of 100 (IQR 7.5-35.5 (range 1-65)). Pre-hospital providers without previous laryngoscopy training achieved high first-time intubation success rates when managing a model of a grade III/IV difficult intubation with an Airtraq laryngoscope. Users evaluated it as easy to use and achieved intubation within an acceptable breath-to-breath interval.

Sex- and age-of-onset-based locus heterogeneity in asthma

Asthma is a complex disease with a genetic component. The results of genome-wide linkage studies imply that locus heterogeneity is likely to be an important feature of the genetics of asthma. To attempt to reduce locus heterogeneity, we hypothesized that the following may form the bases for locus heterogeneity at some asthma susceptibility loci: sex of affected individuals, parental origin of alleles shared by affected sib pairs, and age of onset of wheeze. Analysis of such strata may assist in the identification of novel susceptibility loci, or reveal the basis for locus heterogeneity at previously identified loci. Genotype and phenotype data from genome-wide linkage searches for asthma susceptibility loci from three populations were analyzed. Some regions demonstrated evidence for linkage to affected individuals of a particular sex. There was evidence for excess maternal allele sharing at regions on chromosomes 9 and 11. Regions on chromosomes 2 and 6 were linked to late and early age at onset of wheeze in asthma, respectively. These analyses suggest that the bases that we selected for stratification may be appropriate at certain susceptibility loci for asthma, and may therefore assist in the fine mapping of such loci. Differences in such variables between studies may explain apparent nonreplication of linkage results.

Immuno and functional characterization of CFTR in submandibular and pancreatic acinar and duct cells

Cystic fibrosis results from defective Cl- channel activity mediated by the cystic fibrosis transmembrane conductance regulator (CFTR) gene product. In the gastrointestinal tract this is manifested in abnormal salivary secretion and pancreatic insufficiency. This is generally attributed to defective Cl- transport by the ductal system of the glands. We provide the first immunocytochemical and functional evidence for expression of CFTR protein and Cl- current in rat and mouse submandibular gland (SMG) and pancreatic acinar cells, a site proximal to the ductal system of these secretory glands. Monoclonal and polyclonal antibodies recognizing COOH-terminal epitopes of CFTR show that duct and acinar cells from the two glands express CFTR in the luminal membrane. Specificity of the polyclonal antibody was verified by absence of staining in duct and acinar cells of the SMG of cf-/cf- and delta F/delta F mice. Identification of CFTR in acinar cells was aided by demonstrating coexpression of CFTR and type 3 inositol 1,4,5-trisphosphate receptors in the luminal pole of acini and absence of type 3 inositol 1,4,5-trisphosphate receptors in ducts. Electrophysiological characterization in single SMG duct and acinar cells shows the presence of a protein kinase A-activated, voltage- and time-independent, ohmic Cl- current and absence of repolarization-dependent tail currents, all of which are kinetic properties of the CFTR-dependent Cl- channel. In addition, the channel was activated by the nonhydrolyzable ATP analog 5'-adenylylimidodiphosphate and the benzimidazalone NS-004. Channels activated by all activators were inhibited by glibenclamide and a known inhibitory antiserum [anti-CFTR-(505-511)]. Combined immunologic, functional, and pharmacological evidence allows us to conclude that acinar cells of the SMG and pancreas express functional CFTR-dependent Cl- channels. Because this site is proximal to the duct, modification of activity of this channel in acinar cells is likely to contribute to abnormal salivary secretion and pancreatic insufficiency typical of cystic fibrosis.

Alternate, adjacent 2 and 3:1 meiotic segregation products from a balanced t(13;18) (q12;q11) carrier

We present a case in which alternate, adjacent 2 and 3:1 meiotic segregations have occurred in the pregnancies of a female carrier of a balanced reciprocal translocation -46,XX,t(13;18) (q12;q11). Products of five conceptions effectively showed trisomy 18q, trisomy 18p or monosomy 18p. This is one of the rare rearrangements which can give rise to a variety of segregation modes including adjacent 2.

Isolation and characterisation of nuv11, a mutation affecting meiotic and mitotic recombination in Aspergillus nidulans

A mutant of Aspergillus nidulans, designated nuv11, has been isolated as hypersensitive to the monofunctional alkylating agent MNNG and the quasi-UV-mimetic mutagen 4-NQO. The mutation was recessive, resulting from mutation of a single gene which mapped to chromosome IV, and was non-allelic to the previously characterised repair-deficient mutations uvsB and uvsH which are also located on this linkage group. The nuv11 mutation results in slow growth, deficient intragenic and intergenic meiotic recombination, increased spontaneous chromosome instability, and increased intragenic and intergenic mitotic recombination in homozygous diploids. By screening a wild-type gene bank of A nidulans, a clone (pNUV11A40) has been isolated which complements the nuv11 mutation, restoring wild-type responses to both MNNG and 4-NQO.

Defective reticuloendothelial system function in rheumatoid arthritis

The function of the splenic reticuloendothelial system in patients with rheumatoid arthritis (R.A.) was assessed by determining the clearance of autologous heat-damaged erythrocytes from the circulation. 11/13 patients with active R.A. had a defect in the clearance of red cells and there was a significant inverse correlation between splenic function and the level of circulating immune complexes detected by a Clq-binding assay. Splenic function was normal in 13 patients with inactive disease who had been treated with either gold or prednisone. A serial study on 1 patient with active R.A. showed a clear correlation between fluctuations in disease activity, splenic function, and the level of circulating immune complexes.

Reversal of impaired splenic function in patients with nephritis or vasculitis (or both) by plasma exchange

By studying the clearance of autologous labeled antibody-coated or heat-damaged erythrocytes, we showed that reversible blockade of the splenic component of reticuloendothelial function existed in 14 of 15 patients referred for treatment of nephritis or vasculitis. In 10 patients treated by plasma exchange--alone in three and combined with steroids and cytotoxic drugs in six--reversal of splenic blockade followed in nine, and in the three patients treated solely by plasma exchange this reversal was demonstrated to occur within 48 hours of the procedure. Only gradual reversal of splenic blockade was found in three of five patients treated by steroids with or without cytotoxic drugs; no change in splenic function was observed in two. When circulating immune complexes were detected by a C1q-binding assay, there was, in serial studies, an approximate inverse correlation between splenic function and the level of C1q-binding material, though hyposplenism was also a feature of patients in whom the C1q-binding assay was negative.

Contingency awareness in premature infants

Infants of low birthweight were placed in an artificial contingency situation in which leg movement produced movement of an overhead mobile. When compared with 5 non-contingent controls, these 5 infants showed an increase in frequency of kicks and in the amount of time spent focusing on the mobile.