POS0585 INCIDENCE AND CLINICAL CHARACTERISTICS OF MALIGNANCY IN RHEUMATOID ARTHRITIS PATIENTS – DATA FROM THE MALAYSIAN NATIONAL INFLAMMATORY ARTHRITIS REGISTRY (NIAR)

Background

Patients with rheumatoid arthritis (RA) are at increased risk of developing malignancies, particularly hematologic malignancies. This predisposition for malignancy is attributed to the immune dysregulation, chronic inflammation and the long-term use of disease-modifying anti-rheumatic drugs(DMARDs).

Objectives

This study was undertaken to determine the incidence, patterns of malignancy and identify risk factors of malignancy among RA patients.

Methods

Individuals diagnosed with cancer after the onset of RA between year 2008 and 2020 from the NIAR RA registry were retrospectively examined. Standardized incidence ratios (SIR) and 95% confidence intervals of various cancers were calculated based on the expected and observed frequencies. The expected number of cases were extracted from the Malaysian National Cancer registry report. ANOVA, Chi-squared, and Student’s t test were used to analyze the risk factors for developing malignancy.

Results

Of the 3995 patients in the registry, 97 patients developed malignancies at a mean interval of 9.1 years after RA onset. The total follow-up time was 26841.9 person-years.

The mean age of patients was 59.3 (± 9.25) years, of which 89.7%(n=87) were women and 40%(n=39) were Chinese.

87.6%(n=84) had solid-organ tumours while 12.4%(n=13) had hematological malignancies.

Women showed increased risks of non-Hodgkin’s lymphoma (SIR = 13.1, 95% CI = 9.78 – 17.08), followed by lung cancer (SIR = 12.7, 95% CI = 10.01-15.77) and breast cancer (SIR = 8.8, 95% CI = 7.84 – 9.83).

Men showed increased risks of lung cancer (SIR = 3.79, 95% CI = 2.81 – 4.92) and colorectal cancer (SIR = 1.69, 95% CI = 1.09 – 2.42).

The risk factors for developing malignancy (p<0.05) include age above 60 years, long duration of RA disease, and higher disease activity states.

There were no associations between gender, ethnicity, autoantibodies and DMARDs exposure.

Conclusion

The overall malignancy incidence was increased among RA patients, with women having a 4-fold higher risk. Though the incidence of solid-organ malignancies is higher, the SIR once adjusted was highest for non-Hodgkin’s lymphoma which is consistent with literature review. Hence, cancer screening with continued vigilance among RA patients is recommended.

References

[1]Hwajeong Lee. The risk of malignancy in Korean patients with rheumatoid arthritis. Yonsei Med J. 2019;60(2):223-229.

[2]X.R. Lim, X. Gao, W.L.J. Tan, L.W. Koh, T.Y. Lian,W.Q. See, K.P. Leong, E.T. Koh

•.Abstract: Singapore Patients with Rheumatoid Arthritis Have A Higher Incidence of Solid-Organ Malignancies than The General Population: Findings from The TTSH RA Registry.

•bAnnals of the rheumatic diseases, BMJ Journals

[3]Summary of Malaysia national cancer registry report 2012-2016, Institut Kanser Negara, Ministry of Health, Malaysia

Table 1.

SIR of Malignancy among Rheumatoid Arthritis Patients by Sex and Age Groups

Sex and Age GroupNumber of Patients (%)Person-YearsIncidenceSIR (95% CI*)ObservedExpectedSex (Age Group)Males10 (10.31%)48641.5 (0.54 - 2.94)Age at Diagnosis 50-604 (10.31%)12221 (0.09 - 2.87) 60-706 (60%)36422 (0.52 - 4.44)Females87 (89.69%)54059183.28 (2.49 - 4.17)Age at Diagnosis 30-5012 (13.79%)31751.4 (0.55 - 2.63) 50-6034 (39.08%)22824102.4 (1.54 - 3.46) 60-7041 (47.13%)2812839.33 (6.2 - 13.11)

SIR, standardized incidence ratios; CI, confidence interval.Acknowledgements*CI = (√observed number of cancer cases ± 1.96 × 0.5)^2/(expected number of cancer cases).

Disclosure of Interests

None declared.

Eagle syndrome and carotid artery dissection: a rare skull base cause of stroke

Eagle's syndrome is a rare collection of symptoms that occur secondary to an elongated styloid process or calcified stylohyoid ligament irritating its surrounding structures. Classically, this presents as unilateral throat pain or rarely, as acute neurological symptoms secondary to compression of the internal carotid artery: so called 'stylocarotid syndrome'. Significant neurological events in teenagers, secondary to Eagle syndrome have not been reported. We discuss the rare case of a teenage boy, diagnosed with right internal carotid artery dissection and middle cerebral artery infarction, with no cause initially identified. Following further admission with a transient neurological episode, he was noted to have elongated styloid processes with the right abutting the site of carotid dissection. He underwent styloidectomy and has since remained symptom free. This case highlights the importance of considering anatomical variants when assessing young patients with neurological symptoms, and the potential morbidity and mortality benefit that early surgical intervention may have.

POS1460-HPR MYRA TOUCH FOR DISEASE ACTIVITY EVALUATION IN RHEUMATOID ARTHRITIS: A COMPARISON OF PATIENT-REPORTED OUTCOMES WITH PHYSICIAN’S ASSESSMENT

Background:

Patient-reported outcomes (PROs) have become an essential component of patients’ assessment in the management of Rheumatoid Arthritis(RA).They have been reported to be at least as informative if not more than physician assessed outcomes.

MyRA Touch was pioneered by the Rheumatology Unit of Hospital Tuanku Jaa’far in Seremban Malaysia in March 2018,to engage and empower all RA patients on their own disease activity monitoring. It is an electronic platform, designed to enhanced the application of electronic patient reported outcomes (ePROs) among RA patients where they examine and record their own painful and/or swollen joints for DAS28 calculation and report their health assessment through Routine Assessment of Patient Index Data with 3 Measures (RAPID 3).MyRA Touch is an applications (App) that is user friendly and available in four major spoken languages (English, Chinese, Malay and Tamil) with an animated version for patients who are illiterate.

Objectives:

The objectives of this study are to determine the correlation between:

I)Patient-reported and physician reported DAS28 ESR/CRP

II)RAPID3 and Clinical Disease activity Index (CDAI)

III)RAPID3 and DAS28 ESR/CRP assessed by physician and patient

IV)RAPID3 and inflammatory markers ESR/CRP.

Methods:

This was a cross-sectional study carried out in the Rheumatology Unit of Hospital Tuanku Jaa’far. All data entered through MyRA Touch App from April 2018 till April 2020 was analysed.

Results:

There were a total of 562 patients who entered the data in the App, 87.9% were women. The ethnic compositions of the study subjects comprised of Indians (36.7%) followed by the Malays (34.7%),Chinese (26.3%) and other ethnics (2.3%). About half of patients (59.8%) were in the 51-70 age group whereas 22.9%,1.8% and 15.5% were in the 31-50,18-30 and above 70 age groups respectively. The majority of our patients (96%) were literate. A total of 54.3% of them received secondary education, 27% primary, 12.2% tertiary and 6.6% did not receive any formal education.

There was a high level of correlation between DAS28 ESR/CRP performed by patient and DAS28 ESR/CRP assessed by physician, (r=0.808 for DAS28 ESR and r=0.804 for DAS28 CRP). RAPID3 also showed high level of correlation with CDAI and DAS28 CRP assessed by patient (r=0.700 and r=0.718 respectively). There was a moderate correlation between DAS28 ESR/CRP done by physician with RAPID3 (r=0.656 and r=0.696 respectively).RAPID3 demonstrated little correlation with inflammatory markers ESR and CRP (r=0.141 and r=0.171 respectively).

Conclusion:

PROs via DAS 28 (ESR/CRP) and RAPID3 showed moderate to high correlation with disease activity assessed by physician. We can empower patients to perform their own disease assessment by using the MyRA Touch App before seeing their physician and the information provided in the App, can help to reduced consultation time. During the COVID-19 pandemic, telemedicine is very much encouraged. By using the MyRA Touch, patients can assess their own tender and swollen joint count on a homunculus, evaluate their own physical function, health and pain using the RAPID3 parameters. The information obtained from the PROs in the MyRA touch App enables the physician to make a more comprehensive virtual assessment of the patient’s condition which helps in treatment decision making. In conclusion, MyRA Touch is an useful tool for disease activity measurement by patient.

References:

[1]Jenny AA, Diana BC, Omar JC, et al. Usefulness of Patients-Reported Outcomes in Rheumatoid Arthritis Focus Group. Hindawi Publishing Corporation Arthritis, vol 2012,Article ID935187.

[2]Ana MO, Clifton OB. Patient Reported Outcomes in Rheumatoid Arthritis Clinical Trials. Curr Rheumato Rep.2015 April;17(4):501.

Disclosure of Interests:

None declared

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

FRI0077 THE PREVALENCE OF DEPRESSION AND ANXIETY IN PATIENTS WITH RHEUMATOID AND PSORIATIC ARTHRITIS AND ITS CONTRIBUTORY FACTORS

Background:

Rheumatoid Arthritis (RA) and Psoriatic arthritis (PsA) are both chronic, progressive inflammatory arthritis that can cause significant disability and morbidity. Depression in RA has been associated with higher levels of disease activity, pain, fatigue, work disability, lower treatment compliance and increased suicidal risk and mortality [1]. PsA patients suffer from psoriasis and joint involvement; hence have greater odds of depression by 2.1 times compared with RA [2].

Objectives:

To compare the prevalence rates of depression and anxiety and its associated factors between RA and PsA patients in Hospital Putrajaya.

Methods:

A cross sectional survey using the Hospital Anxiety and Depression Scale (HADS) questionnaire were distributed to 300 patients who attended rheumatology outpatient clinic from February – April 2019. The HADS was categorized into 3 groups based on their scores 0-7 (Normal); 8-10 (Borderline); and 11-21 (Abnormal). Data on patient demographics and components of disease assessment scores were recorded. Disease activity was assessed using DAS 28-CRP for all patients. Additional evaluation using Bath Ankylosing Spondylitis Disease Activity Score (BASDAI) and body surface area (BSA) were done for PsA patients. P value of < 0.05 was taken as significant.

Results:

In total, 205 RA and 73 PsA patients were eligible for analysis. Majority of the patients were female, Malay and married for both groups. The mean age group for RA and PsA were 56.2 ± 11.9 years and 51.0 ± 14.6 years. The mean duration of disease for RA were 8 ± 10 years; while for PsA were 6 ± 11 years. The prevalence rates of depression and anxiety for RA were 8.3% and 13.7%; and PsA were 9.6% and 17.8% respectively. Borderline scores for depression occurred in 16.1% of RA patients and 12.3% for PsA. Twenty percent of RA patients (n=41) and twenty-four percent of PsA patients (n=18) scored borderline for anxiety. The significant positive correlations with depression and anxiety in RA include high disease activity scores (r = 0.27; r = 0.31), number of tender joints (r = 0.26; r = 0.24) and pain (r = 0.29; r = 0.27). Higher number of swollen joints significantly correlated with depression (r = 0.16) but not with anxiety. RA patients with Ischaemic Heart Disease (IHD) ± heart failure have higher depression scores (p < 0.05). As for PsA group, high BASDAI score (anxiety: r = 0.34, depression: r = 0.26) and psoriasis involving head and neck region (p < 0.05) were significant associated factors. Age was inversely correlated with anxiety in the PsA group.

Conclusion:

There is higher prevalence of anxiety in both RA and PsA as compared to depression. Higher disease activity scores were associated with depression and anxiety in both RA and PsA with axial involvement.

References:

[1]Faith Matcham et al. “Are depression and anxiety associated with disease activity in rheumatoid arthritis? A prospective study” BMC Musculoskeletal Disorders (2016) 17:155.

[2]Sinnathurai et al. “Comorbids in psoriatic arthritis and rheumatoid arthritis”. July 2018. Internal Medicine Journal.Available fromhttps://doi.org/10.1111/imj.14046

[3]RA Rahim et al. “ Self-reported symptoms of depression, anxiety and stress among patients with Rheumatoid Arthritis in a Malaysian rheumatology centre – prevalence and correlates”. Med J Malaysia Vol 73 No 4 August 2018

Disclosure of Interests:

None declared

Concurrent micro- to macro-cardiac electrophysiology in myocyte cultures and human heart slices

The contact cardiac electrogram is derived from the extracellular manifestation of cellular action potentials and cell-to-cell communication. It is used to guide catheter based clinical procedures. Theoretically, the contact electrogram and the cellular action potential are directly related, and should change in conjunction with each other during arrhythmogenesis, however there is currently no methodology by which to concurrently record both electrograms and action potentials in the same preparation for direct validation of their relationships and their direct mechanistic links. We report a novel dual modality apparatus for concurrent electrogram and cellular action potential recording at a single cell level within multicellular preparations. We further demonstrate the capabilities of this system to validate the direct link between these two modalities of voltage recordings.

A novel use of cement as a salvage procedure in patients with complex spinal injuries with proximal junctional failure

Long-construct fixations can be complicated by proximal junctional kyphosis. In elderly, high-risk patients with numerous comorbidities, lengthy surgical times and increased blood loss associated with revision osteotomies and extension of fusions are not often tolerated and pose serious life-threatening risks. We present a salvage technique used in a patient with proximal junctional failure and demonstrate its role in improving symptoms and functionality in those not deemed fit for major surgery. Pre- and postoperative pain scores in accordance with the visual analogue scale, walking distances and radiographs were reviewed in a patient who underwent the salvage technique to ascertain the subjective and objective difference in pain and functionality. The patient showed marked improvement in pain scores and walking distances postoperatively. Additionally, the degree of proximal junctional kyphosis was lower on postoperative radiographs. While holding risks of its own, our described technique can be performed in select cases and is a good salvage procedure in high-risk patients. It prevents their exposure to the risks that accompany large revision operations and fusion models with further potential to fail. We recommend that our technique is performed only at specialist centres.

Skill acquisition and stress adaptations following laparoscopic surgery training and detraining in novice surgeons

BACKGROUND

Surgical training and practice is stressful, but adaptive changes in the stress circuitry (e.g. perceptual, physiological, hormonal, neural) could support skill development. This work examined skill acquisition and stress adaptations in novice surgeons during laparoscopic surgery (LS) training and detraining.

METHODS

Twelve medical students were assessed for skill performance after 2 h (BASE), 5 h (MID) and 8 h (POST) of LS training in weeks 1-3, and then after 4 weeks of no training (RETEST). The stress outcomes included state anxiety, perceived stress and workload, heart rate (HR), heart rate variability (HRV), and salivary testosterone and cortisol concentrations. Functional near-infrared spectroscopy was used to assess cortical oxygenation change, as a marker of prefrontal cortex (PFC) activity.

RESULTS

Skill performance improved in every session from BASE (p < 0.01), with corresponding decreases in state anxiety, stress, workload, low- and high-frequency HRV in the MID, POST and/or RETEST sessions (p < 0.05). Left and right PFC were symmetrically activated within each testing session (p < 0.01). The stress and workload measures predicted skill performance and changes over time (p < 0.05), with state anxiety, mean HR and the HRV measures also showing some predictive potential (p < 0.10).

CONCLUSIONS

A 3-week LS training programme promoted stress-related adaptations likely to directly, or indirectly, support the acquisition of new surgical skills, and many outcomes were retained after a 4-week period without further LS training. These results have implications for medical training and education (e.g. distributed training for skill development and maintenance, stress resource and management training) and highlighted possible areas for new research (e.g. longitudinal stress and skill profiling).

Acute multifocal placoid pigment epitheliopathy associated with erythema nodosum and a flu-like illness

Acute multifocal placoid pigment epitheliopathy (AMPPE) is a rare inflammatory vasculitis of the choroid. Despite primarily being a disorder of the eye, a number of extra-ophthalmological features have been described in AMPPE and may accompany the visual disturbances. Such patients may be admitted under the care of physicians for evaluation of a systemic illness. We report AMPPE occurring in a 37-year-old man in his thirties admitted with a flu-like illness, erythema nodosum, visual disturbances and raised inflammatory markers. Conditions such as bacterial endocarditis and vasculitis, were considered before a diagnosis of AMPPE was made. The case illustrates how AMPPE can be a diagnostic dilemma, particularly when associated with extra-ophthalmological features. The epidemiology, clinical features, diagnosis and therapy of AMPPE are also discussed.