OP0265-HPR IMPACT OF COVID-19 PANDEMIC ON RHEUMATOLOGY PATIENTS IN NORTHERN IRELAND – A WEB BASED CROSS-SECTIONAL SURVEY

Background:

Concern for the susceptibility of rheumatology patients to severe COVID-19 illness has been raised since the start of the pandemic. Rheumatic disease and their immunosuppressant therapies placed many patients into the ‘clinically extremely vulnerable’ group when the UK’s shielding guidance commenced on 23 March 2020. The impact of DMARDs/glucocorticoids/biologics on COVID-19 remains under investigation 1. A recent study suggested caution may be required with rituximab and sulfasalazine in COVID-19 patients 2.

Objectives:

The objective of this study is to evaluate the impact of the COVID-19 pandemic on rheumatology patients in Northern Ireland by assessing demographics, rheumatic disease, medications, disease progress, shielding advice, access to primary & tertiary care and incidence of COVID-19 infection.

Methods:

A web-based cross-sectional survey was completed in Northern Ireland. The study duration was between 23rd November 2020 and 22nd January 2021. The questionnaire included consent, demographic details, medication history, comorbidities, disease course, patient experience, shielding advice, COVID-19 illness and hospitalisation. The survey was publicised by sending 6,032 Belfast Trust NHS patients a link via SMS, posters were displayed in rheumatology departments, and links made available via NHS/Versus Arthritis social media platforms.

Results:

There were 2,615 responses and of these 2,539 had been completed and were analysed. Most respondents were aged 45+ (78.27%) and female (N=1819). Rheumatoid arthritis (41%) and psoriatic arthritis (29%) were the most common diagnoses. Just over one third (35.27%, N=896) of patients were on biological drugs. Most patients were taking methotrexate (28.04%) followed by hydroxychloroquine (15.20%) and adalimumab (12.52%). The majority (79.6%) continued treatment during the pandemic. There was evidence of disease ‘flaring’ in 30.75% of patients who had stopped treatment. Of the respondents surveyed 7.8% (N=198), tested positive for Covid-19 and of these 77.55% reported that they had received adequate shielding advice, primarily from GP or UK government sources. Only 11.11% (N=22) of those who tested positive for Covid-19 required hospital admission and 2 patients required intensive care support. Both patients requiring ICU were not on immunosuppression. Less than one third of patients testing positive for COVID-19 were on biological drugs (30.3%, N=60). Cardiovascular disease was the most prevalent comorbidity. Of the 22 patients hospitalised with COVID-19, 13.64% (N=3) were on solitary sulphasalazine therapy.

Conclusion:

The survey showed low levels of COVID-19 hospitalisation despite most patients continuing DMARD/biologic/glucocorticoid therapy. This has been replicated in other studies 1, however data continues to be gathered on the safety of some biologic drugs particularly rituximab 2. Most of our patients received clear understandable shielding guidance from a variety of sources. Many patients expressed fear of mortality, isolation and mental health issues. The survey findings indicated that stopping medication can have a negative impact on disease control.

References:

[1]Robinson PC, Yazdany J. The COVID-19 Global Rheumatology Alliance: collecting data in a pandemic. Nat Rev Rheumatol. 2020 Jun;16(6):293-294.

[2]Strangfeld A, Schäfer M, Gianfrancesco MA, et al. Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry. Annals of the Rheumatic Diseases Published Online First: 27 January 2021. doi: 10.1136/annrheumdis-2020-219498

Disclosure of Interests:

None declared

What is the evidence for interactions between filaggrin null mutations and environmental exposures in the aetiology of atopic dermatitis? A systematic review

BACKGROUND

Epidemiological studies indicate that gene-environment interactions play a role in atopic dermatitis (AD).

OBJECTIVES

To review the evidence for gene-environment interactions in AD aetiology, focusing on filaggrin (FLG) loss-of-function mutations.

METHODS

A systematic search from inception to September 2018 in Embase, MEDLINE and BIOSIS was performed. Search terms included all synonyms for AD and filaggrin/FLG; any genetic or epidemiological study design using any statistical methods were included. Quality assessment using criteria modified from guidance (ROBINS-I and Human Genome Epidemiology Network) for nonrandomized and genetic studies was completed, including consideration of power. Heterogeneity of study design and analyses precluded the use of meta-analysis.

RESULTS

Of 1817 papers identified, 12 studies fulfilled the inclusion criteria required and performed formal interaction testing. There was some evidence for FLG-environment interactions in six of the studies (P-value for interaction ≤ 0·05), including early-life cat ownership, older siblings, water hardness, phthalate exposure, higher urinary phthalate metabolite levels (which all increased AD risk additional to FLG null genotype) and prolonged breastfeeding (which decreased AD risk in the context of FLG null genotype). Major limitations of published studies were the low numbers of individuals (ranging from five to 94) with AD and FLG loss-of-function mutations and exposure to specific environmental factors, and variation in exposure definitions.

CONCLUSIONS

Evidence on FLG-environment interactions in AD aetiology is limited. However, many of the studies lacked large enough sample sizes to assess these interactions fully. Further research is needed with larger sample sizes and clearly defined exposure assessment. Linked Comment: Park and Seo. Br J Dermatol 2020; 183:411.

Disease trajectories in childhood atopic dermatitis: an update and practitioner's guide

BACKGROUND

Atopic dermatitis (AD) is a heterogeneous disease with a multifactorial aetiology and complex pathophysiology. This heterogeneity translates into different trajectories of disease progression with respect to severity, persistence and risk of development of atopic comorbidities. Determining which possible disease trajectories or comorbidities any individual child might develop is challenging in clinical practice. Tools that help identify paediatric patients at higher risk of disease progression would greatly aid clinicians.

METHODS

We reviewed recent cohort studies to synthesize and simplify the epidemiological data to try to identify shared clinically relevant characteristics that may help physicians estimate the risk of disease progression in paediatric patients with AD.

RESULTS

Despite the variability in data collection and methods of analysis and their limitations, there are common patterns of early-childhood AD that may aid in the estimation of risk for disease progression. Factors associated with risk of AD progression include younger age of onset, family history of atopy, greater AD severity, filaggrin mutations, urban environment and polysensitization and/or allergic multimorbidity. Based on these factors, we provide a practitioner's guide for identifying, counselling and/or referring infants and children with AD at potentially higher risk of developing persistent AD and atopic comorbidities. We also present clinical scenarios to illustrate how these data relate to real-life situations.

CONCLUSIONS

Useful insights are provided for physicians and patients to inform them better about the risk of AD progression and to help guide care pathways for the paediatric population with AD. What's already known about this topic? The complex pathophysiology of atopic dermatitis (AD) translates into a heterogeneous clinical presentation and trajectories of disease progression. Although the consensus is that most paediatric patients with AD will eventually 'outgrow' the disease or follow the longitudinal trajectory known as the 'atopic march', a significant proportion will develop persistent AD and/or other atopic conditions. No known factors conclusively predict the risk of progression or development of comorbidities. What does this study add? Recent analyses of data from large cohorts of paediatric patients with AD have suggested the existence of potentially discrete clusters of patients who present with relatively common AD phenotypes. These studies have shed some light onto the factors associated with risk of progression, which we review in this article. A practitioner's guide with clinical scenarios is provided to help identify patients at high risk of progression to determine whether a patient should be monitored and/or would require specialist referral.

Diversity and dynamics of the DNA- and cDNA-derived compost fungal communities throughout the commercial cultivation process for Agaricus bisporus

Commercial cultivation of the button mushroom Agaricus bisporus is performed through the inoculation of a semipasteurized composted material. Pasteurization of the compost material prior to inoculation results in a substrate with a fungal community that becomes dominated by A. bisporus. However, little is known about the composition and activity in the wider fungal community beyond the presence of A. bisporus in compost throughout the mushroom cropping process. In this study, the fungal cropping compost community was characterized by sequencing nuc rDNA ITS1-5.8S-ITS2 amplified from extractable DNA and RNA. The fungal community generated from DNA extracts identified a diverse community containing 211 unique species, although only 51 were identified from cDNA. Agaricus bisporus was found to dominate in the DNA-derived fungal community for the duration of the cropping process. However, analysis of cDNA extracts found A. bisporus to dominate only up to the first crop flush, after which activity decreased sharply and a much broader fungal community became active. This study has highlighted the diverse fungal community that is present in mushroom compost during cropping.

Subacute seizure incidence in thrombolysis-treated ischemic stroke patients

BACKGROUND

To assess the incidence of seizures in acute ischemic stroke patients treated with chemical (tPA) thrombolysis.

METHODS

Retrospective study including all thrombolysis patients treated in Calgary between January 1, 2001, and October 31, 2006. Descriptive statistics and age/sex-adjusted P values were calculated.

RESULTS

Of 400 eligible patients (median age 74.0 years, range: 24-77), 16 (4%) developed post-stroke seizures: 10 (62.5%) within one week (early) and 6 (37.5%) after 1 week but within the hospital stay (late). Single-vessel anterior circulation involvement (93.8% vs. 87%, P = 0.34) and hemorrhage (37.5% vs. 20%, P = 0.15) were more common in those with compared to without seizures but did not reach statistical significance. Atrial fibrillation was more common in those with (56.3%) than without (36.1%) seizures (P = 0.04). Death during admission was more likely (P = 0.03) in those who sustained seizures (37.5%) compared to those without seizures (17.6%).

CONCLUSIONS

In this cohort of tPA-treated patients, post-stroke seizures were associated with atrial fibrillation and early mortality.

Experience with a wipe guaiac-based faecal occult blood test as an alternative test in a bowel screening programme

The format of the traditional guaiac faecal occult blood test (gFOBT), particularly the collection technique, might cause difficulties for some. A multistage evaluation of alternative tests was performed. Firstly, four tests with different faecal collection approaches were assessed: a focus group recommended further investigation of a wipe gFOBT. Secondly, 100 faecal samples were analysed using two wipe tests and the routine gFOBT: no differences were found. Thirdly, a wipe gFOBT was introduced. Over 21 months, 400 requests were made and 311 wipe kit sets were submitted for analysis: 153 (49.2%) were negative, 21 (6.8%) positive (all 3 kits positive), 96 (30.9%) weak positive (1 or 2 positive) and 41 (13.2%) un-testable. Forty-three participants were referred for colonoscopy. Outcome data were provided on 39 participants: nine declined colonoscopy, two were judged unsuitable, two did not attend, two were already in follow-up, 13 had normal colonoscopy and two normal barium enema, two had diverticular disease, two had a metaplastic polyp, four had a low-risk adenoma and one had a high-risk adenoma. No participant had cancer. Detection of significant neoplasia was small. The use of the wipe gFOBT was ceased: it cannot be recommended as a screening test for bowel cancer.

Management of vascular birthmarks: review of a multidisciplinary clinic

Vascular birthmarks comprise a diverse group of congenital lesions and represent a significant cosmetic and functional burden for patients. They remain a diagnostic and management challenge for physicians due to their extremely variable clinical presentation and often complex anatomical associations. As each type of vascular lesion has a treatment program individual to it, optimal functional and cosmetic outcomes require accurate diagnosis. Primary physicians readily diagnose and manage uncomplicated lesions, such as isolated haemangiomas and innocuous capillary malformations. However, given the complexity and relative rarity of many other vascular birthmarks, specialised multidisciplinary clinics are central to their management. In this review, we present our experience regarding the diagnostic range of vascular anomalies, associated symptomatology, and management of patients with vascular birthmarks attending the multidisciplinary Joint Vascular Birthmark Clinic at Our Lady's Children's Hospital, Crumlin. Vascular tumours represented 57% of cases reviewed, malformations accounting for 43%. Of patients not previously seen at the JVBC or by any of the individual consultants, the initial or referring diagnosis was incorrect in 42%. Significantly, 62% of vascular malformations were assigned an incorrect diagnosis, highlighting the need for a specialised clinic.

Pneumatic retinopexy: success rate and complications

AIM

To evaluate the success rate and complications of pneumatic retinopexy performed at a university hospital and to identify which patients are best suited for pneumatic retinopexy.

METHODS

This was an interventional case series. Retrospective review of 61 patients who had pneumatic retinopexy performed by two retina surgeons at two University of California, San Francisco hospitals between 1998 and 2004. Patients who had been treated for rhegmatogenous retinal detachment (RRD) with pneumatic retinopexy were identified by reviewing operative reports and billing records. The primary outcome measure was anatomical reattachment of the retina with a single intervention. Secondary outcome measures included postoperative visual acuity and postoperative complications.

RESULTS

33 of 61 (54%) cases were successful with a single procedure. 40 of 61 (66%) cases were successful with repeat injection of gas or laser retinopexy alone. All cases had anatomical success at final follow up. Age, myopia, lens status, and number of breaks were not proved to be risk factors for failure. The average duration of follow up was 15 months.

CONCLUSIONS

In this case series, pneumatic retinopexy was less effective for the repair of RRD than most large published reports. However, failure of pneumatic retinopexy followed by scleral buckle or pars plana vitrectomy did not negatively influence visual acuity at final follow up.

Patch angioplasty reduces morbidity and restenosis following carotid endarterectomy

Background

The role of patch angioplasty in the prevention of stroke and restenosis following carotid endarterectomy remains controversial, partly because of confounding variables such as surgical expertise and selective shunting.

Methods

A consecutive series of 177 carotid endarterectomies performed on 168 patients by, or under the supervision of, one surgeon between December 1992 and July 1999 with routine shunt insertion and completion arteriography was studied. Until April 1997 arteriotomies were closed primarily, with patch angioplasty reserved for small vessels or patients found to have occlusion of the internal carotid artery at operation. After April 1997 Dacron patch closure was performed routinely. All patients had duplex ultrasonography 3 months following endarterectomy.

Results

The indication for surgery and patient characteristics were similar in those who had primary closure and those with patch angioplasty. The postoperative morbidity and incidence of restenosis is shown in the Table.

One of two patients found at surgery to have a recently occluded internal carotid artery had a stroke. The only patient with patch angioplasty and postoperative reocclusion had the lupus anticoagulant and reported amaurosis. Two wound infections overlying Dacron patches resolved with antibiotics and there were no episodes of patch disruption.

Conclusion

This study provides further evidence that patch angioplasty following carotid endarterectomy may reduce postoperative morbidity and early restenosis.

Incidence and pattern of long saphenous vein duplication and its possible implications for recurrence after varicose vein surgery

BACKGROUND

The incidence of long saphenous vein (LSV) duplication has not been clearly established. This anomaly could have implications for recurrence after varicose vein surgery.

METHODS

Some 103 saphenograms obtained in 85 patients being considered for peripheral arterial bypass surgery were reviewed. Non-ionic contrast medium was injected directly into the vein or its tributaries at the ankle. Duplications of the LSV and their relation to thigh and calf perforator veins were assessed and recorded by two independent observers.

RESULTS

There was evidence of duplication of the LSV in 50 (49 per cent) of the 103 saphenograms. Most duplications were present in the thigh (88 per cent) and the most common pattern was a closed loop (54 per cent). Perforator veins were connected to one branch of the duplication in 42 per cent of the legs (20 per cent of all 103 legs); in half the perforator vein was connected to the non-dominant branch of the duplication. Only ten of the 18 patients who had bilateral saphenograms had duplications in both legs, and only one patient had the same pattern of duplication on both sides.

CONCLUSION

The incidence of LSV duplications is higher than previously reported.

Infusional 5-fluorouracil can be a pain in the neck: A case for repositioning displaced Hickman lines

Increasing numbers of patients receive infusional chemotherapy or total parenteral nutrition via Hickman or Grochong lines. Although the insertion of these indwelling catheters is generally performed under radiological guidance and their positions verified by chest radiography, it is still feasible for them to become displaced at a later date. This possibility should be excluded in patients who develop unusual symptoms during the course of their infusional therapy. We review the reported complications associated with Hickman lines, and present a case history demonstrating that interventional radiology has a valuable role in displaced line repositioning, after the exclusion of thrombosis and infection.