Is the patient-perceived impact of psoriatic arthritis a global concept? An international study in 13 Arab countries (TACTIC study)

The Psoriatic Arthritis Impact of Disease (PsAID-12) questionnaire, a recommended measure of patient-reported impact for psoriatic arthritis (PsA), was initially developed in Europe and may lack universal validity. Recognizing the need for a culturally appropriate tool for Arab patients, this study aimed to TranslAte, CulTurally adapt, and validate the PsAID in ArabIC (TACTIC). The PsAID-12 was translated into Arabic using a rigorous process of double translation, back-translation, and cognitive debriefing. The Arabic version was then validated through a study conducted in 13 Arab countries in 2022. Participants were consecutive literate adult patients diagnosed with PsA and fulfilling the CASPAR criteria. Collected data included PsAID-12, disease activity, and legacy patient-reported outcomes. Psychometric properties, such as internal consistency, construct validity, and test-retest reliability, were examined. Factors associated with high PsAID-12 total scores (> 4) were explored using multivariable binary logistic regression. A culturally adapted Arabic PsAID-12 questionnaire was achieved with minor rephrasing. The validation study included 554 patients from 13 countries (mean age 45 years, 59% females), with a mean PsAID score of 3.86 (SD 2.33). The Arabic PsAID-12 demonstrated excellent internal consistency (Cronbach's α = 0.95), and correlations with other measures ranged from 0.63 to 0.78. Test-retest reliability (N = 138 patients) was substantial (intraclass correlation coefficient, ICC 0.90 [0.86-0.93]; Cohen's kappa 0.80). Factors associated with a high PsAID score were disability (odds ratio, OR 3.15 [2.03-4.89]), depression (OR 1.56 [1.35-1.81]), widespread pain (OR 1.31 [1.12-1.53]), and disease activity (OR 1.29 [1.13-1.47]). Pain and fatigue were identified as the most impactful PsAID-12 domains for PsA patients. The Arabic PsAID is a valid and reliable measure that reflects the priorities of patients with PsA. PsAID scores correlated with disease activity and legacy outcome measures, as expected, indicating PsAID is a consistent measure of PsA impact across cultures. These findings highlight the potential of the Arabic PsAID in improving the care provided to Arabic-speaking patients worldwide.

What is the best referral strategy for axial spondyloarthritis? A prospective multicenter study in patients with suspicious chronic low back pain

OBJECTIVE

To assess the value of referral strategies for axial spondyloarthritis (axSpA) in patients with suspicious chronic inflammatory low back pain (LBP), to estimate the value of inflammatory back pain (IBP) for referral, and to identify the predictive factors of the final diagnosis of axSpA in Middle Eastern Arab countries.

METHODS

The study was multicentric, prospective, and conducted in LBP first-line clinics (rheumatology, internal, family medicine, orthopedic surgery, neurosurgery, and neurology). Consecutive adult patients aged under 45years were included in case of LBP suspicious of inflammatory nature according to the first-line physician. The rheumatologist's final diagnosis was the gold standard. The diagnostic properties of ten referral strategies (Brandt I, II, III, Hermann, RADAR, RADAR 2/3, MASTER, Braun, CAFASPA, and ASAS) and of IBP were calculated. A multivariable logistic regression identified the clinical predictive factors of axSpA.

RESULTS

In 515 referred patients, axSpA was confirmed in 48%, refuted in 43%, and diagnosis remained inconclusive in 9%. The optimal referral strategy was the MASTER (PLR 3.3), which comprises IBP, good response to NSAIDs, positive HLA-B27, and SpA family history. Considering strategies without HLA-B27, the RADAR 2/3 had a PLR of 2.9 (IBP, good response to NSAIDs, any extra-musculoskeletal manifestation). The predictive factors for axSpA were MRI sacroiliitis, positive HLA-B27, high CRP, psoriasis, IBP, and longer symptom duration. Of all patients, 35% were self-referred, 16% were referred by primary care physicians, and 15% by neuro/orthopedic surgeons.

CONCLUSION

Optimizing physicians' awareness of these clinical features may enhance referral in axSpA.

How to optimize recruitment strategies of patients with rheumatic and musculoskeletal diseases for online surveys: experience from an international study

The use of online surveys as a recruitment tool for clinical research has recently expanded; nevertheless, optimal recruitment strategies remain poorly identified. Objectives. The study aimed to identify the most effective recruitment strategies for online research studies and to determine the optimal survey channels for obtaining patients' responses. This is a post-hoc analysis of the ARCOVAX (ArLAR COVID Vaccination) study. Multiple recruitment strategies were disseminated in Arabic, English, and French. The proportion of enrolled patients was correlated with each strategy. Channels used by patients to complete the survey were divided into three categories (social media (SoMe), doctor, and patients' associations). These channels were correlated with the patients' characteristics and the country's Gross Domestic Product (GDP). A total of 1595 patients from 19 Arab countries completed the survey. Patients' mean age was 39 years, 73.2% (1159) were females, 17.8% (284) had a university education level and 93.1% (1468) answered the survey in Arabic. The most effective recruitment strategies were personalized WhatsApp reminders to recruiters (30% of enrolled patients), technical support in response to access issues (27%) and sharing recruitment status by country on a WhatsApp group (24%). The channels used to complete the survey were: SoMe in 45% (711), doctor in 40% (647), and patients' associations in 8.5% (233), and correlated with age and GDP. To optimize recruitment, it is recommended to combine multiple strategies and channels, use the native language and be active (mobilize teams), reactive (provide prompt technical support), and proactive (share regular updates and reminders).

APLAR recommendations on the practice of telemedicine in rheumatology

INTRODUCTION

The COVID-19 pandemic led to rapid and widespread adoption of telemedicine in rheumatology care. The Asia Pacific League of Associations for Rheumatology (APLAR) working group was tasked with developing evidence-based recommendations for rheumatology practice to guide maintenance of the highest possible standards of clinical care and to enable broad patient reach.

MATERIALS AND METHODS

A systematic review of English-language articles related to telehealth in rheumatology was conducted on MEDLINE/PubMed, Web Of Science and Scopus. The strength of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach as well as the Oxford Levels of Evidence. The recommendations were developed using a modified Delphi technique to establish consensus.

RESULTS

Three overarching principles and 13 recommendations were developed based on identified literature and consensus agreement. The overarching principles address telemedicine frameworks, decision-making, and modality. Recommendations 1-4 address patient suitability, triage, and when telemedicine should be offered to patients. Recommendations 5-10 cover the procedure, including the means, data safety, fail-safe mechanisms, and treat-to-target approach. Recommendations 11-13 focus on training and education related to telerheumatology.

CONCLUSION

These recommendations provide guidance for the approach and use of telemedicine in rheumatology care to guide highest possible standards of clinical care and to enable equitable patient reach. However, since evidence in telemedicine care in rheumatology is limited and emerging, most recommendations will need further consideration when more data are available.

831 Bouveret’s Syndrome (A Gallstone Disease Causing Gastric Outlet Obstruction): A Case Series and Review of Literature

Bouveret’s syndrome refers to a gastric outlet obstruction due to the impaction of a large gallstone following retrograde migration via a bilio-duodenal fistula. Although no clear management guideline has been formulated, different treatment modalities have been described, including endoscopic stone removal using classical endoscopic devices, like snares and forceps; or fragmentation of stones with new devices, such as laser and extracorporeal shockwave lithotripsy (EWSL).

We report a case series of Bouveret’s syndrome with interesting radiological and endoscopic findings which have been successfully managed either via endoscopic measures such as stone extraction and/or duodenal stenting, or surgical intervention. The report is followed by a literature review including diagnostic and management options of this rare condition. All our patients were elderly with multiple comorbidities. Two patients presented with upper gastro-intestinal bleeding, while the other two presented with abdominal pain and bilious vomiting. The diagnosis was confirmed by computerised tomography (CT) scan and upper gastro-intestinal endoscopy. Endoscopic stone removal was successful in one case. In one patient, stone was fragmented but could not be removed completely, so he was managed via duodenal stent insertion. The other two patients required surgical intervention. One case was complicated by gallstone ileus which required laparotomy and extraction of stones from two sites, while the other required subtotal cholecystectomy, stone extraction and repair of duodenal fistula. The patients recovered well. The diagnosis of Bouveret’s Syndrome is made after performing appropriate imaging studies. The first line management option is endoscopic treatment. If this fails, surgical intervention is recommended.

865 Reducing Delays in Cholecystectomy Surgery of Patients Admitted with Gallstone-Related Disease Within Gold Standard Time Frame Set Out By NICE

Introduction

As per NICE guidelines, Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) aims for 80% of eligible patients with gallstone-related disease to receive their cholecystectomy within 8 days of presentation1. Only 63.6% of eligible patients at East Lancashire Hospitals NHS Trust (ELHT) had their surgery within the target time. This project was done to identify the reasons behind ELHT not achieving the set target and to implement changes to overcome this.

Method

This was a retrospective review of a prospectively collected data of 444 patients from the ELHT Chole-QuIC database (July 2019-November 2020). Data were analysed in three periods: initial period (July 2019-November 2019), pre-COVID-19 period (December 2019-February 2020), COVID-19 period (March 2020-November 2020). Time to surgery was established. If the 8-day target was not met, reasons behind the delay were recorded.

Results

During the first cycle, the main reasons delays included the patients being temporarily unfit (13.8%), insufficient theatre capacity (13.8%) and variations in treatment plans (11.32%). 8% of patients had re-admissions related to their gallstone disease. Changes were implemented forward included a clear local gallstone disease management pathway and CholeQuIC referral system, increasing theatre capacity, and allocating pre-operative assessment slots. Gold standard cholecystectomy target period improved from 63.6% to 67.4% within three months of changes. However, the figure drastically reduced during the COVID-19 pandemic (36.3%) as elective surgeries were temporarily suspended.

Conclusions

The implementation of a gallstone disease management pathway, a coordinated referral system and additional theatre capacity contributed to the increase in cholecystectomies that were performed within the 8-day national target period.

1137 Improving the Use of Pre-Operative Skin Antiseptics (Chlorhexidine Pink and Betadine) To Reduce Umbilical Port Site Infections Following Laparoscopic Cholecystectomy and Appendicectomy

Introduction

Approximately 8% of patients who undergo laparoscopic surgery develop port site infections1. This would negatively impact recovery and increase rates of readmission. Patients’ skin is a major source of pathogens that results in surgical site infection (SSI). Therefore, optimisation of antiseptic skin preparations may decrease postoperative umbilical port site infection (UPSI).

Method

A retrospective analysis of 226 cases from August 2019 till October 2020 at East Lancashire Hospital NHS Trust was performed. The first cycle included 122 patients (58 cholecystectomies and 64 appendicectomies), and a further 104 patients (51 cholecystectomies and 53 appendicectomies) after emphasising on using chlorhexidine pink as skin preparation. The presence of UPSIs within 30 days post-surgery was recorded.

Results

In the first cycle, the local preparation that was used in patients with UPSI was chlorhexidine pink (21.4%) and betadine (78.6%). The surgical team were then educated regarding the benefits of chlorhexidine pink over betadine as local skin preparation. In the second cycle, 63.3% used chlorhexidine pink and 36.7% used betadine. After the above implementation, there was a reduction in the rate of UPSI (18.0% to 15.7%) and readmission rates (7.2% to 5.9%) in patients who had undergone laparoscopic cholecystectomy. In patients who had undergone laparoscopic appendicectomy, a similar trend in UPSI rates was identified as well (7.1% to 5.5%) and readmission rates (5.5% to 1.9%).

Conclusions

The incidence of UPSI was reduced with the use of chlorhexidine pink compared to betadine. This may have contributed to the decrease in UPSI cases and led to a reduction in re-admission rates.

Frequency and molecular epidemiology of Panton-Valentine leukocidin gene in Staphylococcus aureus colonising HIV-infected patients

BACKGROUND

HIV-infected patients pose a high risk of contracting skin and soft tissue infections caused by Staphylococcus aureus. Those who are colonized with methicillin-resistant S. aureus (MRSA) that carry Panton-Valentine leukocidin (PVL) are predisposed to severe infections that could lead to necrotic skin infections. However the association of S. aureus specifically methicillin sensitive S. aureus carrying PVL gene in HIV patients has not been widely reported. Here, we study the prevalence and the molecular epidemiology of PVL-producing S. aureus in HIV-infected patients.

METHODS

Swabs from four body sites of 129 HIV-infected patients were cultured for S. aureus and identified by standard microbiological procedures. The isolates were subjected to antimicrobial susceptibility testing by disk diffusion against penicillin, erythromycin, clindamycin, and cotrimoxazole. PCR was used to detect the PVL gene and genetic relationship between the isolates was determined by using pulse field gel electrophoresis.

RESULTS

A total of 51 isolates of S. aureus were obtained from 40 (31%) of the patients. The majority (43.1%) of the isolates were obtained from the anterior nares. Thirteen (25.5%) of all the isolates were resistant to more than one category of antibiotics, with one isolate identified as MRSA. Thirty-eight (74.5%) isolates (including the MRSA isolate) carried PVL gene where the majority (44.7%) of these isolates were from the anterior nares. A dendogram revealed that the isolates were genetically diverse with 37 distinct pulsotypes clustered in 11 groups.

CONCLUSION

S. aureus obtained from multiple sites of the HIV patients were genetically diverse without any clonality observed.

Overview of diagnostic performance and results for the first operation phase in Wendelstein 7-X (invited)

Wendelstein 7-X, a superconducting optimized stellarator built in Greifswald/Germany, started its first plasmas with the last closed flux surface (LCFS) defined by 5 uncooled graphite limiters in December 2015. At the end of the 10 weeks long experimental campaign (OP1.1) more than 20 independent diagnostic systems were in operation, allowing detailed studies of many interesting plasma phenomena. For example, fast neutral gas manometers supported by video cameras (including one fast-frame camera with frame rates of tens of kHz) as well as visible cameras with different interference filters, with field of views covering all ten half-modules of the stellarator, discovered a MARFE-like radiation zone on the inboard side of machine module 4. This structure is presumably triggered by an inadvertent plasma-wall interaction in module 4 resulting in a high impurity influx that terminates some discharges by radiation cooling. The main plasma parameters achieved in OP1.1 exceeded predicted values in discharges of a length reaching 6 s. Although OP1.1 is characterized by short pulses, many of the diagnostics are already designed for quasi-steady state operation of 30 min discharges heated at 10 MW of ECRH. An overview of diagnostic performance for OP1.1 is given, including some highlights from the physics campaigns.

Malignant melanoma masqueraded as ingrown toe nail

We report a case in a 62-year-old female who presented with a year history of dull aching pain of the left big toe, which was aggravated by pressure on the nail and relieved by analgesia. Tissue biopsy confirmed the diagnosis of malignant melanoma. There was a black colour swelling about 3x8 mm in size over the medial side of the dorsum of left big toe with a scar of previous operation. Histopathological examination showed on gross section of 2 blackish area one infiltrate the bone the other the tumour not infiltrate the proximal interphalangial joint with another satellite lesion 20mm from main tumour area was found. Malignant cells were large with abundant cytoplasm, hyperchromatic nuclei and some prominent eosinophilic nucleoli. Melanin pigment was markedly seen. The big toe was amputated. We here highlight a case where the patient was diagnosed and managed as having ingrown nail of the left big toe while in actual fact she had a subungual amelanotic melanoma.

Efficacy of a single 6 mg/kg versus two 3 mg/kg caspofungin doses for treatment of disseminated candidiasis caused by Candida albicans in a neutropenic mouse model

We compared the efficacy of single six mg/kg and 2x3 mg/kg caspofungin doses to the traditional one mg/kg daily against C. albicans in a neutropenic murine model. In lethality experiments, all regimens improved survival (p<0.0014 for all three isolates); differences among the treated groups were not statistically significant. We calculated kidney fungal burdens on each study day for six days postinfection using two isolates in two experiments. In the first three days, only the six mg/kg dose produced significant decrease on all study days (p<0.05-0.001), but differences between the three treatment arms disappeared by 4-6 days postinfection (p<0.05 for all isolates on all days).

Effect of surface morphology and temperature on the structural stability of nanoscale wavy films

The atomic scale structural stability of freestanding wavy gold (Au) nanofilms was investigated using molecular dynamics simulations. The waviness in the Au film was formed by cleaving sinusoidal surfaces from a [Formula: see text] bulk crystal. The degree of waviness was varied by changing the wavelength of the sinusoidal surface profile. Films were then equilibrated at different temperatures (between 10 and 1080 K) and their structural stability was monitored. The MD simulation results revealed that the stability of films depends on temperature as well as the waviness of the film surface. It was shown that the size-dependent melting point depression of Au plays the dominant role in causing the structural instability of wavy films.