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`VDI Score increased from the time of diagnosis till the time of last follow-up
`and this rise was statistically significant (p≤0.002) in all groups. The mean
`VDI Score for the APS group at diagnosis was 4.86 and was significantly
`higher than for the aPL positive (mean VDI Score=2.02, p=0.0001) and neg-
`ative (1.93, p=0.0001) groups. At last time of follow-up the mean VDI Score
`for the APS patients was 6.27 and this value was higher than for the aPL
`positive (mean VDI Score=3.51, p=0.0001) and negative (2.96, p=0.0001)
`groups (see Figure1). 9 (4.9%) patients died, 4 of whom were assessed for
`aPL: 2 had APS and 2 positive aPL.
`Conclusions: APS is a predictor of irreversible organ damage in vasculi-
`tides. We suggest that determination of aPL is warranted in the diagnostic
`work-up of vasculitis patients.
`
`BHPR – audit/service delivery
`
`371. DO ALL PATIENTS WITH CHRONIC
`INFLAMMATORY ARTHRITIS IN DISTRESS NEED A
`DOCTOR?
`
`A.G. Richards, S.M. Bintley-Bagot. TherapiesDepartment,TheRoyal
`LiverpoolUniversityHospital,Liverpool,Merseyside,UnitedKingdom
`
`Background: The patient with chronic inflammatory arthritis can experience
`significant distress as their level of function declines and we struggle to man-
`age their pain effectively. The burden of responsibility increases for carers as
`the patients independence is loss.
`At clinic visits, the doctor is presented with a long complicated history, a
`distressed family, multifunctional problems and social care issues. Busy clinic
`settings often prevent detailed discussion of problems raised.
`Our purpose as Clinical Specialists in Occupational therapy and Physiother-
`apy was to establish a rapid response therapy service to meet the needs of
`patients with chronic inflammatory arthritis in distress whilst they remain in
`their own home.
`Methods: Referral criteria was formulated, patients were jointly assessed by
`a Specialist O.T. and P.T. favouring a social care model of practice within 4
`weeks. A treatment plan was formulated, implemented and evaluated.
`Results: 42 referrals recieved. F:M 36:6 aged 34-93, disease duration av
`15.4 yrs 45% not on DMARDS. 0% employed 100% needed carer support
`73% had accomodation that did not meet their needs. 34% required referrals
`to local agencies. 16.6% did need to see a doctor for review of medication.
`17% needed a referral to other specialities but did not need to see a doctor.
`This graph displays functional problems identified and therapy intervention.
`
`Summary of therapy intervention.
`
`Conclusions: Predominantly patients with chronic inflammatory arthritis in
`distress did not present with medical problems. They focused on functional,
`social, emotional and housing issues. Our focus on treatment was to restore
`function, prevent falls, improve safety, gain pain control, liase with commu-
`nity support networks and most importantly to address the patients/families
`concerns.
`The service was cost effective in terms of reduced ambulance requests,
`clinic appointments, and hospital admissions.
`94% patients were very satisfied and felt the service met their needs.
`Common themes were identified enabling a guideline of therapy manage-
`ment of chronic inflammatory arthritis to emerge.
`Evaluation of the rapid response therapy service has highlighted the diverse
`role specialist therapists can contribute. Limited time/resources make it cru-
`cial we identify the most appropriate professional to review the patient in the
`
`most relevant setting.If these patients are to maintain maximum indepen-
`dence they do need a doctor but their need for highly skilled therapy staff is
`much greater.
`
`372.
`"I WANTED TO GIVE SOMETHING BACK":
`THE POSITIVE EFFECTS OF VOLUNTEERING AT A
`COMMUNITY-BASED ARTHRITIS RESOURCE CENTRE
`E.D. Hale1, G.J. Treharne1,2, C. Gordhan3, P.A. Bacon3, G.D. Kitas 1,2,3.
`1DepartmentofRheumatology,DudleyGroupofHospitalsNHSTrust,
`Dudley,WestMidlands,UnitedKingdom;2SchoolofPsychology,University
`ofBirmingham,Birmingham,UnitedKingdom;3Departmentof
`Rheumatology,DivisionofImmunityandInfection,SchoolofMedicine,
`UniversityofBirmingham,Birmingham,UnitedKingdom
`
`Background: Community-based arthritis resource centres provide informa-
`tion on a wide range of rheumatic conditions. Trained volunteers offer sup-
`port, information and signposting to patients, their families and friends.
`Methods: We sought to understand the impetus for volunteering and the per-
`ceived personal effects for the volunteers. Semi-structured interviews were
`conducted with four female trained volunteers, aged 45-77, at a community-
`based arthritis resource centre. All four volunteers have a rheumatic disease.
`Interviews were audio-recorded, transcribed verbatim and analysed using In-
`terpretative Phenomenological Analysis.
`Results: The impetus for volunteering came from a sense of strength gained
`from adversity and the desire to share experiences with others. The two ma-
`jor themes that emerged were Sharing Experiences and Making Choices.
`Participants’ were very aware of the value of personal support and encour-
`agement coupled with written information, due to their own experiences of
`uncertainty and isolation. Talking to another person with actual experience of
`rheumatic disease was perceived as very valuable as "it only takes one qual-
`ified volunteer you know". Re-establishing feelings of control and choice can
`take some time for people with rheumatic disease. Volunteering facilitates
`this process for both client and volunteer. Awareness of the new "changed"
`body is used as a positive example of accomplishment, reframing that which
`could be perceived negatively. Sharing knowledge and giving support re-
`establishes feelings of self-worth and being needed for the volunteers. The
`volunteers acknowledged that their work enabled them to focus on others
`rather than themselves, although they seized the opportunity to portray them-
`selves in a positive way. This enabled the volunteers to become "visible"
`again within society and less isolated. Helping someone to leave "much
`lighter in step" than when they came in made the volunteers’ feel needed
`and their role worthwhile.
`Conclusions: Trained volunteers at community-based arthritis support cen-
`tres can offer confidential support, information and signposting to clients
`(patients,
`their families and friends) without
`time constraints,
`in a non-
`threatening atmosphere. Volunteers with personal experience of rheumatic
`disease act as positive role models and gain personal benefit by enhancing
`their own feelings of self-worth.
`
`373.
`"JOINING THE DOTS": ISOLATION,
`UNDERSTANDING AND INTEGRATED HEALTHCARE
`FOR PATIENTS WITH LUPUS
`E.D. Hale1, G.J. Treharne1,2, D.L. Mitton1,3, S. Mole1, Y. Norton4,
`G.D. Kitas 1,2,5. 1DepartmentofRheumatology,DudleyGroupofHospitals
`NHSTrust,Dudley,WestMidlands,UnitedKingdom;2Schoolof
`Psychology,UniversityofBirmingham,Birmingham,UnitedKingdom;
`3SchoolofHealthSciences,UniversityofBirmingham,Birmingham,West
`Midlands,UnitedKingdom;4WestMidlandsBranch,LupusUK,Coseley,
`WestMidlands,UnitedKingdom;5DepartmentofRheumatology,Divisionof
`ImmunityandInfection,SchoolofMedicine,UniversityofBirmingham,
`Birmingham,UnitedKingdom
`
`Background: Systemic lupus erythematosus (SLE) is a multisystem disease
`requiring multidisciplinary health and psychosocial care.
`Methods: We examined the impact of external (social) and internal (psy-
`chological) features on SLE patients’ perceptions of healthcare provision.
`Semistructured interviews conducted with ten women, aged 32-68 with SLE
`for 1-12 years, were audio-recorded, transcribed verbatim and analysed us-
`ing Interpretative Phenomenological Analysis.
`Results: Three themes emerged: Isolation, Understanding and Communi-
`cation. Participants described how medical advice produced physical and
`subsequent social Isolationand felt that healthcare professionals did not ap-
`preciate its consequences. The body became physically isolated as it was
`concealed with clothing to protect from photosensitivity and with makeup to
`cover rashes. This theme was connected to feelings of "difference" to others,
`due to appearance and energy changes, and lack of Understanding. Partic-
`ipants expressed the opinion that no-one really understood what it was like
`to have lupus. Socially, they found that family and employers could not un-
`
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`Poster Session 3. BHPR – audit/service delivery
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`derstand the fluctuating nature of the disease. There was great concern to
`appear "legitimately" ill and to have a label for their condition. For some this
`had entailed a lengthy search within healthcare services, which highlighted
`Communicationissues. They felt that only specialists had some understand-
`ing of their condition but even they did not understand psychosocial con-
`cerns. GPs and non-specialist doctors were felt to be poorly informed about
`lupus, undermining confidence in treatments and healthcare providers. Par-
`ticipants often saw several specialists and did not know whom to approach
`to talk about their concerns. Lack of communication at an interdisciplinary
`level left them feeling that "nobody is joining the dots".
`Conclusions: The effects of SLE and measures that minimise the ef-
`fects of photosensitivity have implications not fully understood by healthcare
`providers. Lack of communication left patients with concerns that could be
`remedied. Integrated clinics and the presence of trained volunteers with lu-
`pus, such as those available at the lupus open-access group in Dudley, en-
`sure more adequate information from "someone who really understands".
`This may help minimise feelings of isolation.
`
`374.
`THE NATIONAL LIBRARY FOR HEALTH -
`TRAUMA, ORTHOPAEDICS AND MUSCULOSKELETAL
`SPECIALIST LIBRARIES
`A.C. Redmond1,2, R. Armstrong2, A. Brockelhurst 2, K. Dziedzic 2,
`D. Pattison2, A. Hammond2, J.A.M. Gray 2. 1AcademicUnitof
`MusculoskeletalDisease,UniversityofLeeds,Leeds,W.Yorks,United
`Kingdom;2Trauma,OrthopaedicsandMusculoskeletalSpecialistLibraries,
`NHSNationalProgramforIT,London,UnitedKingdom
`
`Background: The National electronic Library for Health comes under the
`umbrella of the National Library for Health, a development of existing library
`services for the NHS and higher education, and itself part of the Department
`of Health’s National Program for IT.
`There are 19 specialist libraries covering medical specialities from cancer
`through respiratory care, to women’s health, and including dedicated spe-
`cialist libraries for Trauma, Orthopaedics and Musculoskeletal care. There
`are additional generic portals for 11 professional groups including most of
`the AHPs.
`Methods: A team of associate editors and reviewers source, review and
`summarise information for relevance, quality and accessibility before pro-
`ducing a short summary of its merit and providing a link to the resource.
`Results: The NeLH is used by around 200,000 people every month and has
`developed a strong identity as a source of authoritative evidence and best
`practice to support health care.
`The NeLH provides direct access to important health care resources such as
`the National Service Frameworks, NICE guidelines, and protocols and care
`pathways as well as on-line access to the Cochrane database of systematic
`reviews, PubMed/Medline and 1000 full text journals.
`Conclusions: This paper will outline the main features of
`the NeLH
`Trauma, Orthopaedics Musculoskeletal Specialist Libraries, highlighting ser-
`vices available and advising clinicians on how to get the most from the library.
`The tabbed features stratifying information according to the hierarchy of ev-
`idence will be introduced, along with advanced features such as searching
`for information using index terms. Finally, the SL’s future role in linking to the
`electronic care record will be outlined, describing how the system will de-
`velop in time to suggest evidence, and to support prompts and reminders in
`the electronic care pathway.
`
`375. A RETROSPECTIVE AUDIT OF SECONDARY
`HEALTH CARE UTILISATION OF PATIENTS WITH
`FIBROMYALGIA
`
`S. Ryan, P. Dawes, M. Kirwan. StaffordshireRheumatologyCentre,The
`HaywoodHospital,Burslem,StokeonTrent,UnitedKingdom
`
`Background: Fibromyalgia is the third commonest reason for a rheumato-
`logical referral. Fibromyalgia has a negative effect on the individual in terms
`of reduced physical, psychological and social function and on society with in-
`creased use of health care utilisation and sickness benefits. In 2000 a Nurse
`Consultant was appointed to develop a Chronic Musculoskeletal Pain Ser-
`vice. One of the aims of this service was to reduce the fragmentation of the
`existing service, which resulted in patients attending numerous specialists
`and receiving conflicting advice regarding care management. The objective
`of this audit was to assess secondary health care utilisation following atten-
`dance at a Consultant Nurse-led pain clinic.
`Methods: 60 consecutive new patients who had been reviewed in the Con-
`sultant Nurse-led pain clinic were selected from the fibromyalgia database
`by a research nurse not involved in the patients’ clinical care. The hospital
`computerised information system was utilised to obtain information regarding
`which secondary health care services had been accessed five years prior to
`the pain clinic appointment and which secondary care services were being
`
`utilised 12-36 months following attendance at the pain clinic. Demographic
`data and the number of attendance at each secondary care appointment
`was also recorded.
`Results: The sample consisted of 57 women and 3 men, mean age of 41
`years (age range 29-71 years). 42 patients were married and 22 were in em-
`ployment. In the 5 years prior to attending the Consultant Nurse-led clinic pa-
`tients were accessing between 1-16 different hospital specialities (median 5).
`The number of different hospital specialities being accessed 12-36 months
`following attendance at the pain clinic ranged from 1-11 with a median of
`1. Fifty-three patients reduced the number of specialities they were seeing,
`3 patients increased the number and 4 patients continued to see the same
`number of specialists. Services patients were no longer accessing included
`Rheumatology (n=39), Imaging (n=33), Orthopeadics (n=30), Accident and
`Emergency (n=27) and Gynaecology (n-15). The total number of secondary
`care appointments in all specialities fell from a median of 12 (range 1-76) to
`2 (range 1-30).
`Conclusions: Having a designated Consultant Nurse-led service for the
`management of patients with Fibromyalgia may reduce the utilisation of sec-
`ondary care specialities.
`
`376. BENCHMARKING THE
`NURSE CONSULTANT ROLE IN RHEUMATOLOGY
`S. Ryan1, A. Browne2, S. Hennell 3,
`D. Home4, A. Wild5, D. Homer6. 1StaffordshireRheumatologyCentre,
`StokeonTrent,UnitedKingdom;2RoyalOldhamHospital,Oldham,United
`Kingdom;3WirralHospitalNHSTrust,Wirral,UnitedKingdom;4Department
`ofRheumatology,WestMiddlesexUniversityHospital,Middlesex,United
`Kingdom;5WorcestershireAcuteHospitalsNHSTrust,Worcester,United
`Kingdom;6DepartmentofRheumatology,SellyOakHospital,Birmingham,
`UnitedKingdom
`
`Background: The Nurse Consultant role was introduced in 1998 to expand
`the clinical career pathway and retain experienced nurses in clinical care.
`These roles are essential to strengthen professional leadership whilst provid-
`ing a framework to develop research and educational initiatives. Core stan-
`dards for Nurse Consultants in rheumatology have been devised to support
`role development.
`Methods: Rheumatology Nurse Consultants (n=6) have devised a forum for
`quarterly meetings with the aim of providing peer supervision and collabora-
`tion on role developments. The first outcome was the creation of core stan-
`dards using national criteria as a benchmark which were developed using
`a mapping exercise achieving majority consensus. The resulting criteria fo-
`cused on role function including expert clinical practice, education, research,
`leadership.
`Results: Specific core standards for rheumatology Nurse Consultants have
`been developed. Fifty per cent of the role will involve clinical care e.g. nurse-
`led initiatives addressing patient focused outcomes with the remaining time
`divided between service improvements, developing education and research
`opportunities. The standards are adaptable and will be influenced by the
`needs of the local population, resources, knowledge and skills of the Nurse
`Consultant and team members. The standards also include the support
`mechanisms required to perform the role including supervision, secretarial
`and information technology. A future objective of the group will be to conduct
`peer review visits to benchmark the implementation of the standards.
`Conclusions: The core standards are relevant to rheumatology Nurse Con-
`sultant role development. It is envisaged that all Nurse Consultants will struc-
`ture their role around the standards, personalised to their area of work or
`interests and that they will provide a framework for new or aspiring Nurse
`Consultants.
`
`377.
`TELEPHONE FOLLOW UP OF PATIENTS
`COMMENCING ORAL BISPHOSPHONATES
`
`G. Loghan, T.W. O’Neill. DepartmentofRheumatology,
`HopeHospital,Salford,Manchester,UnitedKingdom
`
`Background: Bisphosphonates are widely used in the management of os-
`teoporosis. Non compliance may, however, limit the effectiveness of therapy.
`The aim of this study was to determine whether telephone follow up can be
`used as a tool to detect non compliance and side effects amongst osteo-
`porotic patients who have recently commenced bisphosphonate therapy.
`Methods: Men and women with osteoporosis attending the metabolic bone
`clinic at Hope hospital, Salford and who were recommended bisphosphonate
`therapy, were registered for telephone follow up. At the hospital, patients
`are given a hand-written note to take to their GP with a view to prescribing
`therapy, followed by a dictated clinic letter. Patients were contacted 6 weeks
`following their clinic visit and information obtained about whether or not they
`were currently taking therapy, and, if not, the reasons for this. If they were
`taking therapy, they were asked whether they were taking it appropriately
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`i147
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`(based on manufacturers recommendations) and if they were experiencing
`side effects.
`Results: In total 63 patients with osteoporosis were registered for telephone
`follow up. Their median age was 70 years and 54 (86%) were female. Of
`those registered, 56 were contacted (after an average of 2 telephone calls)
`with the remaining patients unable to be contacted. Of the 56 who were
`contacted 17 (30%) were not currently taking therapy. The reasons for this
`were because they had developed side effects (2), were apprehensive about
`taking the medication they had received (5), had not yet received if from their
`GP (4), were not clear why they had been prescribed it (3) and other reasons
`(3). Of the 39 who were currently taking therapy, almost all were taking it
`according to manufacturers recommendations, though a significant number
`(15) were experiencing some side effects. As a result of the telephone follow
`up, 22 patients were referred back either to the clinic for assessment or to
`their general practitioner with recommendations about therapy. One patient
`required a home visit.
`Conclusions: In conclusion telephone follow up is a useful tool in the early
`detection of non-compliance and side effects associated with bisphospho-
`nate therapy in patients with osteoporosis.
`
`378. EVALUATION OF AN EVIDENCE-BASED
`PHYSIOTHERAPY PROGRAMME FOR THE MANAGEMENT
`OF PATIENTS WITH OSTEOARTHRITIS OF THE KNEE
`
`M.J. Domaille, R. Mascarenhas, N. Dayal, J.R. Kirwan. Rheumatology
`Centre,BristolRoyalInfirmary,Bristol,UnitedKingdom
`
`Background: The aim of this study was to determine the outcome of a phys-
`iotherapy programme for patients with osteoarthritis (OA) of the knee which
`was based on published studies, and to compare this to the outcomes of re-
`search based programmes. The purpose was to evaluate whether improve-
`ments in pain and function demonstrated following research trials actually
`translate to the clinical setting.
`Methods: Based on a review of published studies a Physiotherapy OA Knee
`Programme of group education and exercise, was set up to be delivered for
`one hour per week over six weeks. Prior to commencing the programme
`all clients were assessed by a Chartered Physiotherapist and any individual
`treatment was completed.
`Education covered anatomy of the knee, pathology of OA, benefits of exer-
`cise, use of heat and cold, indications for walking aids and the importance of
`footwear. Exercise comprised of a five minute warm up followed by a circuit
`of eleven stations. Each of the stations had 3 exercise options: "easy", "mod-
`erate" and "difficult". Patients performed the "easy" option at each station for
`2 minutes on Week One of the programme and progressed to the "moderate"
`and "difficult" options as they were able during the course of the programme.
`Outcomes were measured using the WOMAC questionnaire and a visual
`analogue scale (VAS) for pain which were completed by all patients prior to
`Session 1 and immediately following the final session. Further analysis was
`performed using confidence intervals and a paired t-test. The outcomes from
`this Bristol OA Knee Programme were then compared with results from four
`papers using similar interventions and evaluation tools.
`Results: 103 patients completed the programme. For WOMAC scores and
`pain VAS see Table 1. The results demonstrated statistically significant (p<
`0.05) reductions in pain, stiffness and disability. The greatest improvement
`was in reduction in pain (43% in VAS) which was a larger effect size than
`that reported following similar OA Knee Programmes, which showed a mean
`reduction of 16% in VAS. Other changes were similar to those reported in
`clinical trials.
`
`WOMAC scores pre and post OA Knee Programme
`
`Outcome
`
`WOMAC pain
`WOMAC stiffness
`WOMAC disability
`WOMAC overall
`VAS pain
`
`Pre-group
`Mean score
`9.5
`4.3
`32.8
`46.4
`66.9
`
`p<0.05 for all mean change scores
`
`Post-group
`Mean score
`8.1
`3.8
`28.4
`40.2
`38.2
`
`Percentage
`improvement
`15
`11
`14
`14
`43
`
`Conclusions: This study is representative of a true clinical service aimed
`at managing patients with OA of the knee. Despite research trials gener-
`ally having greater levels intervention, this programme has demonstrated a
`higher reduction in VAS pain scores and has also shown a significant im-
`provement in overall WOMAC which is comparable with the results from re-
`search trials.
`
`379. SETTING UP A PATIENT REFERENCE GROUP TO
`INFORM SERVICE DELIVERY IN A RHEUMATOLOGY
`UNIT
`
`A.E. Griffiths, J. Novak, S. Balshaw, M.P. Lynch, V.E. Abernethy,
`J.K. Dawson. RheumatologyPracticeDevelopmentUnit,StHelens&
`KnowsleyHospitalsNHSTrust,StHelens,Merseyside,UnitedKingdom
`
`Background: There has been a move to give patients a real say in the way
`the NHS works. This has been highlighted recently in the BSR standards of
`care for patients with RA. In 2003 we set up a Rheumatology patient refer-
`ence group (PRG). The aim of the presentation is to outline the process of
`setting up the PRG and identify the impact it has had on our Rheumatology
`Unit.
`Methods: To become a member of the PRG a defined recruitment pro-
`cess has been developed, including an application pack for prospective pa-
`tients/carers. An elected Chairman and Secretary run the group. Terms of
`reference have been drawn up by the group.
`Objectives of the group are to enable service users to comment on the ser-
`vice provided and to contribute to planning, delivery and evaluation of the
`Unit.
`The PRG meets regularly to action comments collected from other services
`users, discuss proposed service developments and review prospective pa-
`tient information.
`Results: The group devised a system whereby they canvas the views of
`Rheumatology Out-patients on a 6 weekly basis. To date approximately 500
`patients have had the opportunity to comment on the service. 114 comments
`sheets have been completed, providing 194 comments/suggestions. Of the
`themes emerging, 74% of the comments show satisfaction with Unit staff and
`service/care received, and 26% of comments highlight concerns which have
`been reviewed by the PRG. All patient comments are acted on by the group,
`which involves corresponding with Trust Management including the Chief
`Executive, the Rheumatology multi-disciplinary team and reporting back to
`the patient/carer if requested.
`To date, changes brought about by the PRG include access to the Rheuma-
`tology Department being improved with increased disabled car parking,
`strategically placed seating and review of unsuitable doors (all funded by
`the Trust). Reopening of in-patient beds when the Rheumatology ward was
`temporarily closed was influenced by the group. Changes to the service in-
`clude a manned nurse led Helpline service being available for an hour each
`day in addition to 3 telephone Helplines using answer machines, and blood
`monitoring clinics are moving to an appointment system.
`In addition, 20 patient information leaflets have been reviewed to ensure
`appropriate written communication, and reports provided. The PRG has also
`served as a model for other specialities setting up their own groups.
`Conclusions: The PRG has been instrumental in evaluating, monitoring and
`developing St Helens and Knowsley Trust Rheumatology Unit. With surpris-
`ing speed the PRG has already canvassed and improved the quality of the
`service provided.
`
`380. CAN PIIINP HELP IN MONITORING RHEUMATOID
`ARTHRITIS PATIENTS ON METHOTREXATE?
`M. Lloyd1, S. Burton1, U. David2, P. Cusick 3. 1Departmentof
`Rheumatology,FrimleyParkHospital,Frimley,Surrey;2Departmentof
`ClinicalBiochemistry,FrimleyParkHospital,Frimley,Surrey;3Audit
`Department,FrimleyParkHospital,Frimley,Surrey,UnitedKingdom
`
`Background: A 67 yr old rheumatoid arthritis (RA) patient of ours was ad-
`mitted with acute liver failure and died shortly afterwards. He had been on
`methotrexate (MTX) for the previous 5 years and had had normal liver func-
`tion tests (LFTs) until just before admission. Liver ultrasound (US) on admis-
`sion suggested early fibrosis and portal hypertension. This prompted us to
`look at serum type III procollagen aminopeptide (PIIINP) in our RA patients
`on MTX. Standard LFTs are a relatively insensitive test for liver fibrosis and
`several reports have suggested that PIIINP, particularly when used sequen-
`tially, may be a better test.1 This issue is particularly relevant in view of recent
`national patient safety advice.2
`Methods: PIINP tests have been requested when thought to be clinically
`indicated in 36 patients with RA. Tests were identified via biochemistry
`database and notes pulled. Notes were available on 25 patients. Data were
`analysed using Formic software.
`Results: 25 patients had a total of 31 tests. Female:male ratio was 17:8.
`
`Characteristics of patients with normal and raised PIIINP
`
`Age (yrs)
`RA duration (yrs)
`MTX duration (yrs)
`Total MTX dose (mg)
`
`Normal PIIINP (n=9)
`56
`6
`3
`2050
`
`Raised PIIINP (n=16)
`65
`13
`4.5
`2308
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`Mean age: 62 yrs (range 43-75yrs). Average duration of RA: 10.5 yrs (2-
`25yrs), mean duration of MTX treatment: 4 yrs (1-10yrs). 7 patients were
`taking regular folic acid. To our knowledge, none took excess alcohol. Rea-
`sons for testing PIIINP were: raised ALT (20 patients), raised alkaline phos-
`phatase (8), raised MCV (1) and long duration of treatment (1). Liver US was
`requested in 14 patients. 5 scans were abnormal, all suggesting fatty infiltra-
`tion. All 5 patients had high PIIINP. Conversely, 5 patients with normal liver
`US had raised PIIINP. MTX was stopped in 7 patients. 2 of these had raised
`PIIINP alone; 2 had raised PIIINP and abnormal US.
`Conclusions: This is a small but on-going study, intended to stimulate dis-
`cussion. A "new generation" of MTX treated RA patients may be emerging
`who are at potential risk of undiagnosed liver damage. These are patients
`who have been on the drug for many years, may accumulate co-medication
`and may slip into excess alcohol intake. Our data are limited by the absence
`of liver biopsy as a "gold standard" but the reality is that biopsies are now
`very rarely used in rheumatology.We are starting to use PIIINP, in conjuction
`with liver US3, to inform our decisions about MTX continuation.
`References
`[1] Br J Dermatol 1996;135:538-544
`[2] www.npsa.nhs.uk/advice
`[3] Br J Dermatol 1987;116:491-495
`
`381. AUDIT: BONE SCINTIGRAPHY USE IN THE
`INVESTIGATION OF FOOT PAIN IN THE OUT PATIENT
`CLINIC OVER A 5 YEAR PERIOD
`
`E.A. Justice, P. Newton, M. Collins. DepartmentofRheumatology,New
`CrossHospital,Wolverhampton,UnitedKingdom;DepartmentofRadiology,
`NewCrossHospital,Wolverhampton,UnitedKingdom
`
`Background: This audit had a dual purpose: Firstly, to define the indica-
`tions for bone scintigraphy in the investigation of foot pain and create from
`the current literature a "Gold Standard" with which to compare our own de-
`partment’s practice; secondly to analyse whether those requests compliant
`with the gold standard had a greater yield of useful clinical information com-
`pared with non-compliant requests.
`Methods: 35 patients were identified having searched radiology requests
`for "foot pain" and "bone scintigraphy" from the period April 1998 to April
`2003. The notes and reports from the scans were reviewed retrospectively
`by one clinician (EJ). The following data were collected: name and age at the
`time of bone scan; the specific clinical problem necessitating the bone scan,
`for example "heel pain", any relevant past medical history and the reason
`given for requesting the scan, for example "Possible plantar fasciitis". The
`findings of the scan, any intervention and the subsequent clinical course of
`each patient were looked at. The reasons for requesting a scan were then
`compared with 10 "Goldstandard" indications defined following a review of
`current literature.1,2,3 (see Appendix) The scan report of those adherent to
`the "Gold standard" were then analysed and defined as being either helpful
`or unhelpful in the patient’s management. The same analysis was performed
`on non-adherent scans.
`In this way we hoped to test the robustness of the "Gold standards" in order
`to create departmental Guidelines for the use of Bone Scintigraphy.
`Results: Demographics: Mean age 50.6 years, Range of ages 14-72 years,
`12 male, 23 female.
`24/35 Scans ordered according to "Gold standard" (27 accounts given for 24
`patients)
`Of the "appropriately" ordered scans, what proportion were helpful in aid-
`ing/changing the diagnosis and management:
`Helpful: 18/24 (75%)
`Unhelpful: 2/24 (8.3%)
`Normal scan 4/24 (16.6%)
`11/35 scans ordered inappropriate:
`6/11 helpful (54.5%)
`3 of which lead to an alternative diagnosis and 3 of which were normal.
`Normal Bone Scans:
`In total 7/35 had normal scans
`At follow up 2/7 had no symptoms and none had any long term problems
`Conclusions: 68.5% scans were ordered according to literature- derived
`"Gold standardsYield of useful
`information is higher in those ordered ac-
`cording to Guidelines: 75% v 54.5%
`Higher rate of negative scans in the group of "inappropriately ordered" scans:
`27% v 16%
`A negative scan can be reassuring as there were no long term sequelae in
`our group.
`
`382. RHEUMATOID ARTHRITIS PATIENT EDUCATION
`IN THE UK – WHAT IS ON OFFER AND HOW IS IT
`DELIVERED?
`Z. Cockshott 1, S. Hewlett 1, C. Almeida1, P. Richards 1, R. Lowe2,
`J. Kirwan1, R. Study Group. 1AcademicRheumatology,UniversityofBristol,
`Bristol,UnitedKingdom;2PsychologyDept,UniversityofWales,Swansea,
`UnitedKingdom
`
`Background: Many UK Rheumatology Centres aim to provide RA Patient
`Education/Self Management programs. Whilst these are assumed to be sim-
`ilar in nature and content, there is no standardised format. This abstract de-
`scribes 11 such programs delivered in the UK.
`Methods: Eleven UK patient education programs were described as part
`of the RA Self-Efficacy RASE Study. A structured questionnaire explored
`course content, organisation and participants. Responses were either by
`self-report (6/11) or by interview (5/11).
`Results: The size of education "group" ranged from 1 to 12 patients (mean
`7), with two centres offering education on a one-to-one basis. The total num-
`ber of sessions in a program range