Low-dose dietary supplementation with omega-3 fish oils in systemic lupus erythematosus not only has a therapeutic effect on disease activity but also improves endothelial function and reduces oxidative stress and may therefore confer cardiovascular benefits.

Objective To explore the role of chronic inflammation in rheumatoid arthritis (RA) on cognition. Methods and analysis Six hundred sixty-one men and women aged ≥55 years who fulfilled the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria for RA were recruited from three healthcare trusts in the United Kingdom (UK) between May 2018 and March 2020. Study participants took part in interviews which captured sociodemographic information, followed by an assessment of cognition. RA specific clinical characteristics were obtained from hospital medical records. Participants were cognitively assessed using the Montreal Cognitive Assessment (MoCA) and were classified as cognitively impaired if they scored ≤27/30 points. Linear regression analyses were conducted to identify which demographic and clinical variables were potential predictors of cognitive impairment. Results The average age of participants was 67.6 years and 67% (444/661) were women. 72% (458/634; 95% CI 0.69 to 0.76) of participants were classified as cognitively impaired (MoCA≤27). Greater cognitive impairment was associated with older age (p = .006), being male (p = .041) and higher disease activity score (DAS28) (with moderate (DAS28 > 3.1) (p = 0.008) and high (DAS28 > 5.1) (p = 0.008)) compared to those in remission (DAS28 ≤ 2.6). There was no association between MoCA score and education, disease duration, RF status, anti-cyclic citrullinated peptide (anti-CCP) status, RA medication type or use of glucocorticoids or non-steroidal anti-inflammatory drugs (p > 0.05). Conclusion This study suggests that cognitive impairment is highly prevalent in older adults with RA. This impairment appears to be associated with higher RA disease activity and supports the concept that chronic systemic inflammation might accelerate cognitive decline. This underlines the importance of controlling the inflammatory response.

Structural and functional changes in wall and endothelial components of arterial blood vessels underlie the accelerated vascular disease progression in systemic lupus erythematosus (SLE). Using pulse contour analysis we sought to determine if subclinical vascular abnormalities could be identified in a well-characterised cohort of patients with SLE who had no increase in traditional cardiovascular risk factors. Radial artery pressure waveforms were obtained by applanation tonometry and pressure envelopes were analysed by descriptive and model-based approaches. Waveshape morphology was quantified by a novel eigenvector approach and model-based compliance indices of the large arteries (C1, capacitative arterial compliance) and small arteries (C2, reflective arterial compliance) were derived using a third-order four-element modified Windkessel model. Data were recorded from 30 patients with SLE (mean age 44 +/- 7 years and mean SLAM-R 10 +/- 4) and 19 age-matched control subjects. Significant differences in the lower frequency sinusoidal components of the pressure waveforms were evident between groups (P < 0.05). Both C1 and C2 were significantly reduced in patients with SLE: C1 mean +/- SD 13.5 +/- 4.0 ml/mmHg x 10 versus C1 17.5 +/- 4.8 ml/mmHg x 10 (P = 0.003 in patients vs. controls, respectively) and C2 5.2 +/- 3.4 ml/mmHg x 100 versus C2 9.4 +/- 2.8 ml/mmHg x 100 (P < 0.001 in patients vs. controls, respectively). In this group of SLE patients, without an excess of traditional cardiovascular risk factors and SLAM-R scores indicating mild disease, descriptive and model-based analysis of arterial waveforms identified vascular abnormalities at a preclinical stage.

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BackgroundBritish Society of Rheumatology (BSR) guidelines, due to be updated in April 2018, recommend consideration of CT PET when there is suspicion of large-vessel GCA (LV-GCA) in patients with prominent systemic symptoms, limb claudication or persistently high-inflammatory markers despite adequate glucocorticosteroid therapy. Vascular Ultrasound is unhelpful in assessment of the aorta.ObjectivesWe investigated the use of CT PET in suspected cases of LV-GCA and its impact on management of patients in the BHSCT from August 2016 to August 2017.MethodsThe IT support team in Royal Victoria Hospital provided a list of CTPET scans requested under the specific code for vasculitis and/or Pyrexia/infection and another code for general. Of the 250 scans identified under these codes, 34 scans were requested by Rheumatology for possible vasculitis following a review of the electronic care records. A proforma was used to aid data collection.ResultsFemale:Male ratio was 3.25:1, with a mean age of 65. 88% of the scans were requested due to a suspected diagnosis of vasculitis and 12% were for follow up of known vasculitis. 24% of CT PET scans were positive for large vessel vasculitis (LVV). The ESR was greater than 50 mm/hr in 75% of positive scans. Of those patients with a positive CT PET scan, 88% were treated with steroids. Of those patients with a negative CT PET scan, 42% were treated with steroids. It is noteworthy that 29% of patients were on steroids at the time of CT PET which may impact results. 60% of patients who were on steroids at the time of CT PET were on 60 mg of prednisolone daily. 31% of patients with negative scans were on steroids at the time of CT PET. 46% of patients with negative CT PET scans remained on steroid treatment. Steroid treatment was continued in patients with negative scans on basis of active aortic valve histology ±clinical criteria for diagnosis of GCA ±cerebral vasculitis on neuroimaging ±polymyalgia rheumatica evident on CTPET. CT PET changed management in 65% of patients with positive results supporting steroid treatment and negative results guiding withdrawal of steroids.ConclusionsWe are fortunate to have access to CT PET in Northern Ireland. CT PET scans changed management in 65% of our patients, despite 29% of patients being on steroid treatment prior to CT PET. We wish to increase awareness of the role CTPET in the diagnosis and management of LVV. We are liaising with radiology colleagues to refine and maximise appropriate referrals for CT PET scans for patients with suspected vasculitis.References[1] BSR and BHPR guidelines for the management of giant cell arteritis. Bhaskar Dasgupta, et al. Rheumatology, Volume 49, Issue 8, 1 August 2010, Pages1594–1597, Published: 05 April 2010[2] EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Christian Dejaco, et al. Ann Rheum Dispublished online January 22, 2018Disclosure of InterestNone declared

Endoscopic ultrasound 20 1 (1%) 2(3%) 14(19%) 1(1%) 2(3%) Total 73 9 (12%) 3(4%) 31(42%) 7(10%) 23(32%)Three false negative cases where a later histological diagnosis of malignancy was present contained no diagnostic cellular material.To date no false positive diagnosis has occurred and all patients with malignant diagnosis have died except those diagnosed in the last 6 months. Conclusion: Pancreatic FNAC is a useful procedure in the majority of cases at our institute. Our inadequate/inconclusive rate is low. In fact our analysis shows that the inadequate rate for EUS guided FNAC pancreas is only 5% despite the fact that on site assessment of adequacy is not yet carried out. This is in a small group of patients however. No false positive diagnosis was identified. Discrepancies between cytological and histological diagnosis have been due to unrepresentative samples. We intend to proceed with on site assessment of adequacy in future cases. We will continue to review all cases where pancreatic FNA is carried out at our weekly pancreatic/hepatobiliary clinicopathological multidisciplinary team meeting and within our department at peer review meetings.

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Case report - Introduction Ankylosing spondylitis is a chronic inflammatory condition involving spine, chest and sacroiliac joints. It can be associated with extra spinal manifestations which include uveitis and enthesitis, as well as other features of an inflammatory spondyloarthropathy including psoriasis and inflammatory bowel disease. It is characterised by the presence of inflammatory back pain, limited range of spinal movement, sacroiliitis on imaging, excess spinal bone formation and a high prevalence of HLA-B27. The main aims of treatment are to improve symptoms and retain function as well as to prevent disease complications. Case report - Case description A 49-year-old male diagnosed with ankylosing spondylitis at the age of 23 (HLA-B27 positive, classical radiographic features on plain radiographs and MRI), with background of meningitis and subsequent epilepsy (not on treatment since the age of 13), severe hip osteoarthritis and osteoporosis. He has peripheral elbow and knee synovitis. At the age of 27 he developed sight-threatening bilateral recurrent anterior uveitis complicated by cystoid macular oedema (causing central vision loss). Initial management included anti-inflammatories and steroids. He progressed to biologics but developed a rash on adalimumab. He was switched to infliximab in 2010. In 2015 it was switched due to reduced response to golimumab which was non-beneficial. Subsequently he was switched to etanercept but after 3 months it was discontinued due to eye flare. The patient’s therapy was switched to certolizumab, which was non-beneficial for spine and discontinued. In 2016, infliximab was retried as the patient thought it worked best. Unfortunately, in 2018 patient developed Infliximab antibodies and treatment was changed to secukinumab. After 9 months this was stopped owing to ongoing active eye and spine disease. Adalimumab was re-tried; however, it was discontinued as it was showing no benefit. In 2020 Eeanercept (Benepali) was re-tried; however, only for 4 months because of severe flare of joint and eye disease. Tofacitinib was commenced but was non-beneficial and hence it was discontinued. Currently he continues on ixekizumab, oral prednisolone and also receives steroid eye and joint injections. On commencing biologics he was on methotrexate; however, the patient stopped. He was switched to mycophenolate mofetil which he remained on for 10 years. It was switched to methotrexate to try and control peripheral inflammatory joint disease better (re-tried for the second time) which the patient has recently discontinued as he felt it was non-beneficial. Case report - Discussion The case is very challenging. The patient’s disease continues to flare despite changing therapies. He continues to get flares in his back disease, eye disease and peripheral synovitis. His latest BASDI was 5.1 and VAS was 9/10. Measurements: intermalleolar distance 15cm, modified Schober’s 4cm, right lateral flexion 3.8cm and left lateral flexion 11cm. His latest MRI of whole spine and SI joints (in 2020) showed signs of previously active seronegative spondyloarthropathy with established cervical and thoracic ankyloses as well as bilateral sacroiliac joint ankylosis. There is a need for repeated steroid injections to the knees as well as the eyes. He continues on oral prednisolone which was first started in 2006. This is associated with multiple side effects, i.e., osteoporosis. The patient has already completed 8 years of bisphosphonate therapy. He is under regular review with the osteoporosis clinic. His bone density scan showed worsening bone mineral density and bisphosphonates had to be restarted. The patient adjusted medications depending on his symptoms. Recently he also discontinued methotrexate as he felt it was of no benefit to him at all. We are very limited at present to find combined medications to manage both the patient’s inflammatory back disease and inflammatory eye disease. Case report - Key learning points This patient was diagnosed with ankylosing spondylitis 26 years ago. To date he has tried 5 different anti-TNF agents (two of which have also been re-tried at a different time point). This failed to control his disease as he continued to experience flares in either inflammatory back or eye disease. The biologic classes were also changed – he has tried one IL-17A agent as well as a JAK-I. Unfortunately, they both failed to control his disease. He currently continues on a second IL-17A; however, he still requires steroid eye and joint injections as well as systemic steroids. Throughout the years he has tried different DMARDs – most recently methotrexate. Unfortunately, the patient decided to discontinue it as he felt it was of no benefit to him. All of the above indicates that there is still a need to find a collaborative treatment option that will control the patient’s inflammatory back disease, inflammatory eye disease and peripheral synovitis. The aim would be, if possible, to decrease the steroid dose as well (currently on prednisolone 15mg daily) in order to prevent the steroid-associated side effects.