Background/Aims The role of art in rheumatology is under-investigated. Several well-known artists have suffered from rheumatic disease. Their insights and achievements potentially provide reassurance and encouragement to our patients. Creating art may also offer therapeutic benefits for patients. Finally, the artistic environment can affect mood and behaviour. We highlight several inspirational artists. Methods Four artists offer valuable insights: Michaelangelo (d. 1564) was able to master sculpture, painting and architecture despite hand osteoarthritis and persisted in working until his death, age 89. Pierre-Auguste Renoir (d. 1919) developed severe RA aged 50. He continued to paint for the rest of his life, being carried to outdoor scenes on a sedan and designing an innovative rolling canvas to complete some of his finest work. He painted on small pieces of wood at night to distract from his arthritic pain. Frida Kahlo (d.1954), the Mexican artist, experienced chronic generalised pain and fatigue in keeping with fibromyalgia. This was after a bus accident at eighteen resulted in multiple pelvic and vertebral fractures. Self-portraiture became the cornerstone of her bold art during the solitude of her convalescence. Maud Lewis (d.1970), the Canadian folk painter, had JIA in early childhood resulting in a limp and severe hand changes. She spent much time indoors due to her pain and the ridicule faced from her peers. She developed an eagerness for drawing; to the extent that she painted on any surface she could find of her small cottage. Results These artists’ own words reveal the resilience they gained from their art. Renoir stated: 'Out of doom and misery the most beautiful song may rise'. Lewis reported ‘As long as I’ve got a brush in front of me, I’m alright.’, whilst Kahlo was similarly quoted to say ‘I am broken. But I am happy to be alive as long as I can paint’. A small study in 2017 with 17 patients with RA showed improvement not only in hand function but also self-perception and quality of life after participating in daily art-based intervention (origami, painting and clay modelling) for four weeks. Furthermore, a common theme between these famous artists was how they favoured bright colours in their artwork, which may have positive effects on mood. Colouring can reduce stress in children in paediatric waiting rooms. Within other settings, research suggests that visual art depicting nature can reduce anxiety in emergency department waiting rooms. Conclusion Although exceptionally talented people, the artists discussed show the inspiring possibilities of creativity despite severe rheumatic disease. We suggest sharing these stories with our patients and considering further study into the therapeutic potential of creating art in rheumatic conditions. Attention should be paid to the artistic environment in which we see our patients. Disclosure S. Amar: None. M. Lloyd: None.
AimTo investigate the qualitative aspects in patient selection and the quantitative impact of disease burden in real world treatment of vitreomacular traction (VMT) and implementation of the National Institute for Health and Care Excellence (NICE) guidance (TA297).MethodsA monocentric, retrospective review of consecutive patients undergoing optical coherence tomography (OCT) imaging over a 3 month period. Patients with VMT in at least one eye were identified for further data collection on laterality, visual acuity, symptoms, presence of epiretinal membrane, macular hole and treatment selection.ResultsA total of 3472 patients underwent OCT imaging with a total of 6878 eyes scanned. Out of 87 patients, 74 patients had unilateral VMT (38 right, 36 left) and 13 patients had bilateral VMT. Eighteen patients with unilateral VMT satisfied NICE criteria of severe sight problems in the affected eye. Eight were managed for a coexisting pathology, one refused treatment, one patient did not attend, two closed spontaneously, and one received ocriplasmin prior to the study start date. Only two patients with unilateral VMT received ocriplasmin and three underwent vitrectomy. Those failing to meet NICE criteria for unilateral VMT were predominantly asymptomatic (n=49) or had coexisting ERM (n=5) or both (n=2).ConclusionOcriplasmin provides an alternative treatment for patients with symptomatic VMT. Our data shows that the majority of patients with VMT do not meet NICE TA297 primarily due to lack of symptoms. Those meeting NICE criteria, but not treated, tended to have coexisting macular pathology. Variation in patient selection due to subjective factors not outlined in NICE guidance suggests that real world outcomes of ocriplasmin therapy should be interpreted with caution.
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ObjectiveTo estimate the incidence of anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies utilising different testing criteria, and review the clinical details of a series of patients with associated autoimmune myopathy. MethodsThe incidence of anti-HMGCR antibodies in 2019 from 3 groups, South West London, Berkshire/Surrey and Southampton, were compared in the adult population. Anti-HMGCR antibodies were measured by commercial chemiluminescent and immunodot assays. The case notes of patients with anti-HMGCR antibodies were reviewed for the case series. ResultsThe estimated incidence of anti-HMGCR antibodies in the first 2 groups was 1.94 per million adults per year, and in the third group 10.3 per million adults per year. In the first 2 groups the test criteria restricted analysis to specific clinician request for anti-HMGCR. In the third group test criteria included cases with less specific clinical features or a cytoplasmic indirect immunofluorescence anti-nuclear antibody pattern. The latter strategy had a positive predictive value of 66.1% for anti-HMGCR associated myopathy. A case series of 27 patients with anti-HMGCR antibodies revealed 19 with myopathy, oesophageal involvement in 26% and median peak CK 8000 IU/L. Response to treatment, including intravenous immunoglobulin, was good with CK normalising after median 5.5 months. In 8 cases there was no evidence of autoimmune muscle disease, 7 not statin exposed. ConclusionVarying criteria result in a 5-fold difference in estimated incidence of anti-HMGCR antibodies, revealing positive cases without evidence of myopathy. Patients with anti-HMGCR myopathy respond well to immune suppression, supporting wider testing for these antibodies amongst patients with myopathy.
Background:Despite the advent of newer imaging techniques, temporal artery biopsy (TAB) retains a key role in the diagnosis of giant cell arteritis (GCA). The classical histological description of GCA is that of granulomatous lesions characterized by a transmural inflammatory infiltrate1. Giant cells are typically noted in the internal elastic lamina. Vascular remodeling and structural changes are also frequently described, with intimal hyperplasia or fragmentation, fibrosis and calcifications1.Objectives:To identify the type and location of the inflammatory lesions in TAB-positive cases of GCA.Methods:We conducted a retrospective analysis of all TABs undertaken at our unit between 2011- 2018 with clinical record review. TABs were performed by vascular, ophthalmology and ENT teams.Results:379 TABs were reviewed of which 68 (17.9%) were reported as positive and 10 (2.6%) were equivocal (presence of fragmentation and intimal thickening). Of the TAB-positive cases, 43 (63.2%) were greater than 1cm in keeping with the British Society for Rheumatology guidance and 65 (95.6%) were biopsies in patients on corticosteroids at the time of procedure. The following tables demonstrate the frequency of the type and location of the inflammatory lesions detected in TAB-positive cases of GCA.Type of inflammatory lesionFrequencyChronic inflammatory infiltrate (lymphocytes, macrophages, plasma cells)66Giant cells41Intimal thickening22Intimal fragmentation33Location of inflammatory infiltrateFrequencyFull thickness32Intima only7Intima and Media only3Media only7Media and Adventitia only8Adventitia only4Intima and Adventitia only3Not recorded4Conclusion:Only 60% of our TAB-positive biopsies had giant cells present. Although perhaps surprisingly low, this finding is similar to other studies1,2. It emphasises the need to review the body of a report as well the conclusion. Other non-giant cell features present in positive reported biopsies may suggest a less certain diagnosis and prompt clinical review. There was considerable variablity in the style of reporting. With no standardised scoring system in place, the variable spectrum of inflammation and differences in reporting, there is the potential for inconsistencies amongst pathologists in interpreting and recording TAB results. Consistent reporting templates and close collaboration between rheumatologists and pathologists is needed to help correlate clinical, laboratory and imaging findings.References:[1]Cavazza A, Muratore F, Boiardi L, Restuccia G, Pipitone N, Pazzola G, et al. Inflamed temporal artery: histologic findings in 354 biopsies, with clinical correlations. Am J Surg Pathol. 2014;38(10):1360-70.[2]Hernandez-Rodriguez J, Murgia G, Villar I, Campo E, Mackie SL, Chakrabarty A, et al. Description and Validation of Histological Patterns and Proposal of a Dynamic Model of Inflammatory Infiltration in Giant-cell Arteritis. Medicine (Baltimore). 2016;95(8):e2368.Disclosure of Interests:Soha Khaled Amar: None declared, Dimitrios Christidis: None declared, George Kousparos: None declared, MARK LLOYD Speakers bureau: £700 into department fund
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