Treat to target strategies of inflammatory arthritis primarily focuses on pharmacological management. We introduced the assessment of lifestyle alongside composite scores of disease activity aiming for patients to achieve optimal health and to promote patient centred care. Lifestyle can influence treatment options and the course of the disease in particular physical activity levels, obesity, smoking, stress and alcohol use. Health professionals have the opportunity in the early stages of the disease course to include assessment and discussion about lifestyle in clinical practice. This can open up the dialog with patients when they express a desire to optimise their treatment plan by addressing lifestyle . Patients completed the American Lifestyle Assessment short-form questionnaire 6 weeks after a diagnosis of IA. Data collection included age, diagnosis , BMI and number of co-existing comorbidities. This self-reported tool examines six domains of lifestyle (sleep, weight management, nutrition, exercise, purpose and connection/mental health and smoking/substance use. Domains of lifestyle that patients were most motivated to change as well as key motivators for change. A total of 126 questionnaires were completed, 65.87% had a diagnosis of rheumatoid arthritis and 34.13% had psoriatic arthritis. 41.63% were male and female 56.40 % were female. 35.71 % of patients were current smokers, 54.76% consumed alcohol, and 1.69% used recreational drugs. The most common unhealthy lifestyle at presentation was being overweight or obese with over 56.40% having a BMI above 30, 70.34% of patients expressed a desire to lose weight and 41.23% had at least 1 pre-existing comorbidity and 25.41% presenting with 2 comorbidities. The second unhealthiest behaviour was not meeting physical activity recommendations with 32.40 % patients exercising less than 1 time per week, with 26.19% 1-2 times per week. 56% of patients reported that they ate packaged foods, sugary drinks and fast food several days a week, 29.7% consumed less than 2 portions of fruit and vegetables daily. 46% of patients had several days when they felt down, depressed or hopeless. 31.3% of patients slept less than 5 hours per night, and 30.83% felt several days a week of fatigue. The top three pillars patients were most motivated to change were exercise, weight management and mental health and the key motivator for change was family. Lifestyle assessment identified the pillars which were most meaningful to our patients. It has allowed us to provide a holistic approach and a rationale for the inclusion of lifestyle medicine into our pathway of care in line with best practice guidelines at an early stage of the disease course. The self-reported nature of the questionnaire lends itself to bias. This cohort were also in the very early stages their disease course. U. Martin: None. N. O’Keeffe: None. B. Irudayaraj: None. T. Fitzgerald: None. S. Alston: None.

Objectives: To assess patients’, carers’, nurses’ and physicians’ perspectives and experiences regarding patient education (PE) and support of Methotrexate (MTX) treatment in Europe. Methods: An international team of researchers and clinicians, including rheumatology nurses, a pharmacist, a rheumatologist, and three patient representatives, developed a survey. Common and sample-specific questions were conceived for adult patients or carers (≥18 years) of children/young people with RMDs, nurses, and physicians working in rheumatology practice in Europe. The survey was available in English and, for patients/carers, in eight additional languages, disseminated between May 2022 and May 2023. Ethics committee approval was obtained (116_CEIPC/2022_IPC). Results: A total of 1526 patients, 145 carers, 354 nurses, and 291 physicians (96% rheumatologists), from 26 European countries participated. Only 28% of patients had a PE with nurse when starting oral MTX, with a slight increase to 42% for the subcutaneous form, with variations across Europe (Northern=69%, Eastern=52%, Western=50%, Southern=23%). Patients’ perspectives align with physicians, whereas nurses reported higher access rates. Around 77% of patients had/have concerns about side effects, which were discussed with health professionals in 69% of the cases, though 46% of these concerns remained unresolved. The priority ranking of topics to be addressed in PE was similar overall for the three subgroups. Conclusion: PE and support regarding MTX are unequal across Europe and can be improved by offering opportunities to clarify concerns through more access to nursing consultations. There is an overall agreement between patients and clinicians regarding key areas of education, although a tailored approach is required.

Abstract Background/Aims Data collection to assess the impact of rheumatology advanced nurse practitioners (RANPs) on service quality tends to prioritise the quantitative impact on waiting lists and hospital admissions. However, patients’ views on the quality of service experienced is fundamental and essential to achieve high quality of care. Recording patients experience of care has the potential to improve quality of care. The Irish Rheumatology Nursing Forum (IRNF) wanted to measure patients' experience of care by an RANP and highlight triggers for change to enhance the quality of care delivery nationally. Methods The IRNF conducted a service evaluation postal survey using patient reported experience measure (RA PREM), previously designed, and validated for use with rheumatology patients. This tool examines eight domains of care specific to patients with inflammatory arthritis (need and preferences; care coordination; information about care; daily living; emotional support; family and friends; access to care) and is proven to be effective in measuring and monitoring patient experience. Minor adjustments were made to the questionnaire specific to the role of the advanced nurse practitioner. Patients seen by an advanced nurse practitioner within the previous 12-months were supplied with a questionnaire and a stamped address envelope during a 6-week period, in early 2022. Patient participation was voluntary, postal return of a complete survey implied consent. Results Eleven eligible rheumatology centres with twenty advanced nurse practitioners participated nationally. A total 350 questionnaires were disseminated, 188 completed questionnaires were returned, (54% response rate). In the previous 12-month period 38% of respondents had at least 2 appointments. Appointments with the advance nurse practitioner were predominantly face-to-face (73%), and a further 26% were telephone consultations. Most patients reported involvement in their care decisions, being emotionally supported, and that communication and service access were timely. Patients endorsed a good experience of care for their inflammatory arthritis (67% strongly agreed, 25% agreed). Most patients (71%) reported good control of their arthritis which allowed them to get on with usually daily life activities. Results from the self-care domain demonstrated low levels of knowledge about patient organisations and self-management programmes. Conclusion Optimising the quality of care delivered by advance nurse practitioners is contingent on measuring patient experience. The self-management organisations/programme knowledge deficit among patients will be addressed by the IRNF in partnership with the patient organisation Arthritis Ireland. It is incumbent on advanced practice nurses to undertake service evaluations for quality improvement and further service development. Periodic use of PREMS is a feasible way to inform service evaluation for quality improvement. Disclosure U.E. Martin: None.

AIMS:A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be "high-risk" with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients.METHODS:TRAC-24 was a prospective, phase IV, single centre, open label, parallel group, randomized controlled trial (RCT) involving patients undergoing primary unilateral elective THA. The primary outcome measure was the indirect calculated blood loss (IBL) at 48 hours. The patients were randomized into three groups. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional oral regime for 24 hours postoperatively, group 2 only received the intraoperative dose, and group 3 did not receive any TXA.RESULTS:A total of 534 patients were randomized, with 233 in group 1, 235 in group 2, and 66 in group 3; 92 patients (17.2%) were considered high-risk. The mean IBL did not differ significantly between the two intervention groups (848.4 ml (SD 463.8) for group 1, and 843.7 ml (SD 478.7) for group 2; mean difference -4.7 ml (95% confidence interval -82.9 to 92.3); p = 0.916). No differences in mortality or incidence of VTE were observed between any group.CONCLUSION:The addition of oral TXA for 24 hours postoperatively does not reduce blood loss beyond that achieved with a single 1 g IV perioperative dose alone. There may be a clinically relevant difference in patients with a normal BMI, which warrants further investigation. Critically, there were no safety issues in patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease. Cite this article: Bone Joint J 2021;103-B(7):1197-1205.

Abstract Background/Aims  Telemedicine can be broadly defined as the use of telecommunication technologies to provide medical information and services. It can be audio, visual, or text. Its use has increased dramatically during the COVID-19 pandemic to ensure patient and healthcare worker safety. Any healthcare professional can engage with it. It carries benefits like reduced stress and expense of traveling, maintenance of social distancing, and reduced risk of infection. There are some potential drawbacks such as lack of physical examination, liability and technological issues. Methods  A questionnaire was sent to 200 patients, selected from different virtual clinics (new and review, doctor and ANP led) run between March and May 2020 in the rheumatology department of University Hospital Waterford. We formulated 14 questions to cover the following aspects: demography, the purpose of the consult, punctuality, feedback, medico-legal concerns, and free text for comments. A self-addressed return envelope was included. Results  83 responses were received. 2 were excluded. The ratio of females to male respondents was 59: 41, with the majority over 60 years old. The main appointment type was review 67 (83%). 80% of patients were called either before or at the time of their scheduled appointment. The vast majority (98.8%) of our patients had confidence in our data protection and trusted our system to maintain their confidentiality. 95% stated that they felt comfortable, were given enough time to explain their health problem and felt free from stress. The respondents who preferred attending the clinic in person (17 in total) compared to the virtual were mostly follow up patients- 12 vs. 5 new. Conclusion  Patient satisfaction among those surveyed was high, despite having to introduce the service abruptly during the COVID-19 pandemic. There are many improvements we can adopt to improve our service and even maintain after the pandemic as a way of communicating with our stable patients. As we are covering a large geographical catchment, we can continue to implement the virtual clinic for some appointments. We should prioritize our efforts on identifying the right patient and the type of service we can offer, further training of staff, and increasing awareness of the patients as to how to get the most out of a virtual appointment. Disclosure  F.A. Altamimi: None. U. Martin: None. C. Sheehy: None.

Abstract Background Methotrexate (MTX) remains the standard treatment for inflammatory arthritis. For patients prescribed MTX they tell us that they find it difficult to source correct information. Patients require this at different time points in their disease and in different formats that encompass literacy and language challenges. Patients are usually given instruction about MTX at the time of their diagnosis when they are faced with absorbing a lot of information in a very short time frame, yet the majority of patients are required to take MTX for the duration of their disease. Methods Following on from the development of the MTX patient education guide in Ireland in 2017 we looked at developing the content into a different format. In partnership with a digital media company and the pharmaceutical industry the content was converted into a digital media card and website for use in the clinical setting. The content was designed as an additional support to patients prescribed MTX. The animation consists of both audio and images and provides the viewer with essential information and key messages required when taking MTX. The animation guides the patient through MTX, outlines how it works, how to take MTX, and highlights the important safety issues and monitoring required when taking MTX. Audio content was written by the author and designed in collaboration with a digital media company. The digital media card and website was launched nationally in September 2018 with the support of the Irish Rheumatology Nursing Forum and Arthritis Ireland. Rheumatology departments nationally were provided with copies of the digital media card and details of the website. Patients can use the digital media card and be signposted patients to www.methotrexate.ie. Results Since the launch of both the website and the digital media card there has been 1.5 K sessions, and 1.4K users on the website. The website has been accessed globally with over 781 users from Ireland, 220 from the United States and 144 from the United Kingdom. The website is accessed predominately by mobile device followed by tablet device. Conclusion To date the website continues to be accessed by patients and we have received very positive feedback. The digital media card has been adopted nationally and has become incorporated as part of the education of patients about MTX. Both the website and the digital media card are designed to support and enhance the education about MTX and not replace the formal education that nurses give to patients about MTX. The next step is to survey both the patients and healthcare professionals using the tools and identify what additions may enhance these tools. For further information go to www.methotrexate.ie to access the website and view the animation. Disclosures U.E.S. Martin Honoraria; U.M has received honoraria from Novartis, Abbvie Ireland. Grants/research support; U.M has received educational grants from Novartis, Janssen, Abbvie, Pfizer.

INTRODUCTIONThere are over 40,000 people living in Ireland with inflammatory arthritis (IA), a condition that is potentially destructive in nature and can have personal, social and economic consequences. Although we have witnessed dramatic changes in the treatment of IA in the last two decades, methotrexate (MTX) remains the first-line treatment for patients with a diagnosis of IA. Despite the fact that MTX is so commonly prescribed, there is a lack of educational materials both for healthcare professionals (HCPs) and patients. The aim of the present study was to develop a suite of MTX material for patients.METHODSA comprehensive literature review of MTX (evidence, educational materials and practice guidelines) in the treatment of IA was undertaken. The content of the documents was developed, and the format and structure of the documents were agreed. A tailored patient educational guide, information/monitoring booklet and alert card were designed to address the lack of educational materials for this condition. A national pilot study of the documents was conducted (a postal questionnaire for patients and electronic survey for clinical nurse specialists). Results and recommendations were incorporated into the final documents. These documents were also incorporated into the National Clinical Care Programme-rheumatology-methotrexate pathway.RESULTSA 26-page evidence-based educational guide was produced to support the HCP in educating patients taking MTX, in conjunction with a patient information/monitoring booklet and alert card to support the patient.CONCLUSIONSThese documents are now widely available and used in clinical practice in Ireland, providing patients with standardized, evidence-based information about MTX.

While it is has been proven that tranexamic acid (TXA) reduces blood loss in primary total hip and knee arthroplasty (THA and TKA), there is little published evidence on the use of TXA beyond 3 h post-operatively. Most blood loss occurs after wound closure and the primary aim of this study is to determine if the use of oral TXA post-operatively for up to 24 h will reduce calculated blood loss at 48 h beyond an intra-operative intravenous bolus alone following primary THA and TKA. To date, most TXA studies have excluded patients with a history of thromboembolic disease.

Aims:To determine if sequential application of povidone iodine-alcohol (PVI) followed by chlorhexidine gluconate-alcohol (CHG) would reduce surgical wound contamination to a greater extent than PVI applied twice in spinal surgery patients. Patients and Methods: A single-centre, interventional, two arm, parallel group randomised controlled trial of 407 patients attending hospital for elective spinal surgery was conducted. For 203 patients, pre-surgical skin disinfection was by application of PVI (10% [w/w (1% w/w available iodine)] povidone iodine in 95% industrial denatured alcohol; Videne Alcoholic Tincture) twice and for 204 patients application of PVI once followed by application of CHG (2% [w/v] chlorhexadine gluconate in 70% [v/v] isopropyl alcohol; Chloraprep with tint). The primary outcome measure was post-skindisinfection surgical site contamination determined by aerobic and anaerobicbacterial growth from post-skin disinfection samples. Results: The detection of viable bacteria in any one of the post-skin disinfection samples (culture-positive) was significantly lower in the group treated with both PVI and CHG than in the group treated with PVI alone: 29.1% (59) vs 41.7% (85), P=0.009; relative risk, 0.574; 95% confidence interval, 0.380 to 0.866. Conclusions: Skin antisepsis with sequential application of PVI and CHG more effectively reduces surgical wound contamination than PVI alone.

INTRODUCTIONMethotrexate is commonly used in patients with inflammatory arthritis. The aim of the present study was to ascertain the prevalence of side effects that patients on methotrexate were tolerating and to establish their adherence to the medication.METHODA questionnaire was developed for completion by the healthcare professional with the patient, and piloted in one centre. The questionnaire was then used in six other centres, with the addition of a question about the attractiveness of stopping methotrexate treatment. Efficacy and toxicities were scored for severity on a 10-cm visual analogue scale (VAS). Adherence to the drug was also explored.RESULTSThe prevalence of 'any side effect' ranged from 57% to 86%. The most frequent side effects were fatigue (53%); nausea (38%); mouth ulcers (23%) and hair loss (23%). Efficacy averaged 6.5 cm on the VAS. Results from the combined survey revealed that toxicity averaged 5.9 cm for fatigue, 4.8 cm for nausea, 4.4 for mouth ulcers, 3.9 cm for hair loss and 5.7 cm for 'other' side effects. 13.5% of patients revealed that they had forgotten to take the drug for an average of two weeks, and 25% for an average of 2.5 weeks in the previous year. Participants were more likely to reveal this to a nurse than a doctor.CONCLUSIONPatients put up with a considerable number of side effects in order to benefit from methotrexate therapy. Adherence to this drug merits further study. Copyright © 2015 John Wiley & Sons, Ltd.

The outlook of inflammatory joint diseases has changed significantly with the advent of TNF blockers. However, these advances come with a trade off-risk of infections, especially tuberculosis. The Irish society of rheumatology has proposed guidelines to investigate and treat latent TB infection (LTBI), which is in accordance with majority of international recommendations. This protocol requires that every patient with LTBI should have chemoprophylaxis. INH and different anti-rheumatic drugs are known to cause hepatic and gastrointestinal complications. We sought to investigate the toxicity of adding prophylactic anti-TB medications to different DMARDs and anti-TNF agents. We prospectively documented the course of all patients who were prescribed chemoprophylaxis for LTBI, from August 2007 to August 2008. Arrangements were made for central re-issuing of prescription of INH or rifampicin, after reviewing monthly liver function tests and following telephone interview seeking presence of adverse events. Out of 132 patients who were commenced on different TNF blockers, only 23 patients (17%) were diagnosed with LTBI and were given prophylaxis as per recommended guidelines. Thirty-nine percent (9 out of 23) of patients discontinued INH because of adverse events. Primary reason for discontinuation in these 9 patients was as follows: 3 patients got marked transaminitis (transaminases > 5 times the normal limit), 5 patients had non-resolving gastrointestinal intolerance (mainly nausea), and one patient developed non-resolving rash. We have found a significant number of our patients (39%) who could not continue anti-TB prophylaxis due to either gastrointestinal intolerance or hypertransaminesemia.

Purpose of Study: This phase I study assessed tolerability and local effect of a liposome dispersion with povidone-iodine (polyvinylpyrrolidone-iodine, PVP-I) as nasal spray. Procedures: Three groups received liposomal dispersion with PVP-I (2.2, 4.4 and 0% as control) in single and repeated use (3 days, three times a day). A set of functional and cytological tests as well as safety assessments were performed. Results: No safety-relevant finding or serious adverse events were reported, no evidence for cyto- nor genotoxicity obtained. No clinically relevant changes in mucosa appearance, nor in olfactory sense, nor in ciliary activity (sensitive indicator of local tolerance) occurred and no complaints about nasal airflow obstruction were observed. All liposomal formulations had a positive effect on the nasal mucosa, challenged by allergy in some volunteers. Conclusions and Message: Application of liposomal PVP-I spray to the nasal mucosa does not result in any demonstrable limitation of the nasal function nor in detectable damage to the multilayer ciliated epithelium of the nose. Improvement of various parameters of nasal function under liposomal PVP-I suggest improved mucociliary clearance. Explanation could be humidification, improved surfactant (phospholipid) level and/or sufficient mucolytic activity of iodide due to local application of the constituents.

Background: Allergic rhinitis is associated with nasal mucosal inflammation. Exhaled nitric oxide may by a useful marker of inflammation and has recently been shown to be increased in patients with asthma. Objective: The purpose of this study was to determine whether exhaled levels of nitric oxide are increased with nasal breathing in patients with seasonal allergic rhinitis compared with nonatopic individuals and whether there is an increase with oral breathing consistent with lower respiratory inflammation in the absence of clinical asthma. Methods: Nitric oxide levels in exhaled air were measured by chemiluminescence in 18 nonatopic volunteers and 32 patients with seasonal rhinitis. Measurements were made with both nasal and oral exhalation and orally after 10 seconds of breath-holding. The detection limit was 1 part per billion (ppb). Results: In control subjects nasal levels of nitric oxide in exhaled air (mean +/- SD, 24.7 +/- 9.2 ppb) were higher than those after oral exhalation (11.1 +/- 2.5 ppb, p < 0.0001). Breath-holding significantly increased levels of nitric oxide in exhaled air ina time-dependent manner. Levels of exhaled nitric oxide were significantly higher for all measurements in patients with seasonal rhinitis, with levels without breath-holding of 35.4 +/- 11.3 ppb (p < 0.001) in nasally exhaled air and 16.3 +/- 5.9 ppb (p < 0.001) in orally exhaled air. Nasal levels were significantly higher than oral levels in subjects with rhinitis (p < 0.0001). Conclusions: The results indicate that exhaled nitric oxide may be a useful marker for nasal inflammation in patients with seasonal rhinitis and suggest that generalized airway inflammation may be present, even without clinical asthma, in such patients.

Immunohistochemical staining of endobronchial biopsies has identified increased expression of the 21-amino-acid peptide endothelin (ET) and the inducible form of the enzyme nitric oxide synthase (iNOS) within the airway epithelium in asthma. Elevated concentrations of ET are also recovered in bronchoalveolar lavage fluid from asthma patients. iNOS generates the gas nitric oxide from L-arginine, and elevated levels of NO in exhaled air have been described in asthma. ET is a potent bronchoconstrictor and levels of ET in lavage and resting airflow obstruction are correlated. The effects of ET on bronchomotor tone may be modified by NO as this is a bronchodilator. The relative balance between ET and NOS may thus contribute to resting bronchomotor tone. ET also stimulates fibroblast proliferation, collagen gene expression and through its inhibitory actions on collagenase will promote airway wall collagen deposition and contributes to airway wall thickening which underlies bronchial hyperresponsiveness. The regulation of these epithelial events may thus be important to the control of asthma.