514 F1-taught Orthopaedic Teaching for Students (FOTS)

Introduction F1 doctors, despite being expected to teach, have had reduced opportunity to do so during COVID-19. Medical students have also become increasingly concerned for upcoming exams due to time away from placements. A national orthopaedic teaching programme was designed to provide F1 doctors with opportunities to develop their teaching skills and synergistically improve students’ confidence in performing clinical orthopaedic examinations. Method A University Trauma & Orthopaedics society coordinated the teaching programme consisting of 6-weekly online sessions on each joint examination (shoulder, hip, knee, hand, ankle and lumbar spine). Each session was delivered by two F1 tutors. Pre- and post-session MCQs were provided to students to assess improvement in knowledge. Anonymous feedback forms were also disseminated. Results From the 341 students that attended, 87.1% provided feedback. 86.2% felt that they had de-skilled due to time off, with a mean 15 weeks off from placement. Based on a 5-point Likert scale, students displayed a mean improvement in confidence (1.9±1.1, p < 0.001) and MCQ scores (1.4±1.3, p < 0.001) before and after the sessions. 91.6% of students agreed that the use of online teaching increased attendance. Of the 10 tutors, all reported improvement in confidence to teach and teaching skills. Conclusions We demonstrate that online delivery of clinical orthopaedic examinations is effective and present our findings to encourage similar teaching programmes to be adopted at other locations and specialities.

F1-taught orthopaedic teaching programme for students (FOTS)

IntroductionThe COVID-19 pandemic has impacted students learning, with the time off resulting in students ‘de-skilling’, increasing concerns for upcoming observed structured clinical examinations. Foundation Year 1 (F1) doctors (F1s), despite being expected to teach, rarely receive formal preparation, with COVID-19 exacerbating opportunities to practice. As such, a national orthopaedic teaching programme was designed to provide F1s with opportunities to develop their teaching skills and to synergistically teach medical students how to perform clinical orthopaedic examinations.MethodsSix weekly sessions, each delivered by two newly qualified F1 tutors, on each joint examination were delivered online via Zoom Video Communications (USA). Presession and postsession multiple choice questions (MCQs) were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors.ResultsOf the 341 students that attended, 87.1% provided feedback. 86.2% felt that they had de-skilled due to time off, with a mean 15 weeks off from placement. Based on a 5-point Likert scale, students displayed a mean improvement in confidence (1.9±1.1, p<0.001) and MCQ scores (1.4±1.3, p<0.001) before and after the sessions. 91.6% and 95.3% agreed that the use of online teaching increased attendance and laid the foundation for practice. Of the six tutors, all reported improvement in confidence to teach and teaching skills.ConclusionWe demonstrate that online delivery of clinical orthopaedic examinations is effective, increasing the knowledge and confidence of students, while providing opportunities for F1s to teach. We present our findings to encourage similar teaching programmes to be adopted at other locations and specialties, to synergistically benefit students, doctors and ultimately, patients.

Quantile regression for longitudinal data via the multivariate generalized hyperbolic distribution

While extensive research has been devoted to univariate quantile regression, this is considerably less the case for the multivariate (longitudinal) version, even though there are many potential applications, such as the joint examination of growth curves for two or more growth characteristics, such as body weight and length in infants. Quantile functions are easier to interpret for a population of curves than mean functions. While the connection between multivariate quantiles and the multivariate asymmetric Laplace distribution is known, it is less well known that its use for maximum likelihood estimation poses mathematical as well as computational challenges. Therefore, we study a broader family of multivariate generalized hyperbolic distributions, of which the multivariate asymmetric Laplace distribution is a limiting case. We offer an asymptotic treatment. Simulations and a data example supplement the modelling and theoretical considerations.

POS1418 REALIZING EARLY RECOGNITION OF ARTHRITIS IN TIMES OF INCREASED TELEMEDICINE: THE VALUE OF PATIENT-REPORTED SWOLLEN JOINTS

Background:Early diagnosis and management of patients with inflammatory arthritis(IA) are critical to improve long-term patient-outcomes. Assessment of joint swelling at joint examination is the reference of IA-identification; early access clinics are constructed to promote this early recognition of IA. However, due to the COVID-19 pandemic the face-to-face capacity of such services is severely reduced. The accuracy of patient-reported swelling in comparison to joint examination has been extensively evaluated in established RA (ρ 0.31-0.67), but not in patients suspected for IA.[1]Objectives:To promote evidence based care in the era of telemedicine, we determined the accuracy of patient-reported joint swelling for actual presence of IA in persons suspected of IA by general practitioners(GP).Methods:Data from two Dutch Early Arthritis Recognition Clinics were studied. These are screening clinics (1.5-lines-setting) where GPs send patients in case of doubt on IA. At this clinic patients were asked to mark the presence of swollen joints on a mannequin with 52 joints. For this study the DIP joints and the metatarsal joints were excluded and, therefore, a total of 42 joints were assessed for self-reported joint swelling. Clinically apparent IA of ≥1 joint determined by the physician was the reference to calculate sensitivity, specificity, positive and negative likelihood ratios (LR+,LR-), and positive and negative predictive values (PPV, NPV) on patient-level. Pearson correlation coefficients(ρ) were determined. Predictive values depend on the prevalence of a disease in a population. Because the prevalence of IA in a 1.5-lines-setting will differ from a primary care setting, post-test probabilities of IA were estimated for two lower prior-test probabilities as example, namely 20% (estimated probability in patients GPs belief IA is likely) and 2% (prior-test probability with less preselection by GPs), using likelihood ratios and nomograms.Results:A total of 1637 consecutive patients were studied. Median symptom duration was 13 weeks. 76% of patients marked ≥1swollen joint at the mannequin. 41% of patients had ≥1swollen joint at examination by rheumatologists. ρ was 0.20(patient-level)-0.26(joint-level).The sensitivity of patients-reported joint swelling was high, 87%, indicating that the majority of patients with IA had marked swelling on the mannequin. However the specificity was 31%, indicating that 69% of persons without IA had also done so. The LR+ was 1.25; the LR- 0.43. The PPV was 46%, the NPV 77%. Thus the PPV increased hardly (from 41% to 46%) and the NPV somewhat (from 59% to 77%). Also in settings with prior-test probabilities of 20% and 2%, estimated PPVs (from respectively 20% and 2% to 24% and 2%) and NPVs (from respectively 80% and 98% to 90% and 99%) hardly increased.Conclusion:Patient-reported joint swelling had little value in distinguishing patients with/without IA for different prior-test probabilities, and is less valuable in comparison to self-reported flare detection in established RA.References:[1]Barton JL, Criswell LA, Kaiser R, et al. Systematic review and metaanalysis of patient self-report versus trained assessor joint counts in rheumatoid arthritis. J Rheumatol 2009;36:2635-2641.Disclosure of Interests:None declared

POS0385 DURING DEVELOPMENT OF RHEUMATOID ARTHRITIS, INTERMETATARSAL BURSITIS MAY OCCUR BEFORE CLINICAL JOINT SWELLING: A LARGE MRI STUDY IN PATIENTS WITH CLINICALLY SUSPECT ARTHRALGIA

Background:Inflammation of the synovial lining is a hallmark of rheumatoid arthritis (RA). A synovial lining is not only present at synovial joints and tendon sheaths but also at bursae. Inflammation of the synovium-lined intermetatarsal bursae in the forefoot, intermetatarsal bursitis (IMB), was recently identified with MRI. It is specific for early RA and present in the majority of RA patients at diagnosis. During development of RA, MRI-detectable subclinical synovitis and tenosynovitis often occur before clinical arthritis presents. Whether IMB is also present in a pre-arthritis stage is unknown.Objectives:To assess the occurrence of IMB in patients with clinically suspect arthralgia (CSA) and its association with progression to clinical arthritis in a large MRI-study.Methods:We studied 524 consecutive patients presenting with CSA. CSA was defined as recent-onset arthralgia of small joints that is likely to progress to RA based on the clinical expertise of the rheumatologist. Participants underwent unilateral contrast-enhanced 1.5T MRI of the forefoot, metacarpophalangeal (MCP) joints and wrist at baseline. Thereafter patients were followed for detection of clinical arthritis, as identified at physical joint examination by the rheumatologist. Baseline MRIs were evaluated for IMB at all 4 intermetatarsal spaces. Also synovitis, tenosynovitis and osteitis were assessed in line with the RA MRI scoring system (summed as RAMRIS-inflammation). Both IMB and RAMRIS-inflammation were dichotomised into positive/negative using data from age-matched symptom-free controls as a reference. Cox regression analysed the association of IMB with progression to clinical arthritis; multivariable analyses were used to adjust for RAMRIS-inflammation which is known to associate with progression to clinical arthritis. Analyses were repeated stratified for ACPA-status, since ACPA-positive and ACPA-negative RA are considered separate entities with differences in pathophysiology.Results:The baseline MRIs showed ≥1 IMB in 35% of CSA-patients. Patients with IMB were more likely to also have synovitis (OR 2.5 (95%CI 1.2–4.9)) and tenosynovitis (8.9 (3.4–22.9)) on forefoot MRI, but not osteitis (0.9 (0.5–1.8)). Patients were followed for median 25 months (IQR 19–27). IMB-positive patients developed clinical arthritis more often than IMB-negative patients (HR 3.0 (1.9-4.8)). This association was independent of RAMRIS-inflammation (adjusted HR 2.2 (1.4–3.6)). In stratified analyses, IMB was more frequent in ACPA-positive than in ACPA-negative CSA (68% vs. 30%, p<0.001). Moreover IMB predicted clinical arthritis development in ACPA-positive CSA (HR 2.5 (1.1–5.7)) but not in ACPA-negative CSA patients (1.0 (0.5–2.2)).Conclusion:One-third of CSA patients have IMB. IMB is frequently present in conjunction with subclinical synovitis and tenosynovitis. It precedes the development of clinical arthritis, and in particular the development of ACPA-positive RA. These results reinforce the notion that not only intra- but also juxta-articular synovial inflammation is involved in the development of RA.Disclosure of Interests:None declared

POS0506 TENOSYNOVITIS HAS A HIGH SENSITIVITY FOR EARLY ACPA-POSITIVE AND ACPA-NEGATIVE RA: A LARGE CROSS-SECTIONAL MRI STUDY

Background:Clinically evident tenosynovitis can be seen in established Rheumatoid arthritis (RA). Imaging research has recently shown that tenosynovitis at small joints occurs in early RA, contributes to typical RA symptoms (including joint swelling) and is infrequent in healthy controls. Imaging-detectable tenosynovitis is often not recognizable at joint examination, hence its prevalence can therefore be underestimated.Objectives:We hypothesized that if MRI-detectable tenosynovitis is a true RA-feature, the sensitivity for RA is high, in both ACPA-positive and -negative RA, and lower in other diseases that are associated with enthesitis (such as Spondyloarthritis (SpA) and Psoriatic Arthritis (PsA)). So far, no large MRI-study addressed these questions.Methods:Consecutive early arthritis patients (n=1211) from one health-care region underwent contrast-enhanced 1.5T MRI of hand and foot at diagnosis. MRIs were scored for synovitis and tenosynovitis by two readers blinded for clinical data. All included patients with ACPA-positive RA (n=250), ACPA-negative RA (n=282), PsA (n=88), SpA with peripheral arthritis (n=24), reactive arthritis (n=30) and self-limiting undifferentiated arthritis (UA;n=76) were studied. Sensitivity was calculated.Results:The sensitivity of tenosynovitis in RA was 85%; 88% for ACPA-positive RA and 82% for and ACPA-negative RA (p=0.19). The sensitivity for RA was significantly higher than for PsA (65%;p=0.001), SpA (53%;p<0.001), reactive arthritis (36%;p<0.001) and self-limiting UA (42%;p<0.001). The observed sensitivity of MRI-synovitis was 91% in RA and ranged 83-54% in the other groups.Conclusion:MRI-detected tenosynovitis has a high sensitivity for early ACPA-positive and ACPA-negative RA. This supports both juxta-articular (tenosynovitis) and intra-articular synovial involvement is characteristic for RA.Figure 1.Presence of tenosynovitis (in black) in wrist MCPs and MTPs, in rheumatoid arthritis, stratified for ACPA-status and compared to other diseases Legend: RA: Rheumatoïd arthritis; ACPA: anti-citrullinated protein antibodies; UA: undifferentiated arthritisDisclosure of Interests:None declared

Tenosynovitis has a high sensitivity for early ACPA-positive and ACPA-negative RA: a large cross-sectional MRI study

ObjectivesClinically evident tenosynovitis can be seen in established rheumatoid arthritis (RA). Imaging research has recently shown that tenosynovitis at small joints occurs in early RA, contributes to typical RA symptoms (including joint swelling) and is infrequent in healthy controls. Imaging-detectable tenosynovitis is often not recognisable at joint examination, hence its prevalence can therefore be underestimated. We hypothesised that if MRI-detectable tenosynovitis is a true RA feature, the sensitivity for RA is high, in both anti-citrullinated protein antibodies (ACPA)-positive and ACPA-negative RA, and lower in other diseases that are associated with enthesitis (such as spondyloarthritis (SpA) and psoriatic arthritis (PsA)). So far, no large MRI study addressed these questions.MethodsConsecutive patients with early arthritis (n=1211) from one healthcare region underwent contrast-enhanced 1.5T MRI of hand and foot at diagnosis. MRIs were scored for synovitis and tenosynovitis by two readers blinded for clinical data. All included patients with ACPA-positive RA (n=250), ACPA-negative RA (n=282), PsA (n=88), peripheral SpA (n=24), reactive arthritis (n=30) and self-limiting undifferentiated arthritis (UA; n=76) were studied. Sensitivity was calculated.ResultsThe sensitivity of tenosynovitis in RA was 85%; 88% for ACPA-positive RA and 82% for and ACPA-negative RA (p=0.19). The sensitivity for RA was significantly higher than for PsA (65%; p=0.001), SpA (53%; p<0.001), reactive arthritis (36%; p<0.001) and self-limiting UA (42%; p<0.001). The observed sensitivity of MRI synovitis was 91% in RA and ranged from 83% to 54% in other groups.ConclusionsMRI-detected tenosynovitis has a high sensitivity for early ACPA-positive and ACPA-negative RA. This supports that both juxta-articular (tenosynovitis) and intra-articular synovial involvement is characteristic of RA.

Rancang Bangun Alat Bantu Pemeriksaan Knee Joint pada Kasus Osteoarthritis

Background : The Knee joint is a hinge joint with a change formed by the two condyls of the femur that are jointed with the superior surface of the tibial tube. Radiographic examination of the knee joint on AP weight bearing and lateral weight bearing projections is a good projection in revealing joint gaps in the knee joint. The constraints on this examination are when patients who have little difficulty standing on one leg when doing lateral projection of weight bearing. So that a knee joint examination tool is needed in the case of osteoarthrithis.Methods : The purpose of this study was to describe the design, study the function tests and performance tests of knee joint hearing aids in the case of osteoarthrithis.This research is a type of experimental research with the design of a one shoot case study. Data collection is obtained by a check list of results of functional tests and performance test tools. The data obtained was assessed by Guttman's scale and conclusions and suggestions were drawn.This study produced a design in the form of a knee joint examination tool. The tool is made of stainless steel pipes, on a pedestal made of wooden boards, foam and cloth. Based on the calculation of the check list using the Guttman scale.Result: The function test results were 100% and the performance test results were 96%. Until the knee joint examination tool in the case of osteoarthrithis is said to be feasible to use.Conclusion : This knee joint examination aid has a number of parts, a pedestal made of wood sheets, adjustable footrests, and a patient's padded arms. The auxiliary framework uses a 3 cm diameter stainless steel pipe with a thickness of 1 mm. Based on the functional tests in the Radiology Installation of Prof. Dr. Margono Soekarjo Purwokerto obtained results 100% for knee joint examination in osteoarthritis cases with AP weight bearing projections and lateral weight bearing. Based on performance tests which involved 5 respondents who were radiographers were said to be very appropriate with a percentage of 96% with an excess of ease in operation, reducing the movement of patients, and helping the radiographers to produce informative radiographs.

Idiosyncratic volatility, option-based measures of informed trading, and investor attention

We establish a direct link between sophisticated investors in the option market, private stock market investors, and the idiosyncratic volatility (IVol) puzzle. To do so, we employ three option-based volatility spreads and attention data from Google Trends. In line with the IVol puzzle, the volatility spreads indicate that sophisticated investors indeed consider high-IVol stocks as being overvalued. Moreover, the option measures help to distinguish overpriced from fairly priced high-IVol stocks. Thus, these measures are able to predict the IVol puzzle’s magnitude in the cross-section of stock returns. Further, we link the origin of the IVol puzzle to the trading activity of irrational private investors as the return predictability only exists among stocks that receive a high level of private investor attention. Overall, our joint examination of option and stock markets sheds light on the behavior of different investor groups and their contribution to the IVol puzzle. Thereby, our analyses support the intuitive idea that noise trading leads to mispricing, which is identified by sophisticated investors and exploited in the option market.