AB1342-HPR RHEUMATOLOGY ‘HOT CLINIC’ IN A TEACHING HOSPITAL - WHAT CAN BE EXPECTED?

Background:Increased financial and bed pressures faced by the NHS have necessitated significant changes in the service provision of many inpatient medical specialties. At the Royal Derby Hospital, rheumatology has become predominantly outpatient-based and no longer has an allocated ward for inpatients. As a result, weekly rheumatology ‘hot clinic’ have been set up to help facilitate early hospital discharge and specialist outpatient review of patients with suspected rheumatological conditions. It was anticipated that the bulk of referrals would be for conditions requiring early intervention such as suspected giant cell arteritis (GCA) and hot swollen joints. However, there is a paucity of literature on the usefulness of such ‘hot clinics’ and the quality of referrals.Objectives:This study sought to evaluate the range of conditions referred to the ‘hot clinic’ and early outcomes related to follow up or discharge.Methods:The details of patients who attended the ‘hot clinic’ were retrospectively obtained using the hospital’s electronic clinic appointments system. Electronic letters and discharge summaries were reviewed to determine the patient’s presenting symptoms, suspected diagnosis and clinical outcome.Results:A total of 40 patients who attended the ‘hot clinic’ from September 2018 to June 2019 were included. The average time from discharge to ‘hot clinic’ was 3.8 days (range 0-22 days). 27 patients (67.5%) were seen within 7 days of hospital discharge and 2 patients were seen after 18 and 22 days respectively, which spanned over the Christmas and New Year period.87.5% (35) of patients were referred by acute medicine via the ambulatory care ward; 10% (4) by the Emergency Department and 1 by the medical ward. 5 patients were already known to rheumatology (3 with rheumatoid arthritis and 2 with psoriatic arthritis).37.5% of referrals were made for suspected GCA, 35% for rash and possible connective tissue disease (CTD) or vasculitis except for GCA, 20% for swollen joints, and 7.5% for unexplained arthralgia or myalgia.For the patients with suspected GCA, 3 out of 15 were treated as GCA after ‘hot clinic’ review - 2 of these went on to have a temporal artery biopsy and 1 had a positive biopsy for GCA. (All 3 received high dose steroids prior to their clinic appointment). 10 patients were felt to have an atypical headache and 3 of these were referred to neurology for further assessment. The remaining 2 patients were diagnosed with a sinus infection and migraine respectively.Of the 14 patients referred with a rash and possible CTD or vasculitis except for GCA, 2 patients referred with a rash were diagnosed to have IgA vasculitis and referred to dermatology for further management. 2 patients were diagnosed with lupus and were followed up in the CTD clinic. 7 patients were felt to have a self-limiting post-viral or non-specific rash, 2 patients with possible drug-related rash and 1 patient thought to have erythema nodosum.2 patients with swollen joints had a new diagnosis of seronegative inflammatory arthritis and 2 others were diagnosed with gout. 1 patient was diagnosed with osteoarthritis and another with post-viral arthritis and both were discharged.The 3 patients with unexplained arthralgia or myalgia were felt to have self-limiting post-viral illnesses and were also discharged.Conclusion:Suspected GCA is the most common referral to the rheumatology ‘hot clinic’. However, the vast majority of these referrals turned out not to be GCA. The results of this study clearly suggest the need for development of better pathways e.g. for GCA and joint dermatology and rheumatology clinics.Disclosure of Interests:None declared

Headache after dural puncture subarachnoid hemorrhage posing as meningitis

Headache after neuraxial blocks is a common complication. This case discussion highlights an important diagnostic dilemma when a sentinel subarachnoid hemorrhage mimics meningitis after spinal anesthesia. A patient presented with features of meningismus after spinal anesthesia. To confirm diagnosis, a second dural tap was done which resulted in a frank sub-arachnoid hemorrhage. This correspondence highlight importance of early vascular imaging when a patient presents with atypical headache after a dural puncture.

The lesser occipital nerve visualized by high-resolution sonography—normal and initial suspect findings

Background The lesser occipital nerve (LON) supplies the lateral part of the occiput and is—together with the greater occipital nerve (GON)—involved in headache pathogenesis. While the GON was described in high-resolution ultrasound (HRUS), the same does not apply to the LON. We aimed at characterizing the LON in HRUS, and present cases of suspect findings in the course of the LON identified by HRUS. Methods The LON was examined bilaterally in eight anatomical specimens with HRUS ( n = 16). HRUS-guided ink marking and consecutive dissection was performed. Further, measurements of the LON diameter were performed in 10 healthy volunteers ( n = 20), and patient charts were reviewed to identify patients who were considered to have possible pathology of the LON. Results The LON was identified correctly in all cadavers on both sides and all volunteers except for one side ( n = 19). The average diameter was 1.08 ± 0.30 mm. Four patients with pain within the LON territory and presumed peripheral origin of headache (defined as resolution of headache after diagnostic HRUS-guided selective blockade) were identified, and three of these showed interference of the LON with lymph nodes or an accessory muscle belly. Discussion We confirm the possibility of visualization of the LON using HRUS. HRUS may be a helpful adjunct tool in the assessment of patients with atypical headache.