PERFORMANCE of AN EARLY TRIAGE SYSTEM for IDENTIFICATION of PATIENTS with INFLAMMATORY RHEUMATIC DISEASES

Background: The preselection of patients with suspicion of an infammatory rheumatic disease is not easy for general practitioners and orthopedists. In countries with a limited number of practicing rheumatologists waiting lists are often long, since a full rheumatologic examination often needs a long consultation time. Objectives: To test the performance of an early triage strategy for early identif-cation of patients with infammatory rheumatic diseases. Methods: Prior to the SARS-CoV 2 pandemic, physicians caring for patients contacting a tertiary rheumatologic cente were frst contacted by a health-care professional (HPR) who offered an appointment the timing of which was based on the symptoms reported (Step 1). Patients were then seen by a rheumatolo-gist who, within a 10-minute consultation (Step 2), shortly examined the patient to determine the urgency of a planned full work up. The main outcome of the study was the comparison between the initial assessment and the fnal expert diagnosis (Step 3). Results: Within 9 months, physicians caring for 1.180 patients contacted the hospital, 972 of whom kept their appointment (82.4%). Most patients were transferred by GPs (73.1%) and orthopedists (22.1%). The mean time between Step 1 and Step 2 was 10.4 days, while 6.2% of patients were seen within 4 days, 24.4% within 7 days and 69.3% within 12 weeks. Only 36 patients (3.7%) of patients had an already established rheumatic disease. Complaints lasting between 0-4 weeks were reported by 69 (7.1%), of > 4-12 weeks by 100 (10.3%), and of > 12 weeks by 973 (82.6%) patients. Almost 90% of patients reported a pain intensity >4/10 (NRS) for < 2 weeks. An elevated CRP was found in 207 patients (24.5%). Prior treatment with glucocorticoids was reported in 163 (16.8%) and with NSAIDs in 730 (75.1% of) patients. The confirmed diagnosis at Step 3 was rheumatoid arthritis in 127 (13.1%), spondyloarthritis including pso-riatic arthritis in 72 (7.4%), systemic diseases including connective tissue diseases in 112 (11.5%), vasculitides in 41 (4.2%), and crystal arthropathy in 38 (3.9%) patients, while 38 (3.9%) had an infection, a malignancy or a differential diagnosis such as Raynaud's phenomenon or sicca syndrome. Degenerative joint diseases (n=254;26.1%) and non-inflammatory soft tissue syndromes such as fibromyalgia (n=369;38%) accounted for more than half of the patients. Conclusion: This study describes the performance of a standardized triage system hereby confrming the need for an early identifcation and preselection of patients with rheumatic musculoskeletal symptoms, including involvement of HPRs in the initial phase of contact. Based on the results, three patients with musculoskeletal complaints had to be examined in order to identify one patient with an infammatory rheumatic disease.

ENDOVASCULAR RECONSTRUCTION FOLLOWING IVC AND BILATERAL LOWER EXTREMITY THROMBOSIS IN AN ADOLESCENT

Background: Inferior Vena Cava (IVC) abnormalities are a risk factor for the development of lower extremity deep vein thrombosis (DVT). Abnormalities can be congenital or acquired and include IVC atresia, a rare and lesser known problem for adolescents. Adolescents with IVC atresia are at high risk for DVT's that are often refractory to standard anticoagulation methods, including thrombolysis. Objectives: The purpose of this report is to highlight a young patient with extensive lower extremity DVT in the setting of underlying IVC atresia and describe the complex care required. The patient is a 16-year-old with a history of venous insufficiency who presented with low back pain and lower extremity swelling. Thrombotic risk factors included factor V Leiden heterozygosity, oral contraceptive use, and recent COVID-19 vaccination. An MRI completed by the orthopedist for back pain was concerning for abnormal signal in the IVC as well as an IVC aneurysm. A contrast enhanced CT was obtained and demonstrated atresia of the suprarenal IVC, subacute thrombosis of the infrarenal IVC along with an IVC aneurysm, and subacute thrombosis of the bilateral iliac veins. Design/Method: A retrospective chart review of the patient's initial presentation, imaging, and treatments was conducted along with a review of the literature involving similar cases. Results: Initial treatment was intravenous heparin and t-PA mediated thrombolysis. After overnight thrombolysis, venography revealed significant clot lysis;thus, she was transitioned to subcutaneous enoxaparin and discharged home with therapeutic anti-Xa levels. Follow up imaging 3 days later revealed recurrent thrombosis of the deep veins in both lower extremities. She was readmitted, placed on intravenous heparin, and received catheter directed t-PA thrombolysis. Clot burden was so extensive it was further reduced using Angio jet thrombectomy and balloon angioplasty. Because the recurrent clots were attributed to lack of outflow from the underlying IVC atresia, interventional radiology completed endovascular reconstruction of the IVC. She then transitioned from intravenous heparin to therapeutic enoxaparin, clopidogrel, and aspirin. At three month follow up, imaging was negative for clot and her vasculature was widely patent. Conclusion: Pediatric patients with bilateral lower extremity DVTs are uncommon and underlying IVC abnormalities should be considered in the evaluation. Optimal treatment strategies are evolving and include aggressive anticoagulation and endovascular reconstruction.

REMOTE COORDINATION of the MULTIDISCIPLINARY HAEMOPHILIA TEAM with SKELETAL IMAGING SUPPORT. beyond the PANDEMIC

Introduction: Regional referral hospital usually receives patients who live far away in neighboring cities. Due to distance or disability, it was difficult to get medical attention during Covid Pandemia. So a multicenter coordination of a specilized multidisciplinary team has been implemented. Specific patient's problems were assessed in a dynamic and quick way, solving concerns and determining therapeutic and surgical decisions. Methods: Between January 2019 and October 2021, 62 medical consultations in patients with Haemophilia A and B were carried out in the multidisciplinary assessment system. Range of age was between 5 and 43 years. Whats App and other telemedicine systems were used, in order to solve patients concerns. This evaluation platform was valued by the hematologyst, orthopedist and radiologyst altogether. Radiographs, MSK Ultrasound, MRI and patient clinical photos were uploaded when necessary in this WhatsApp Platform to be checked by the multidisciplinary group. Results: First Ultrasound study was usually requested in their place of origin. In some cases technical supervision was required. If this imaging method was not available or there was lack of trained personnel, patients were asked to attend the hospital. Sometimes the use of MRI was recommended. Ultrasound follow up evaluation was always carried out in our hospital. In all cases Musculoskeletal Images were reviewed by our specially trained Radiologyst, centralizing interpretation and decision-making in our institution. Orthopedic Surgeon and Hematolgyst also took part remotely with treatment and kinesic indications to be carried out in their living cities. Sport activity gradually reincorporation was also valorated by this way. All patients issues were finally able to be solved through this platform. Discussion/Conclusion: Patient management has always been done in our hospital, but we have learned to adapt to our patient's needs. Previous implementation of this clinical and imaging management modality allowed us to give a quick answer to the requirements during Covid Pandemia, adecuating treatment in order to resolve the hemorragic episodes. This modality has been very useful in MSK commitment reducing the influx and circulation of patients, speeding up and facilitating access to medical care. Dynamic and fused coordination of the multidisciplinary team, highly committed to the patient's problems is the clue.

Supporting surgeons in their return to training

Aim: t any one time, approximately 10% of the junior doctor workforce (∼5000 doctors) take time out of training. Following the Bawa Gaba case, and with trainees shielding during the COVID pandemic, there is greater scrutiny and demand to support trainees returning to the frontline. Supported Return to Training (SuppoRTT) is a Health Education England Program designed to improve the Return-To-Training (RTT) experience. For surgical specialties there are additional challenges of reintroducing trainees to practical skills. Method: e designed and facilitated the first regional SuppoRTT course for Orthopaedic Specialist Registrars, which consisted of peer and consultant- led clinical updates, forum discussions and externally commissioned professional coaching. A pre-course survey established participants' concerns and expectations about RTT and formed the basis of discussions. A post-course survey assessed value of the course and impact on participants. Results: Eight participants (6 female) attended. Grade of training on return ranged from ST3 to ST8. Main areas of concern related to colleague perception, reduced confidence with decision-making, operative skill fade, and frustrations with organisational elements of managing worklife balance. There was an overwhelmingly positive response to the support offered on our course, particularly to the discussions around RTT concerns and returning to on-calls. All respondents strongly agreed that sharing their concerns and hearing about peer experience was valuable. Conclusions: High numbers of trainees take approved time out of training. RTT is associated with anxiety around performance and safety. Surgical trainees can be supported with a targeted course that offers clinical update, peer support and professional coaching.