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Background:In recent years, the technology based on the analysis of raw ultrasound signals, Radiofrequency Echographic Multi Spectrometry (REMS), has been validated against Dual-energy X-ray Absorptiometry (DXA) for the diagnosis of osteoporosis and risk fracture prediction.Objectives:The aim of this multicenter observational study was to evaluate the diagnostic performance of REMS with respect to DXA in patients with different body mass index (BMI) categories.Methods:The inclusion criteria were: Caucasian women; age between 30 and 90 years; referral by their clinician for spinal DXA assessment; absence of significant walking impairment; signed informed consent.Patients underwent DXA and REMS scans at the lumbar spine, according to the procedures described in Di Paola et al. [1], including an a-posteriori quality check of the examinations in order to guarantee the maximum reliability of the diagnostic outputs.Three groups of patients were considered according to BMI:: underweight (BMI2), normal weight (BMI≥18.5 kg/m2 and 2), and overweight/obese (BMI≥25 kg/m2). DXA and REMS BMD values were also stratified in 3 diagnostic categories: osteoporotic, osteopenic, or healthy.The degree of correlation between DXA and REMS BMD values was quantified by calculating Pearson’s correlation coefficient (r). The diagnostic concordance between REMS and DXA was assessed by Cohen’s K considering the 3 diagnostic categories. REMS´s sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for discriminating patients with and without osteoporosis were also calculated using DXA outcomes as reference. The same statistics were calculated accepting a 0.3 T-score tolerance on T-score values of borderline cases [1].Results:Overall, 4282 patients were enrolled and, after the quality check, 3501 couples of scans were included in the analyses. Of these patients, 122 (3.5%) were underweight, 1964 (56.1%) were normal weight, and 1415 (40.4%) were overweight. The results of the diagnostic performance in patients after BMI stratification are reported in Table 1.Conclusion:We observed an excellent correlation between REMS-based diagnosis with respect to the osteoporosis diagnosis performed by DXA in patients from each BMI category. These results indicate that lumbar spine REMS analysis is a suitable and accurate diagnostic tool for patients with different BMI.References:[1]Di Paola M et al. Osteoporos Int. 2019 Feb;30(2):391-402.Table 1.Diagnostic performance of REMS with respect to DXA considered as reference for patients of different body size.BMIcategoriesrNo tolerance0.3 T-score toleranceSens.Spec.PPVNPVKSens.Spec.PPVNPVKUnderweight0.94697.591.586.898.40.8998.293.289.299.30.91Normal weight0.94692.694.487.096.90.8597.596.792.399.00.93Overweight0.93086.795.884.896.40.8296.397.892.199.00.93Abbreviations: BMI = body mass index; r = Pearson correlation coefficient; Sens. = sensitivity; Spec. = specificity; PPV = positive predictive value; NPV = negative predictive value; K = Cohen’s K.The authors BC, ED, ADP, ML, MM, XN, DOC are equal contributors listed in alphabetical order.Disclosure of Interests:None declared.

Background There is considerable interest in the possible role of vitamin D in respiratory disease, but only one population-based study has reported associations with lung function. Methods The cross-sectional relationships of total dietary vitamin D intake, serum 25 hydroxy vitamin D (25(OH)D) concentrations and three vitamin D receptor (VDR) polymorphisms (Apa1, Fok1 and Cdx2) with lung function and spirometrically-defined chronic obstructive pulmonary disease (COPD) were investigated in men and women aged 59–73 years in the Hertfordshire Cohort Study, UK. Results After controlling for confounders, total vitamin D intake was positively associated with forced expiratory volume in 1 s (FEV 1 ; difference in FEV 1 between top and bottom quintiles of intake 0.079 l (95% CI 0.02 to 0.14), p trend=0.007, n=2942), ratio of FEV 1 to forced vital capacity (FEV 1 /FVC; p trend=0.008) and negatively associated with COPD (OR comparing top and bottom quintiles 0.57 (95% CI 0.38 to 0.87), p trend=0.02). In contrast, serum 25(OH)D concentrations were not related to FEV 1 (p trend=0.89, n=1197) but were positively associated with COPD (p trend=0.046). VDR genotypes were unrelated to lung function and did not modify the effects of dietary intake or 25(OH)D concentrations on lung function. Conclusions The results of this study did not confirm a positive association between blood 25(OH)D concentrations and adult lung function. The apparent relationships with dietary vitamin D are likely to be explained by other highly correlated nutrients in the diet.

Background People in sedentary occupations are at increased risk of hip fracture. Hip fracture is significantly associated with low bone mineral density (BMD) measured at the hip. Physical activity is important in the development and maintenance of BMD, but the effects of occupational physical activity on bone health are unclear. We investigated the influence of lifetime physical activity on BMD at the hip. Methods This was a cross-sectional epidemiological study of the associations between total hip BMD measured by dual-energy X-ray absorptiometry at retirement age and lifetime exposure to occupational physical workload (standing/walking ≥4 h/day; lifting ≥25 kg; energetic work sufficient to induce sweating and manual work). Results Complete data on occupational exposures were available for 860 adults (488 men and 372 women) who had worked ≥20 years. Their mean age was 65 years, and many reported heavy physical workplace activities over prolonged durations. There were no statistically significant associations between total hip BMD and any of these measures of lifetime occupational physical activity in men or women. Conclusions Lifetime cumulative occupational activity was not associated with hip BMD at retirement age. Our findings suggest that, if sedentary work conveys an increased risk of hip fracture, it is unlikely that the mechanism is through reductions in BMD at the hip and may relate to other physical effects, such as falls risk. Further studies will be needed to test this hypothesis.

Background The national audit office reported variation in the quality of services for patients with Inflammatory Arthritis (IA) in the UK in 2009. The Health Quality Improvement Partnership funded a national audit to explore this further. Objectives We set out to assesses whether trusts in England & Wales are achieving the 7 quality standards (QS) published by the National Institute for Health & Care Excellence (NICE). Methods All individuals >16 years presenting to specialist rheumatology services in England & Wales with suspected new onset IA were recruited. Clinician & patient derived data were collected against all NICE QS over the 1st 3 months of specialist care. Results 6,354 patients were recruited nationally from 1 February 2014 to 31 January 2015. 94% of trusts/health submitted data. Patients were predominantly female (66%); white British (79%); and of working age (70%). At recruitment 46% had a diagnosis of Rheumatoid Arthritis (RA); 16% undifferentiated inflammatory arthritis (EIA). Only 17% of patients were referred by their general practitioner (GP) within 3 days of first presentation (QS1); median time interval 34 days. Over 25% waited >3 months. 12% of referrals had no indication that EIA was suspected. Specialist assessment occurred 25% of patients waited >7 weeks. Higher staffing levels (>1 consultant/100,000 population) & the presence of EIA clinics were associated with shorter waiting times (odds ratio (95%CI) 1.3 (1.1–1.4) & 1.6 (1.4–1.7) respectively). Disease modifying anti-rheumatic drug (DMARD) initiation within 6 weeks of referral (QS3) was achieved in 53% of RA patients; 36% were treated with combination DMARDs & 82% with steroids. Clinicians reported that 59% of patients received structured education (QS4). Treat to target plans were set for 91% of patients. These targets were achieved in only 27% (QS5). Almost all trusts reported access to urgent advice (QS6) & incorporated annual review services (QS7). Conclusions This audit has enabled English & Welsh rheumatology services to measure their performance against NICE QS for the early management of IA & RA, benchmarked to regional & national comparators for the first time. The findings clearly demonstrate where improvement is needed. Delays in referral from primary care as well as delays in offering a first appointment in secondary care have been identified as key barriers to effective early arthritis care. Disclosure of Interest None declared

Background Early inflammatory arthritis (EIA) services have undergone substantial reconfiguration in recent years with the recognition of a window of opportunity early on in the disease course as well as the introduction of treat-to-target disease modifying anti-rheumatic drug strategies. As part of a national UK audit into the management of EIA data were collected on patients presenting with inflammatory arthritis for the first 3 months of specialist care. Objectives Here we report the response to treatment at a national level in terms of clinical outcomes. Methods All individuals >16 years presenting to specialist rheumatology services in England & Wales with suspected new onset IA were recruited. Clinician & patient derived assessments of outcome were collected with consent at baseline and after 3 months of specialist care. Data collected included the Disease Activity Score (DAS28), the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire (a validated patient reported outcome measure assessing pain; functional capacity; fatigue; physical/ emotional wellbeing; quality of sleep and coping) and impact upon work status. Results 97% of hospital trusts in England and Wales participated. 6,354 patients with suspected early inflammatory arthritis were recruited between 1st February 2014 to 31st January 2015. Of these 2896 were diagnosed with RA (defined by the presence of polyarticular disease (>5 joints involved) or pauciarticular disease with positive cyclic citrullinated peptide antibody); this represented >40% of estimated expected incident RA cases. At first specialist assessment DAS28 was reported for 91% of RA patients: mean DAS28 was 5.0 (44% of patients a DAS28>5.1 indicating severe disease). The mean RAID score was 5.6 (range 0 not affected to 10 (most affected). After 3 months of specialist care mean DAS28 reduced to 3.5 with 62% achieving a meaningful reduction in DAS28 of >1.2 units. 24% of patients achieved DAS remission. The mean RAID score after 3 months was 3.6; the mean reduction in RAID score was 2.6 and did not meet the minimum clinically important level of 3. Of the working patients aged 16–65 years providing data 7%, 5%, 16% and 37% reported that they were unable to work, needed frequent time off work, occasionally and rarely needed time off work due to their arthritis respectively. 19% reported never being asked about their work by clinicians. Conclusions Although there are data that suggest the severity of RA has diminished in recent years, this audit confirms that at presentation RA remains a disease with significant patient burden. Acknowledging that this audit only captures the first 3 months of care, the results demonstrate important achievements in RA care in contrast to what might have been expected for RA in previous decades. However, less than a quarter of patients achieved remission and improvements in RAID scores were below the accepted minimum clinically important difference within the first 3 months. Disclosure of Interest None declared

Background We have previously described a strategy for Tumour Necrosis Factor inhibitor (TNFi) dose reduction (TDR) for patients with rheumatoid arthritis (RA) that selects patients with “deep remission” using combined clinical and ultrasound (US)[1]. Objectives The aim of this study was to assess the consequences of this TDR strategy [1] on the HAQ, DAS28-CRP and Area Under the Curve of CRP (AUCCRP) after follow-up (mean 28 months). Methods A longitudinal observational study was performed. Patients with RA (ACR-EULAR 2010), on TNFi for >1 year, not taking oral corticosteroids, DAS28 ≤2.6 for >6 months and absent power Doppler synovitis on US underwent TDR by one third. Patients failing TDR (clinically/on US) were re-escalated to full dose. Patients were divided into 3 groups: Non-reducers (group A), sustained dose reducers (group B) and failed dose reducers (group C). We investigated the initial (TNFi start date) and the last HAQ, DAS28 and AUCCRP, as well as before and after TDR. Results 152 patients with RA receiving TNFi were included. Between Oct 2011 & May 2015, 67 (44%) underwent TDR. 3 patients were lost to follow-up. Dose reducers have been followed-up for a mean 30.5 months after TDR. A total of 29 (45%) failed the TDR after a mean (SD) of 9.5 (7.9) months. By a mean (SD) of 22.4 (11.6) months following dose re-escalation, 27 (93%) continued to receive their TNFi, while 2 (7%) had switched to a different biologic. Baseline characteristics of all groups were similar. However, we found that the initial HAQ score on starting TNFi was significantly higher for group A compared to groups B and C (mean 1.59 versus 0.95 and 1.28, respectively, p When compared before and after reduction, both groups B and C showed a similar pattern of functional capacity and AUCCRP. Nevertheless, group B had lower last DAS28 (p Finally, we assessed the changes over time of DAS28 and HAQ scores. Group B had a higher DAS28 reduction then groups A and C (mean 3.6 vs. 2.43 and 2.75, respectively) (p Conclusions RA patients who fail dose reduction appear to have a higher DAS28 than those who were successful despite reintroduction of a standard dose of TNFi. However, in the majority of cases the level of DAS28 was References Marks JL et al. Does combined clinical and ultrasound assessment allow selection of individuals with rheumatoid arthritis for sustained reduction of anti-tumor necrosis factor therapy? Arthritis Care Res. 2015 May;67(6):746–53. Disclosure of Interest L. Serhal: None declared, C. Holroyd: None declared, J. Zarroug: None declared, R. Armstrong: None declared, B. Davidson: None declared, N. Harvey: None declared, E. Dennison: None declared, C. Cooper: None declared, C. Edwards Grant/research support from: Abbvie, MSD, Samsung, Novartis, Lilly, Sandoz, Celltrion, Celgene, Pfizer, BMS, Roche, Consultant for: Consultant, Speakers bureau: Speaker events

Background Care by the multidisciplinary team (MDT) is recommended by the current treatment guidelines in the UK and elsewhere in Europe. In rheumatology the evidence to support the effectiveness of multidisciplinary working is limited.1,2 Furthermore, the availability of all members of the MDT in rheumatology teams across the UK is unclear. Objectives To describe the national provision of MDT care within Rheumatology services across the UK. Methods This was a “service” survey conducted in all rheumatology departments within the UK. In England, the survey was a part of a broader national audit for rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership (HQIP). The approval to undertake this sub-analysis was gained from HQIP and supported by the British Society for Rheumatology research committee and British Health Professionals in Rheumatology. Scotland and Northern Ireland were not included in the national audit therefore a separate, but identical, survey was conducted. The design of the service survey content was agreed in consultation with the BHPR committee, which is formed of health professionals with clinical and research experience in rheumatology. The survey collected organisation data regarding the specific inclusion of, or direct access to, medical, nursing, physiotherapy, podiatry and occupational therapy practitioners as part of the MDT. Detail regarding the whole time equivalent (WTE) availability of each named speciality was recorded and summarised by region. Results The survey response rate was 98% (164/167). Table 1 shows the overall rheumatology staffing levels measured in WTE between professional groups. All departments reported having medical staff present and almost all had a nurse but the inclusion of physiotherapists, occupational therapists and podiatrists in the MDT was variable. Only 48% of the teams surveyed had access to a podiatrist. There was a high degree of regional variation in the provision of health professionals and only 28 (17%) of the surveyed teams had all the named professional groups represented in their multidisciplinary teams. Conclusions There is a high degree of regional variation in the composition and staffing levels of the Rheumatology MDT across the UK. Further research is required determine the most efficient configuration of the MDT in rheumatology services. References Martinez-Gonzalez NA, Berchtold P, Ullman K, et al. Integrated care programmes for adults with chronic conditions: a meta-review. Int. J. Qual. Health Care 2014;26(5):561–70. Bearne LM, Byrne AM, Segrave H, et al. Multidisciplinary team care for people with rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol. Int. 2015;doi:10.1007/s00296-015-3380-4. Disclosure of Interest None declared

Background Recruiting individuals to take part in studies about sexual health can often be difficult due to the sensitive nature of the study topic. As a result, the sample may be less representative of the general population than desired. Understanding potential participants’ views, motivations and concerns may aid in the design of a recruitment protocol that maximises participation and minimises bias. Methods During the initial stages of a study concerning sexually transmitted infections (STIs) at a New Zealand university health centre, a series of focus groups were carried out in order to understand acceptable methods of recruitment. The focus group participants were sought from the study target population and were recruited via posters displayed around the university. Three focus groups of between five and seven participants were conducted. Discussions were audio-recorded and transcribed verbatim. Content analysis methodology was employed using a constant comparative method. Results A key theme that emerged centred around the timing of any approach; students almost unanimously agreed that an approach prior to an STI consultation would be more acceptable than after. Reasons given included wanting to “just get out of there” after seeing the clinician, as well as having something to do during idle time in the waiting room. Many students suggested that they would be less likely to take part after receiving a STI test result that was positive, as they would “not want to think about it”. Conclusion Understanding students’ views around STI testing and research participation helped us to develop a protocol that was sympathetic to the target population’s attitudes and desires, thus improving its acceptability and attractiveness to this population. This information may be useful to other researchers planning sexual health surveys in similar populations. Disclosure of interest statement The authors declare no conflicts of interest.

Background Sexually transmitted infection (STI) rates are known to be high in New Zealand, for example the incidence rate of Chlamydia is almost double that of Australia and the United Kingdom. If public awareness about STIs is low, including knowledge about transmission, risk factors, symptoms and treatment, this could be a contributing factor to the high rates observed. To date however, there has been very little assessment of STI knowledge in New Zealand. We addressed this in this pilot study. Methods This analysis is part of a larger study assessing health-seeking behaviour for STI among students. A questionnaire-based survey was used to obtain basic demographic information and STI knowledge information from students attending a university health centre in the North Island of New Zealand. Students could self-select to take part by picking up a copy of the questionnaire in the waiting room. Seven STI knowledge questions were used, each comprising a statement for which the respondent was asked to indicate ‘True’, ‘False’ or ‘I don’t know’. Correct answers were contrasted with incorrect and ‘I don’t know’ answers to give a general overview of STI knowledge in this population. Results Preliminary analysis of the first 159 questionnaires returned showed variable knowledge of STI transmission, treatment and possible consequences. Students had a good knowledge of transmission, with 88% knowing that STIs can be spread even when symptoms are not present. However, knowledge about treatment and potential sequelae was poor, with 58% of respondents indicating they did not know whether Gonorrhoea could usually be treated with antibiotics, and 44% indicating that they were not aware that some kinds of cancer could be caused by STIs. Conclusion This analysis indicates that some areas of STI knowledge could be improved in this population. This is important because knowledge can be addressed through public health interventions. Disclosure of interest statement The authors declare no conflicts of interest.

Objectives: low levels of physical activity may have considerable negative effects on bone health in adolescence, and increasing screen time in place of sporting activity during growth is worrying. This study explored the associations between self-reported screen time at weekends and bone mineral density (BMD).Design: in 2010/2011, 1038 (93%) of the region’s first-year upper-secondary school students (15–18?years) attended the Tromsø Study, Fit Futures 1 (FF1). A follow-up survey (FF2) took place in 2012/2013. BMD at total hip, femoral neck and total body was measured as g/cm² by dual X-ray absorptiometry (GE Lunar prodigy). Lifestyle variables were self-reported, including questions on hours per day spent in front of television/computer during weekends and hours spent on leisure time physical activities. Complete data sets for 388/312 girls and 359/231 boys at FF1/FF2, respectively, were used in analyses. Sex stratified multiple regression analyses were performed.Results: many adolescents balanced 2–4?h screen time with moderate or high physical activity levels. Screen time was positively related to body mass index (BMI) in boys (p=0.002), who spent more time in front of the computer than girls did (pConclusions: in Norwegian boys, time spent on screen-based sedentary activity was negatively associated with BMD levels; this relationship persisted 2?years later. Such negative associations were not present among girls. Whether this surprising result is explained by biological differences remains unclear

Background Poor sleep quality in older people is common and positively associated with morbidity and mortality. In particular, recent studies have suggested that sleep disturbance may be associated with impaired physical performance (PP) in American older adults. We attempted to replicate these findings in a population of UK community-dwelling older adults. Methods The study population comprised 443 men and women aged 71–80 years from the Hertfordshire Cohort Study, UK. Sleep quality was assessed using the validated Pittsburgh Sleep Quality Index (PSQI). The PSQI is a 10-item questionnaire that assesses a variety of factors related to sleep quality, and results in a global score where >5 is indicative of poor sleep quality. PP was assessed using the Guralnik short physical performance battery (SPPB), a timed up and go (TUG) test and grip strength. Results Completed questionnaires were returned by 373 (84%) participants. 153 (41%) of these participants had a PSQI score of >5, indicating poor sleep. Men, but not women, who reported poor sleep had a significantly lower SPPB score (≤9) after adjustment (age, smoking, alcohol, social class and BMI) (OR 2.42, 95% CI 1.14, 5.14, p = 0.022). This association was robust to additional adjustment for number of co-morbidities and number of medications. Sleep quality was associated with TUG time in men but not women. Men who had poorer sleep quality (PSQI >5) had an average increase (poorer performance) in TUG z-score of 0.30 compared with those with good sleep quality (PSQI ≤5) (95% CI 0.01, 0.59, p Conclusion We found further evidence in support of an association between poor sleep quality and worse PP in older adults. However, differences were observed between men and women. Our results suggest that co-morbidities and medication use may explain some of these observations. Further research into the association between sleep and PP is warranted.

Background Epidemiological studies have shown that weaker grip strength in later life is associated with subsequent disability, morbidity and mortality. Grip strength is a key component of the sarcopenia and frailty phenotypes and yet it is unclear how individual measurements of grip strength should be interpreted in the clinical setting. Using data from general population studies conducted in Great Britain, our objective was to produce cross-sectional centile values for grip strength across the life course. Methods We combined data from 12 general population studies conducted in Great Britain which had measured grip strength using a range of different dynamometers and measurement protocols. We produced centile curves using the Box-Cox Cole and Green distribution. We carried out a series of sensitivity analyses to assess the impact on the centiles produced of dynamometer type and measurement position (seated or standing). Results We combined 60,803 observations from 49,964 participants (26,687 female) to produce gender-stratified cross-sectional centile curves for grip strength from ages 4 to 90 years. The curves suggested three overall periods: an increase to peak in early adult life, maintenance through to midlife and decline from midlife onwards. Males were on average 1.7 times stronger than females from age 25 onwards: males’ peak median grip was 51kg between ages 29 and 39, compared to 31kg in females between ages 26 and 42. Sensitivity analyses suggested our findings were robust to protocol differences between studies. Weak grip strength, defined as strength at least 2.5 SDs below the gender-specific peak mean, increased sharply with age, reaching a prevalence of 23% in males and 27% in females by age 80. Conclusion This is the first study to provide normative data for grip strength across the life course. Our data were drawn from many studies which, in keeping with clinical practice, had used a variety of different measurement protocols; sensitivity analyses suggested that our centile curves were robust to these differences. These centile values have the potential to inform the clinical assessment of grip strength which is recognised as an important part of the identification of people with sarcopenia and frailty.

Background Poor sleep is associated with morbidity and mortality, and research indicates that poor sleep quality is common in older people. The aim of this investigation was to determine the prevalence and risk factors of poor sleep in a community-dwelling older population. Methods The target population was 591 men and women aged 71-80 years from the Hertfordshire Cohort Study. 443 (75.0%) agreed to participate. Sleep was assessed using the validated Pittsburgh Sleep Quality Index (PSQI) in a self-administered questionnaire. The response rate was 91.7% (n = 406). The PSQI assesses a variety of factors related to sleep quality, including estimates of duration and latency and the frequency of specific sleep disturbances. A PSQI score of >5 indicates poor sleep quality. Results 153 (41%) participants had a PSQI score of > 5. The majority (97.3%) reported at least one symptom of disturbed sleep occurring at least once in the past month. The most commonly reported reason for disturbed sleep was getting up to use the bathroom, with 240 (60.3%) participants reporting that this woke them at least 3 times a week. 52 (13.1%) participants reported having taken medication to help them sleep at least once in the past month. Smoking was associated with sleep duration in men but not women, with men who had ever smoked sleeping 35 minutes less compared to those who had never smoked (95% CI 16, 54, p 5 compared to those who easily made ends meet (OR 4.0, 95% CI 1.5, 11.0, p = 0.007). In both men and women, worse self-rated general health was significantly associated with a PSQI score of >5 [OR (95% CI) for fair/bad/very bad health compared to good/very good health: 5.0 (2.3, 11.0), p 5). Conclusion There was a high prevalence of poor sleep in this population. These findings reinforce the need for sleep assessment to be included in routine medical examinations of older people, especially in those with poorer general health.