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A 63-year-old woman presented with headache, progressive somnolence, neurocognitive decline and urinary incontinence through a year. Medical history was unremarkable except for hypertension and hypercholesterolaemia. Neurological examination was normal. Brain MRI showed findings typical for spontaneous intracranial hypotension (subdural fluid collection, pachymeningeal enhancement, brain sagging) and pituitary tumour. The patient’s complaints improved dramatically but temporarily after treatment with each of repeated targeted as well as non-targeted blood patches and a trial with continuous intrathecal saline infusion. Extensive work up including repeated MRI-scans, radioisotope cisternographies, CT and T2-weighted MR myelography could not localise the leakage, but showed minor root-cysts at three levels. Finally, lateral decubitus digital subtraction dynamic myelography with subsequent CT myelography identified a tiny dural venous fistula at the fourth thoracic level. After surgical venous ligation, the patient fully recovered. Awareness of spontaneous dural leaks and their heterogeneous clinical picture are important and demands an extensive workup.

SARS-CoV-2 preferentially targets the human’s lungs, but it can affect multiple organ systems. We report a case of cardiorenal syndrome in a 37-year-old man who had symptoms of fever, myalgia and cough. He tested positive for COVID-19 and presented 5 days later with acute heart failure. Work up was done including echocardiography showing reduced ejection fraction. Later in the hospital course he developed acute renal failure and was treated with intermittent renal replacement therapy. No other definite cause of cardiorenal complications was identified during the course of the disease. A possible link with COVID-19 was considered with underlying mechanisms still needed to be explored. This case highlights the potential of SARS-CoV-2 affecting heart and kidneys. The disease not only involves the organs directly but can exacerbate the underlying comorbid illness.

Background:A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.Objectives:This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.Methods:Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.Results:One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.Conclusion:Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.References:[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036Disclosure of Interests:None declared

ObjectiveThe role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke.MethodsWe retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings.ResultsThere were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring.ConclusionsThis work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.

Background Published guidelines suggest that ECG screening in US athletes may cause excessive anxiety, especially in those with false-positive findings. However, this has never been formally evaluated. Methods and study design Prospective, nonrandomised controlled trial. High school athletes received a standardised history and physical examination (control) or a history and physical examination with an ECG (experimental). Prescreen and postscreen assessments for health attitudes, anxiety and impact of screening on sport were conducted. Results 952 athletes (49.7% girls, mean age 15.5 years) participated (control=150; experimental=802). 4.4% worried about having an underlying cardiac condition, and 73% wanted to learn if they had a cardiac abnormality prior to competition. In the experimental group, 576 had normal screens, 220 had an abnormal screen (by history 15.8%, physical examination 6.2% or ECG 1.7%) but normal work up (false-positive) and 6 were identified with a serious cardiac condition (true-positive, 0.75%). Compared with the control group, those who received an ECG were more likely to: (1) be significantly more satisfied with their screening (p

IntroductionParadoxical reactions (PRs) during treatment of neurotuberculosis are common but late-onset PRs after completion of anti-tuberculous treatment are reported very rarely. The management of late-onset PRs is challenging as excluding other diagnoses is difficult without invasive testing.MethodsTwo cases of late-onset PRs after treatment for neurotuberculosis are reported. The timing of onset, clinical and radiological features of these PRs are described and the diagnostic work up and outcomes after empiric immunosuppression reviewed.ResultsA 24-year-old woman presented with right-sided focal motor seizures 18 months after receiving anti-tuberculous treatment for neurotuberculosis. MRI showed enlargement of a previous left frontal tuberculoma with extensive oedema. A biopsy was not performed as the lesion involved eloquent brain and the patient declined a lumbar puncture. She was treated empirically with corticosteroids for six months and had clinical and radiological improvement.A 56-year-old woman presented with left leg weakness and numbness 20 years after treatment for multiple cerebral tuberculomas. MRI showed a new confluent area of T2 hyperintensity in the right frontal and parietal lobes. Cerebrospinal fluid was negative for acid-fast bacilli. She was treated with corticosteroids for 2 months with progressive improvement.ConclusionsLate onset PRs to neurotuberculosis can occur months to years after completing anti-tuberculous therapy. Recognising this entity is important so unnecessary treatments and brain biopsy may be avoided. Empiric immunosuppression with corticosteroids appears to be safe if early follow up and repeat imaging is arranged.

IntroductionAlcohol related neurological dysfunction affects the central and peripheral nervous system. We present a rare consequence of excessive alcohol consumption. A 42-year-old female consuming 2 bottles of wine daily for the preceding 5 years presented with 12 months of progressive gait disturbance. Examination revealed a spastic paraparesis with prominent dorsal column signs. Extensive work up found no alternate cause for her presentation. The final diagnosis was direct alcohol mediated toxic myelopathy. We reviewed the current literature on this rare condition.MethodsWe searched PubMED/OVID databases with the terms ‘alcohol AND myelopathy’.ResultsThere is a paucity of research on this clinical entity. Sage et al.1 described 5 well-nourished alcoholics presenting with a progressive myelopathy. As with our patient, routine laboratory tests, including nutritional screen, were normal. CT Myelogram revealed no structural cause. CSF was normal. In contrast, a myelopathic syndrome can occur in alcoholic hepatic failure, attributed to portosystemic shunting of blood, with resultant hyper-ammonaemia and demyelination of corticospinal tracts.2–4ConclusionAlcohol associated toxic myelopathy is a rare entity, distinct from hepatic myelopathy. It is thought to result from direct toxic effects of ethanol on corticospinal and large myelinated sensory tracts. The sensory involvement is unique for this entity, which distinguishes it from hepatic myelopathy, where corticospinal involvement predominates. It is prudent to look for other potentially treatable secondary causes of myelopathy. Abstinence from alcohol results in modest improvement in symptoms. Minimal literature exists on this clinical entity and further research is required.ReferencesSage JI, et al. Alcoholic myelopathy without substantial liver disease. A syndrome of progressive dorsal and lateral column dysfunction. Arch Neurol. 1984 Sep;41(9):999–1001.Premkumar M, et al. Hepatic Myelopathy in a Patient with Decompensated Alcoholic Cirrhosis and Portal Colopathy. Volume 2012, Article ID 735906, 4 pages.Koo JE, et al. Hepatic myelopathy as a presenting neurological complication in patients with cirrhosis and spontaneous splenorenal shunt. Korean J Hepatol. 2008 Mar;14(1):89–96.Kori P, et al. Hepatic myelopathy: an unusual neurological complication of chronic liver disease presenting as quadriparesis. BMJ Case Rep. 2013; 2013: bcr2013009078.

BackgroundReported allergy to penicillins is a major clinical problem. Over 10% of parents report drug allergy resulting in higher cost and less than optimum management of infectious diseases.ObjectivesTo determine the relative likelihood of true allergy in patients suspected to have a penicillin allergy and to investigate the risk factors involved. We hypothesized that the vast majority of self-reported penicillin allergies are less likely to be true allergies when proper immunological work up is performed.MethodsPaediatric patients aged 0–18 years presenting to the ADR clinic at the Children Hospital of Western Ontario (CHWO) with suspected antibiotic allergies were included. A retrospective review of charts was conducted to obtain demographic information and results from allergological and in vitro testing. Subjects were evaluated with a radioallergosorbent test (RAST) or the lymphocyte toxicity assay (LTA)/the invitro platelet toxicity assay (iPTA) depending on whether the history was most consistent with an immediate allergy or a delayed hypersensitivity, respectively. Patients with negative RAST or LTA/iPTA were recommended to undergo confirmatory oral challenge test (OCT).ResultsNinety subjects were identified including 75 with possible penicillin allergy and 10 with suspected allergy to a non-penicillin antibiotic. Five subjects presented with a mixed allergy. Based on the results from RAST, in vitro testing and OCTs, the prevalence of a true allergy in the penicillin group was 6.25% vs. 66.67% in the non-penicillin group (p< 0.001). Patients presenting with severe reactions were more likely to be truly allergic (p< 0.01). In-patients were more likely to present with non-penicillin allergies and were subsequently more likely to have a true allergy (p< 0.001).ConclusionsTrue allergy is very rare in patients with suspected penicillin allergies and can be determined with a proper work-up including OCT. Shorter protocols for the evaluation of these patients would be beneficial.Disclosure(s)Nothing to disclose

Aims In recent years the genetic aberrations associated with diffuse large B-cell lymphoma and the new subtype described in the 2008 revision of the WHO classification, ‘B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma’ have been increasingly well defined. Recurrent genetic abnormalities include rearrangements involving MYC (8q24), BCL2 (18q21) and BCL6 (3q27); as the prognostic and therapeutic implications associated with these abnormalities are clarified their accurate identification at diagnosis is becoming increasingly critical. We describe our experience of using a panel of fluorescence in situ hybridisation (FISH) probes on formalin-fixed paraffin-embedded tissue sections in the diagnostic work-up of 162 patients with non-Burkitt high grade B-cell non-Hodgkin9s lymphomas (HG-BNHL). Methods BCL6, IGH-BCL2 and MYC status were determined prospectively in sequential patients presenting with HG-BNHL, with respect to the presence of rearrangements and copy number changes. Small numbers of samples were analysed retrospectively or were studied at relapse in previously untested patients. Results FISH analysis was successful in 160/162 (99%) cases, with abnormalities detected in 118/160 (74%). Conclusions FISH analysis of formalin-fixed paraffin-embedded tissue sections is a highly reproducible technique with an excellent success rate for the detection of genetic abnormalities which will play an increasingly important role in improving risk stratification of patients with HG-BNHL.

Lumbar puncture allows sampling of cerebral spinal fluid (CSF) and measurement of the intracranial pressure and is often a vital part of patients’ diagnostic work up. It is noted that in general documentation of opening pressure is often missed and glucose samples are regularly not sent. We obtained records [n=27] of all patients who had had a CSF sample sent from our acute medical unit between October 2015 and March 2016. We then obtained the medical notes for all patients and, assessed adequacy of LP documentation and whether basic investigations had been sent. With regards to documentation indication for LP (29.6%), contraindications (or absence of) (7.4%), needle gauge (18.5%) and positioning (22.2%) were the least frequently documented areas. No variable was documented every time. In line with the literature the opening pressure was missed in over a third of cases.Cell count was sent in all bar one sample (96.3%). CSF Protein and CSF glucose were both sent for 88.9% of cases but serum glucose was only sent for 44.4% of cases. To improve practice both in terms of documentation and sample sending we have designed a ‘Lumbar Puncture Care Bundle’ to be used by clinicians when performing an LP and placed directly into notes. We plan to re-audit in six months.

Background: Fever of unknown origin (FUO) is a diagnostic challenge. Rheumatologists are often in charge of patients with FUO because the vasculitides, especially, are potential and common causes of FUO. Objective: To evaluate the value of a standardised investigation to identify the cause of FUO. Methods: A standardised work-up programme for patients with FUO was started at the beginning of September 1999. The rate of identified causes of FUO was compared between all patients with FUO admitted to a tertiary care centre of rheumatology between January 1996 and August 1999 (control group) and September 1999 and January 2003 (work-up group). In January 2002 magnetic resonance imaging (MRI) was added to the investigation. Results: 67 patients with FUO were identified—32 before and 35 after institution of the work-up programme. Before implementation 25% of all patients with FUO remained undiagnosed, after implementation 37%. After institution of the investigation the percentage of patients with vasculitides increased significantly from 6% (n = 2) to 26% (n = 9, p = 0.047, Fisher's exact test). This increase could be attributed to the addition of MRI in 2002. When all patients with FUO before 2002 (n = 55) and thereafter (n = 12) were compared the prevalence of systemic vasculitis increased from 11% (n = 6) to 42% (n = 5, p = 0.021). Conclusion: Implementation of a standardised work-up programme for FUO did not improve the overall rate of diagnosis. Addition of MRI significantly increased the diagnosis of systemic vasculitis as the underlying cause of FUO. MRI should be included in the investigation of patients with FUO when vasculitis is suspected.

Background: The previous epidemiological study of paediatric nephrolithiasis in Britain was conducted more than 30 years ago. Aims: To examine the presenting features, predisposing factors, and treatment strategies used in paediatric stones presenting to a British centre over the past five years. Methods: A total of 121 children presented with a urinary tract renal stone, to one adult and one paediatric centre, over a five year period (1997–2001). All children were reviewed in a dedicated stone clinic and had a full infective and metabolic stone investigative work up. Treatment was assessed by retrospective hospital note review. Results: A metabolic abnormality was found in 44% of children, 30% were classified as infective, and 26% idiopathic. Bilateral stones on presentation occurred in 26% of the metabolic group compared to 12% in the infective/idiopathic group (odds ratio 2.7, 95% CI 1.03 to 7.02). Coexisting urinary tract infection was common (49%) in the metabolic group. Surgically, minimally invasive techniques (lithotripsy, percutaneous nephrolithotomy, and endoscopy) were used in 68% of patients. Conclusions: There has been a shift in the epidemiology of paediatric renal stone disease in the UK over the past 30 years. Underlying metabolic causes are now the most common but can be masked by coexisting urinary tract infection. Treatment has progressed, especially surgically, with sophisticated minimally invasive techniques now employed. All children with renal stones should have a metabolic screen.

Endoscopy is recommended as the first investigation in the work up of a patient with dyspeptic symptoms and is essential in the classification of the patient's condition as organic or functional dyspepsia. Although the correlation between mucosal alterations and symptom pattern is difficult, endoscopy will remain the initial investigation of choice for clinically relevant abnormalities that need proper detection and biopsy.

Objective: We sought to determine (1) how often and why emergency medicine resident physicians perform core physical exams in patients with minor peripheral chief complaints (MCCs); and (2) the clinical impact this practice. Methods: This prospective observational study was conducted at an urban emergency department with a 4 year emergency medicine residency. Charts of all emergency department patients presenting with MCCs in June–September 2003 were reviewed by blinded assistants for documentation of (1) core physical exams; (2) abnormal core physical exam findings; and (3) additional work up, treatment or follow up related to abnormal core physical exam findings. In May–June 2004 all emergency medicine residents were asked how often they perform core physical exams on emergency department patients with MCCs and their motivating factors for this practice. Results: 297 patients met MCC inclusion/exclusion criteria. Among the 591 total cardiac, lung and abdominal exams performed, 8 (1.4%, 95% confidence interval (CI) 0.7% to 2.7%) were abnormal and only 1 (0.1%, 95% CI 0% to 0.1%) finding led to further testing (ECG); none prompted change in treatment or follow up. All 46 eligible emergency medicine residents were evaluated; 72% (33) performed core physical exams in half or more patients with MCCs. Their primary reasons were to screen the underserved emergency department population, the belief that such exams are standard of care, and establishment of physician–patient rapport. Conclusions: Because they want to screen an underserved population, establish rapport, and meet what they believe is a standard of care, most emergency medicine residents performed core exams on patients with MCCs. Abnormal core physical exam findings are unusual and rarely lead to further testing or change in management.

A 53-year-old man developed significant mass effect secondary to an ischaemic stroke and was treated with decompressive craniectomy. During the first few days postsurgery he developed orthostatic vertigo with nausea. After a month, with increasing mobilisation and rehabilitation, he started reporting of severe abdominal pain. No aetiology could be found despite extensive local work up and the symptoms were resistant to any symptomatic treatment. Within days postcranioplasty there was a complete resolution of all the symptoms. Conclusion: the sinking flap syndrome can cause abdominal pain and orthostatic vertigo.

Introduction One of the high quality service developments in endoscopy in the UK has been the introduction of the Bowel Cancer Screening Programme due to the rigorous quality assurance not just of the colonoscopy but of all aspects of the patient journey. Whilst the Royal Liverpool is a tertiary referral site for colorectal complex polyp/Endoscopic Mucosal Resection for BCSP and the symptomatic service for the North-West, the patient journey and quality of service varied significantly depending whether they were referred through via the BCSP or the symptomatic route. Methods We modelled the patient pathway within the symptomatic service to the BCSP standard of care. We seconded two SSPs and BCSP admin to work 50% with the EMR service and 50% within BCSP. All referrals were initially reviewed by EMR specialist endoscopists and then handed to the SSPs to be entered onto a bespoke database. Telephone assessment of patients was performed by an SSP who actively managed the patients co-morbidities and charted them on the database. Patients were listed onto dedicated EMR lists with adequate slot allocations as determined by the EMR endoscopist. Post procedure, patients had a follow-up phone call and their histology and post discharge follow up was monitored and managed by the team including MDT handover in the referral centres. Results Since the start of the service (24 th August 2015) 138 patients have been managed through the service. The mean age was 77 years. Referral pathways have included:51% external tertiary referrals, 6% from MDT and 43% internal tertiary referrals. 31 telephone assessments have been performed. In 25% patients a successful intervention by the team resulted in a positive outcome. These included interventions in; Pre-procedure work up & management of co-morbidities (n = 14), administration (n = 12), post-procedure complications (n = 5) and change in management following histology results (n = 3). See Table for full details Conclusion Re-design of the symptomatic EMR service using the expertise within our BCSP with similar principles in pathway management has had a significant impact on patient safety and outcomes within this service. Disclosure of Interest None Declared

Introduction Video Capsule Endoscopy (VCE) has the unique ability to visualise the small intestinal mucosa, which traditionally is difficult to reach with a standard endoscope. The indications for this test are primarily to investigate the small bowel (SB) in patients with Crohn’s Disease (CD) and to evaluate the SB for causes of Iron Deficiency Anaemia (IDA). Despite the high diagnostic yield with VCE, one of its main drawbacks is its low specificity in patients with inflammatory bowel disease (IBD). In a prospective blinded 4 way comparison study, capsule endoscopy had a sensitivity of 83% and a specificity of 53%. 1 We intended to evaluate the additional benefit of VCE in our patient cohort with particular emphasis on those patients who had MRE prior to their VCE as part of their work up for IBD. Methods Patients who had VCE in Nottingham University Hospitals NHS Trust between January 1 st 2014 and January 1 st 2016 were included. Patient data including demographics, previous investigations and the treating physician’s interpretation of results and resultant change in management, from these investigations, were abstracted on to an excel spreadsheet. Results 171 patients were included, of whom 148 were adults and 87 were female. The commonest indication was IDA [n = 70 (41%)]. Diarrhoea and IBD were the second most common indication with 63 patients (37%). SB abnormalities were detected in 96 patients, of which 48 had not previously been visualised on alternative investigations. This changed management in 28 patients (16%) based on the abnormalities detected. There was one complication observed; the capsule remained in the stomach stuck within rugal folds and requiring endoscopic retrieval. 44 patients with suspected CD had MRE prior to capsule endoscopy. Abnormalities were seen in 20 of these capsule endoscopies, of which 14 had not been seen in previous investigations. However, only in 5 patients (10%) did these positive capsule findings facilitate a change in their disease management. Of the 63 patients who were investigated for IBD or diarrhoea, 15 patients were diagnosed with CD in light of the VCE findings. However, of these, only 4 patients had had a change in management, of whom 3 had had findings consistent with CD already demonstrated on MRE. Conclusion VCE is a useful and safe diagnostic test to detect SB pathology. This modality assisted management in 16% of our patient cohort. However, in the setting of IBD it appears that VCE rarely has findings that lead to a change in management over and above MRE. Reference 1 Solem CA, Loftus EV, Jr, Fletcher JG, Baron TH, Gostout CJ, Petersen BT, et al . Small-bowel imaging in Crohn’s disease: a prospective, blinded, 4-way comparison trial. Gastrointest Endosc 2008; 68 (2):255–66. Disclosure of Interest None Declared

We report a case of a 58-year-old woman who presented with a 1-month course of progressive lower and upper extremity weakness in addition to binocular diplopia. Diagnostic lumbar puncture revealed atypical lymphoid cells with 28% blasts. Immunophenotype was consistent with B cell acute lymphoblastic leukaemia (B-ALL). Further work up showed no systemic involvement but extensive thoracolumbar-sacral leptomeningeal disease. The patient was treated with several courses of intrathecal and systemic chemotherapy followed by craniospinal irradiation for consolidation. There was initial steady improvement in neurological symptoms and leptomeningeal disease, the latter being ascertained through radiological studies and cerebrospinal fluid examination. After 10 months of response, the patient relapsed with central nervous system (CNS) and systemic disease. B-ALL is a rare precursor lymphoid neoplasm that generally presents with systemic disease. While CNS involvement is not uncommon, isolated involvement of this compartment without systemic disease is exceedingly rare.

Aim Lumbar puncture (LP) is a crucial investigation in the work up of children with suspected meningitis. LP is not always performed when indicated or in accordance with National Institute for Health and Care Excellence (NICE) guidelines. This survey aimed to assess awareness and knowledge of NICE guidelines surrounding the use of LP for suspected bacterial meningitis at a UK paediatric hospital. We aimed to: assess whether doctors would choose to perform an LP when indicated, recognise LP contraindications and make appropriate decisions about LPs in relation to computed tomography (CT) scans. Methods An online survey with four clinical scenarios was sent to clinicians. Clinician data including grade, speciality and training in performing LPs was collected. Results 142 clinicians that would potentially be managing children with meningitis were sent the survey: 66 responded (46%). When LP was indicated (with no contraindications), 60 (91%) respondents stated they would do an LP. Meningococcal shock was recognised by 51 (82%) respondents as a contraindication. In the scenario suggesting the potential presence of an infective space occupying lesion where LP is contraindicated, 49 (80%) correctly identified the need for CT scan before LP. In the final scenario, the child had two contraindications (fluctuating coma score and focal seizure). 33 (56%) of respondents stated they would undertake the LP if the scan was normal. A further 10 stated they would undertake the LP when the coma score improved leaving 16 (27%) who stated they would not do an LP in either of these situations. There was no significant association between grade, speciality, or LP teaching status and adherence to NICE guidelines. 15 respondents (23%) stated they had received LP training in the last 2 years. Conclusions Our survey of attitudes towards the use of LP in children with suspected bacterial meningitis at a paediatric hospital suggests that knowledge for the straight forward cases was good. However, in the more complex cases, there was a hesitancy to undertake an LP even with an improving patient condition and normal imaging. Specific LP training was limited: this could be an area to focus for improving patient management.

Introduction Small bowel imaging is an important part of the diagnostic work up in Paediatric IBD both for disease classification and identification of complications. Opinion varies as to the modality and timing of small bowel imaging and MRI enteroclysis has become widely available surpassing Barium studies. The utility of Ultrasound abdomen (USS) in small bowel disease has been poorly evaluated in early onset IBD. Aims and objectives We aimed to evaluate the adequacy of USS in detection of small bowel disease at the initial work up of early onset IBD according to the Porto Criteria. We also compared the findings on MRIE to recent small bowel USS, where available, and to historical findings on USS at presentation in a known cohort of patients with early onset Crohn’s disease. Materials and methods Data from patients with an established diagnosis of Crohn’s disease that had MRI small bowel as part of disease reassessment during a two year period (2013–2014) was collected. Findings on MRIE were compared with USS data done at the beginning of illness or concurrently for disease location, behaviour, and presence/absence of complications. Results 33 patients with MRI small bowel study were eligible. The median age at initial diagnosis was 11.2 years. All had USS small bowel at the time of diagnosis. The median time duration to MRIE (as part of disease reassessment) was 31 months. 14/33 patients had abnormalities on MRI small bowel that were previously found on the initial diagnostic ultrasound. 4/28 of patients who had normal initial ultrasound had MRI abnormalities either indicative of small bowel disease progression or the limitation of Ultrasound. Of the 33 patients who had MRI small bowel for disease re- evaluation, 9 patients had a preceding ultrasound within 3 months. The concurrent USS were abnormal in 6 patients and correlated with MRIE findings. Conclusion USS small bowel in the hands of a trained paediatric radiologist is useful in detecting small bowel disease and has high sensitivity as a diagnostic tool. However MRIE supersedes USS in accurate topographic mapping, definition of disease and complications. Despite the absence of small bowel disease at diagnosis, a low threshold is required for reassessing small bowel disease in early onset Crohn’s disease.

We present a case of a 24-year-old woman with previously undiagnosed familial haemophagocytic lymphohistiocytosis (HLH). The patient presented with fevers and cough and was found to have pancytopaenia. She underwent an extensive work up and initially met only 3 of 8 criteria for HLH. Owing to high clinical suspicion, soluble CD25 level was sent and HLH2004 protocol initiated. The soluble CD25 level returned elevated with other laboratory work and the patient met criteria for diagnosis of HLH. Genetic studies revealed a homozygous mutation in PRF1 with absent perforin in cytotoxic cells, consistent with familial HLH. The patient expired before intrathecal chemotherapy could be initiated. This case illustrates the potential for familial HLH to present at an older age, and highlights the importance of early recognition and initiation of treatment of HLH, as patients may not initially fulfil the diagnostic criteria for HLH, and mortality is high if left untreated.

Local and international guidelines recommend that anticoagulation should be initiated before diagnostic work up has been completed, in patients with high clinical probability of pulmonary embolism (PE). However, many patients receiving anticoagulants for suspected PE do not have this disease. We present three cases of life-threatening bleeding complications after treatment with low-molecular-weight heparins for suspected PE. A 35-year-old woman had acute chest pain and died of a ruptured thoracic aneurysm. A man with herpes encephalitis developed acute dyspnoea, and died of intracerebral haemorrhage. And a woman with mild chest trauma had a complicated recovery after life-threatening intrapleural haemorrhage. Neither of these patients had PE. These cases emphasise that delaying diagnostics may pose a risk in patients with acute chest symptoms. An early CT scan may avoid unnecessary anticoagulation in patients without PE, and may help to direct attention to the actual cause.

A 15-year-old boy with severe bilateral hip joint pain and restriction of mobility presented to the casualty ward. He had earlier been treated for tuberculosis of the hip, with no relief. Our work up revealed a case of severe juvenile-onset ankylosing spondylitis with predominant hip involvement and accompanying sacroiliitis.

Bilateral cases of branch retinal vein occlusions (BRVO) are infrequent and often related to systemic disease. A 72-year-old man with biochemical recurrence of prostate cancer was referred for decreased vision in his left eye. Fundus examination and fluorescein angiography disclosed bilateral BRVO with patches of peripheral non-perfusion and macular oedema in the left eye. A systemic work up revealed elevated fibrinogen and reduced free protein S antigen, consistent with an underlying hypercoagulable state. Cancer is a well-known cause of hypercoagulability. We report the first case of bilateral BRVO related to biochemical recurrence of prostate cancer and a proven coagulation derangement.

We report a case of a 52-year-old Caucasian man with invasive ductal carcinoma of the breast. One year after initial diagnosis, he developed a generalised epileptic seizure and neuroimaging showed multiple, calcified intracerebral lesions. Owing to these atypical cerebral imaging findings, comprehensive serological and cerebrospinal fluid analysis was conducted and a latent toxoplasmosis was suspected. In order to distinguish between metastases and an infectious disease, a cerebral biopsy was performed, which verified brain metastases. The patient received whole-brain radiotherapy. The last cerebral CT scan, 18 months later showed stable disease. Calcification of brain metastases in patients with breast cancer is very rare. Owing to their non-characteristic radiological appearance with a lack of contrast enhancement, diagnosis of metastases can be difficult. Infectious diseases should be considered within the diagnostic work up. Owing to possible pitfalls, we recommend a widespread differential diagnostic work up in similar cases, and even in cases with a confirmed primary tumour.

Olmesartan use has been associated with chronic diarrhoea and weight loss due to severe sprue-like enteropathy, yet this is still not well known among clinicians. We present the unique case of an 84-year-old Filipino woman diagnosed with olmesartan-induced sprue-like enteropathy after an extensive work up for chronic diarrhoea, and without improvement despite multiple empiric treatments for nearly 15 months. Withdrawal of olmesartan resulted in clinical and histological improvement. This case provides further evidence for olmesartan-induced sprue-like enteropathy, and emphasises the importance of its awareness and recognition among gastroenterologists and primary care physicians alike.

People who inject drugs are vulnerable to several infections. To the best of our knowledge, this is the first case report of a simultaneous diagnosis of leptospirosis and acute infection or recurrence of occult hepatitis C in an HIV-infected drug user. We report a case of a 47-year-old Caucasian man with HIV infection, on antiretroviral therapy, and with a history of hepatitis C (positive anti-hepatitis C virus (HCV) and HCV RNA persistently negative) who was admitted with febrile acute hepatitis. He was a former injecting drug user, on opioid substitution therapy, who relapsed to injection drug use 3 weeks prior to admission. Work up revealed positive HCV RNA and Leptospira DNA in his urine. Four weeks later he had an undetectable HCV load, and also at 6 months of follow-up. This case highlights the presence of two concomitant infectious aetiologies of acute hepatitis in an HIV-infected drug user.

Background There is a delay between the onset of the first back pain symptoms and the final diagnosis of axial spondyloarthritis (axSpA). This delay can be explained by difficulties for primary care physicians to recognize and subsequently refer potential axSpA patients in the huge number of chronic low back pain (CLBP) patients seen in primary care. At this moment there is no widely accepted referral strategy. Recently the ASAS workgroup proposed recommendations for early referral although these were not yet validated in a primary care setting. Objectives To test the ASAS proposed recommendations for early referral in a primary care setting. Methods Our study population included primary care patients (18-45 years) with CLBP (≥3 months, age at back pain onset Results In total 941 primary care CLBP patients participated (58% female, mean age 36.0 years), of those were 181 (19%) identified as axSpA, 54 of the 181 (30%) were newly diagnosed with ankylosing spondylitis. 773 (82%) patients had at least one parameter present and thus according to the recommendations should be referred to the rheumatologists. The sensitivity of the ASAS recommendation is 100% (181/181), the specificity 22% (168/760) and the positive predictive value 23% (181/773) (Table 1). Conclusions The ASAS recommendation for early referral has a perfect sensitivity in primary care CLBP population. However this comes at the cost of a low specificity, meaning that almost 80% of the referred patients will undergo unnecessary diagnostic work up. A more specific referral strategy will be needed in daily primary care. Acknowledgements An unrestricted research grant was provided by AbbVie. Disclosure of Interest None declared

A 5-year-old boy was admitted with stridor, which was initially interpreted as subglottic laryngitis. He had a history of prolonged hoarseness and his voice was deep for his age. The stridor persisted despite treatment with epinephrine inhalations and intravenous glucocorticoids. A direct laryngoscopy and blood work up did not support the suspected diagnosis. A MRI was then carried out, followed by angiography. The latter revealed an arteriovenous malformation (AVM) involving the lingual and superior thyroid arteries bilaterally. Owing to the rareness and extent of such an AVM, the patient was referred to Paris for further treatment. This case presents the difficulties in diagnostics and emphasises the importance of diagnostics and multidisciplinary approaches with regard to treatment of AVMs.

Pancreaticopleural fistula is an uncommon complication of pancreatitis. The authors describe a case of a man in his mid-40s with a history of alcohol abuse, who presented with dyspnoea and whose chest X-ray revealed a massive left pleural effusion. Further diagnostic work up revealed a pancreaticopleural fistula. There was no improvement with a conservative approach and endoscopic treatment was not feasible, leading to the need for a surgical intervention.

Rarely in modern medicine are we able to observe the natural history of a patient with a sarcoma. This unusual case provides that opportunity. A CT scan was performed on the leg of a 15-year-old boy with a tender soft tissue mass on the lateral aspect of his left calf. Despite showing a lesion consistent with a sarcoma, neither the patient nor his family was informed. Almost a year and a half later, the patient returned and was diagnosed with Ewing's sarcoma. A staging work up showed no metastatic disease. After undergoing chemotherapy and a complete surgical resection of the tumour, the patient remains disease-free 10 years later, indicating that the biology of Ewing's sarcoma may be more important than time to diagnosis in determining outcome.

A 57-year-old Asian woman with type 2 diabetes mellitus, hypertension, obesity, dyslipidaemia and history of breast cancer, was referred to the cardiovascular health and lipid centre for evaluation and management of dyslipidaemia and NASH (Non-alcoholic steatohepatitis) in 2010. She originally had a detailed work up at the liver clinic for elevated liver enzymes, with no associated symptoms. Initial hepatic MRI on 22 January 2007 showed diffuse fatty infiltration quantitated at 15%. We counselled her on lifestyle modifications, including dietary measures and exercise, geared toward weight loss. Over the next 2 years, she lost 24.5 lbs; repeat hepatic MRI on 22 December 2011 showed 6% hepatic fat, which is within the normal range. This case demonstrates the efficacy of significant weight loss in the improvement and resolution of NASH. We believe that this is the first case report documenting this through liver MRI.

Objective To study the role of Interferon gamma release assay (IGRA) (QuantiFERON–TB Gold In Tube) in blood in the diagnostic work up of active tuberculosis (TB) in a high TB prevalence region. Design Prospective, comparative group study. Setting Subjects presenting to the services of the Pulmonary Medicine Department of a large tertiary care teaching hospital in northern India. Methods We prospectively enrolled, 30 cases of smear or histopathology proven newly diagnosed tuberculosis (18 pulmonary (PTB) and 12 extra-pulmonary (EPTB)) patients controls along with 30 healthy controls. All cases and controls underwent Tubercular Skin Test (TST) using 0.1 mL (1 tuberculin units) of purified protein derivative RT23 and IGRA using QuantiFERON-TB-Gold In Tube assay (QFT) in blood. For TST an induration ≥10 mm was taken as positive. QFT testing was performed and interpreted as per manufacturer9s (Cellestis) instructions. Results We studied 30 patients of active tuberculosis (18 PTB and 12 EPTB) and 30 healthy controls (14 men and 13 women, mean age 35.03±13.23 years). TST positivity had a sensitivity of 83.33% and 66.67% and specificity of 60% for both categories for the diagnosis of active PTB and EPTB respectively. In contrast QFT positivity had a sensitivity of 61.11% and 58.33% and specificity of 50% for the diagnosis of active PTB and EPTB respectively. Conclusions In this study the QFT-IGRA had a limited overall usefulness in the diagnosis of active pulmonary and extrapulmonary TB. QFT, thus can neither be taken as rule in nor rule out test in a high TB prevalence region like India. TST with all its limitation probably will continue to serve a useful purpose. Larger prospective studies are needed in high incidence countries to determine the sensitivity and specificity of IGRAs, their ability to serve as useful rule-out test for active TB.

We report the case of an adolescent girl who was 14 years old at initial presentation. A shy, immature and timid individual, she began to have recurring, progressive episodes characterised by insomnia, paranoia, distorted thinking and mood instability with a mix of depressive and manic-like symptoms. An extensive medical work up was unrevealing. Her family noted a pattern that coincided with her menstrual cycle. An endocrine consult was obtained, and the diagnosis of catamenial psychosis was performed. After treatment with leuprolide, resulting in a shutdown of the hypothalamic-pituitary-ovarian axis, the patient’s symptoms were resolved completely.

Background As in other autoimmune diseases, even in systemic sclerosis (SSc) the assessment of disease activity (DA) is essential to detect the window of opportunity for a successful treatment. The so far proposed composite indexes for DA assessment imply a long and expensive patient9s work up. Nailfold videocapillaroscopy (NVC) is commonly regarded as an instrument useful for SSc diagnosis and subsetting, and the presence of megacapillaries is considered the hallmark of an active disease. Objectives Since microvascular endothelial activation represents the key mechanism of the disease progression, the present study was specifically designed to evaluate whether the presence and number of micro-hemorrhages (MH) and micro-thrombosis (MT) in NVC could be considered potential predictors of DA in SSc. Methods The study population was constituted by 107 patients with SSc, 50 with the diffuse cutaneous (dc) and 57 with the limited cutaneous (lc) variants of the disease. European Scleroderma Study Group (ESSG) index (Valentini G, et al. Ann Rheum Dis 2001; 60:592-8)) was assumed as the gold standard for DA assessment, and patients having a score ≥3.5 classified as active. NVC was performed at the same time of DA evaluation. The sum of MH and MT detected by NVC examination in 2° to 5° fingers of both hands (named as NEMO score) was then obtained. Results The enrolled patients were predominantly females (97/107), had a mean age of 55.8 yrs. (range 18-84 yrs.) and mean disease duration of 6.1 yrs. (range 0-30 yrs.). According with the defined cut-off value of ESSG index, 32/107 patients were active (14 with dcSSc and 18 with lcSSc). NEMO values were significantly correlated with ESSG index scores (r=0.56, p 0.001), but not with patients9 age and disease duration. Considering the other components of ESSG index, NEMO score was significantly higher in patients having scleredema (p Conclusions The presence of MH and MT appears to be a good predictor for DA in patients with SSc, and enhances the role of NVC as a quick and easy technique to select the patients potentially candidate to be more aggressively treated. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3167

Introduction Secretin enhanced magnetic resonance cholangio-pancreatography (S-MRCP) has been used as part of the diagnostic algorithm for the diagnosis of patients presenting with acalculous biliary type abdominal pain (ABAP); the exact role of this diagnostic modality is unclear. The aim of this study was to assess the diagnostic yield of S-MRCP in a large HPB tertiary referral centre in the investigation of patients with ABAP. Methods Retrospective analysis of a prospectively maintained database of all patients presenting with ABAP in whom a S-MRCP was requested from June 2008 to May 2013. The findings of S-MRCP were compared with those of MRCP and EUS (performed prior to S MRCP) and the diagnostic yield of S-MRCP in the work up of a patient presenting with ABAP was estimated. Results Of the 117 patients with ABAP [28 males and 89 female; mean age 48 yrs] were referred for S-MRCP, 114 (97.4%) patients successfully completed the scan. Of these 37 patients who had a normal MRCP, S-MRCP identified significant findings in 8 (22%) patients (Table 1). In the present study 78 (67%) patients had EUS. Out of the 41 patients who had a normal EUS, S-MRCP was able to identify significant pathology in 21 (54%) patients (Table 1). Conclusion This study suggests that S-MRCP has a 22 and 54% additional diagnostic yield in ABAP patients who have a normal MRCP and a normal EUS respectively. The commonest abnormality identified in these patients on S-MRCP was obstruction at ampulla or proximal PD. S-MRCP should be considered in the diagnostic algorithm of patients with ABAP. References 1 Mariani A, Arcidiacono PG, Curioni S, et al . Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology. Dig Liver Dis 2009 Oct;41(10):753-8 2 Matos C, Metens T, Deviere J, et al . Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography. Gastrointest Endosc 2001 Jun;53(7):728-33 Disclosure of Interest None Declared.

Scleritis and uveitis are ocular inflammatory diseases often presumed to be autoimmune and associated with underlying systemic disease.1 Other autoimmune diseases have been shown to confer increased risk for malignancy, including lymphoma.2–4 We present two patients diagnosed with scleritis and lymphoma and examine whether there is an association between ocular inflammatory disease and malignancy. We reviewed the records of 133 scleritis patients presenting to our ocular inflammatory diseases clinic at Oregon Health & Science University (OHSU) between 1993 and 2006. Access to this database was reviewed and approved by the OHSU institutional review board. Two patients with a diagnosis of lymphoma were identified. Patient A developed scleritis 13 years before being diagnosed with lymphoma at the age of 48. Hodgkin’s lymphoma was found incidentally on a chest x ray during repeated work up for ocular disease. Patient B was diagnosed and treated for Hodgkin’s lymphoma at the age of 24 without recurrence. She developed …

Introduction Significant cardiac disease may exclude patients from orthotopic liver transplantation (OLT) or may require intervention to make OLT feasible. Non-invasive methods of cardiac assessment (ECHO and cardiopulmonary exercise stress test (CPEX)) are used to help minimise the need for cardiac catheterisation (CC). Aims/Background To audit the use of CC in OLT assessments at a regional liver unit in Northern Ireland. Method All patients who underwent formal OLT assessment in RVH from January 2008 to June 2012 were included. Information was obtained from the RVH Liver Unit database and cross referenced with radiology and patient centre records. Patient records for all those who had CC were reviewed to determine outcomes. Results 188 patients underwent full OLT assessment, of whom 43 (23%) required CC. The indications for CC were: 22 had multiple CVS risk factors, 11 had abnormal ECHO, 3 abnormal MPI, 1 abnormal CPEX and 6 other. Overall, 31 (72%) of 43 CC patients had no significant cardiac disease detected. 12 (28%) patients had significant cardiac disease, of whom, 7 were not listed and 5 had intervention (3 PCI with stenting, 2 PFO closures (1 not listed)). 27 (62.8%) patients who underwent CC were listed for OLT. One patient suffered a fatal variceal haemorrhage immediately post CC (without PCI). Conclusion The most common reasons for requiring CC during OLT workup were multiple CVS risk factors and abnormal ECHO. CPEX rarely detected significant disease. Mortality post CC was 2%, however, interpretation of this result is limited by the small sample size.

Introduction In 2008 BSPGHAN guidelines for Inflammatory Bowel Disease (IBD) were published. The South-West of England paediatricians have developed a regional clinical network whereby children, suspected of having IBD travel to Bristol for full diagnostic work-up. Post diagnosis care is provided by paediatricians at the local hospital with advice from Bristol and a joint three monthly out-patient clinic in Swindon. Children with very severe disease or needing surgery are dealt with by Bristol team. Effectiveness of this model was audited and found to be improved after the introduction of BSPGHAN guidelines Aim This pilot study aimed to assess parent and patient views regarding quality of service provided within Swindon/Bristol regional network. Subjects and methods Thirteen children aged Results 9/13(69%) responded to telephone survey, 3/13(23%) had moved out of area and 1/13(8%) could not be contacted by telephone. Of 9 patients, 4 had Crohn’s disease, 3 Ulcerative colitis and 2 Indeterminate colitis. 4/9(45%) parents felt their concerns were adequately addressed initially at Swindon whereas all parents were satisfied with services provided at Bristol for diagnostic work up. 6/9(67%) parents felt they were satisfied with the expertise available locally for post-diagnosis management. However 8/9(89%) parents were happy with follow-up care by the joint care services at Swindon. Conclusion This single centre pilot demonstrated that joint care provided by this model not only leads to care more concordant with BSPGHAN guidelines but is appreciated and valued by parents. There is scope for further improvements. This pilot study provides a template for ensuring and improving parent/patient involvement and stisfaction; there are plans to modify the questionnaire taking into account any suggestions for improvements and roll it out over the whole SW shared care IBD network soon.

Background In daily practice, the diagnostic work-up of patients with possible axial spondyloarthritis (SpA) starts with clinical and laboratory data. In many patients MRI and/or X-rays of the SI-joints (MRI-SIJ and X-SIJ) are performed to be able to diagnose patients with confidence. Objectives To investigate what the contribution is of imaging (MRI-SIJ and X-SIJ) in making a final diagnosis with confidence. Methods All patients with chronic back pain (≥3 months, ≤2 years, onset Results In 52/157 of the patients (33.1%), the rheumatologist was confident about the diagnosis, either SpA (n=31) or no-SpA (n=21), based on clinical and laboratory data only. Imaging was positive in 32/157 patients (20.4%). In 3/52 patients (5.7%) the rheumatologist was confident about the diagnosis no-SpA, but revised the diagnosis into confident SpA after imaging. In 9/52 patients (17.3%), the rheumatologist was confident about the diagnosis based on clinical data only, but was not confident anymore after receiving negative imaging. In 105/157 of the patients (66.9%), the rheumatologist was not confident about the diagnosis. After performing imaging, the rheumatologist was confident about the diagnosis in 73/105 patients: SpA in 21 (20.0%) patients and no-SpA in 52 (49.5%) patients. In the remaining 32 (30.5%) patients imaging did not change confidence, nor diagnosis (table). Conclusions Imaging (MRI-SIJ and/or X-SIJ) is useful for the rheumatologist in the large majority of patients with possible axial SpA, except for the patients in which the rheumatologist is confident about the diagnosis of SpA before imaging. Disclosure of Interest None Declared

Background and Aims Encephalitis is a relatively rare but potentially devastating condition 1 . Our study investigated the presentation and management of children with encephalitis presenting to a tertiary UK hospital. Methods Cases of encephalitis presenting during 2001 – 2009 were identified using clinical coding records and a clinical database maintained by the paediatric infectious diseases team. Inclusion criteria were children between the ages of 3 months to 16 years who presented with an acute encephalopathy. A retrospective case notes review was performed and management compared to local infectious disease guidelines for children with an unexplained acute encephalopathy. Results 71 cases were identified and notes were found in 58 cases. 29 cases met the study criteria. The commonest presenting features were confusion (86%), fever (69%), seizures (62%) and headache (60% in those aged over 5 years). Microbiological and metabolic workup was inconsistent in relation to the local hospital guidelines. In particular exclusion of metabolic causes of acute encephalopathy was fully undertaken in only 28% of children. Confirmed or probable infectious aetiologies were identified in 21 cases (72%) with HSV (17%), VZV (10%) and EBV (7%) being the most commonly identified pathogens. Other final diagnoses included Acute Disseminated Encephalomyelitis (14%). With regards to treatment, 97% of children were started empirically on aciclovir although 43% were prescribed half or less of the recommended dose for encephalitis. Anti-microbial use was also inconsistent between cases: ceftriaxone was started in 76%, azithromycin in 34% and amoxicillin in 12%. Conclusion The initial investigation and management of children with an acute encephalopathy who are subsequently diagnosed with encephalitis did not fully follow the guideline in 76% of cases. The most important finding was the high incidence of inadequate aciclovir dosing in the empirical treatment of children with suspected encephalitis. Recently published guidance highlights the importance of a full clinical, microbiological and metabolic work up and emphasises the correct aciclovir dose 1 . Although encephalitis is an uncommon condition, awareness of its management is vital to prevent the high morbidity associated with the disease. Reference Thompson C, Kneen R, Riordan A, Kelly D, Pollard AJ. Encephalitis in children. Arch Dis Child. 2012 Feb; 97(2):150–61.

Introduction Dyspepsia is a common symptom, thought to affect up to 46% of the population 1 . In order to streamline investigation and management in primary care, guidelines have been formulated by both the BSG and NICE. These advocate that prior to endoscopy patients are reviewed with respect to precipitating medications, helicobacter pylori (HP) status and are trialled on a proton pump inhibitor (PPI) 1, 2 . Methods Using our computer based endoscopy database we retrospectively reviewed the direct access GP referrals for the endoscopic investigation of dyspepsia and reflux. We examined 260 cases referred to the North and East Hertfordshire NHS trust between January and December 2012 looking for adherence to guidelines. Results In our cohort 56% were female, with the average age of patients being 55.8 years old. 10% were considered to be urgent referrals, whilst 16.5% were referred via the two week wait. Only 30% patients were tested for HP status prior to investigation, with 10 patients having had serology and 80 tested using stool antigen testing. Just 15 patients (6%) in the cohort tested positive for HP by either serology, stool antigen, CLO or gastric biopsy. A greater proportion received a trial of a PPI, 53.8% receiving a full course, whilst 36.5% had used a PPI inconsistently and 9.6% had never tried a PPI. Only 45 patients (17%) had both HP testing and a trial of a PPI. An alternate cause of pathology was considered in 12 patients with investigation with an abdominal ultrasound, in 3 cases this was as a consequence of the endoscopist’s suggestion. The most common findings on endoscopy were oesophagitis, gastritis and duodenitis, 21% of examinations were entirely normal. Four cancers were identified within the 46 two week wait referrals. Conclusion Our data has confirmed that the patients in this cohort received inadequate work up in primary care, leading to unnecessary endoscopic investigation. The average age of the patients in this group indicates that many were at an age where pathology such as malignancy would be highly unlikely. Lack of adherence to guidelines is likely to be the reason for the low diagnostic yield of significant pathology, although our endoscopic findings are consistent with those of previous studies1. The low prevalence of helicobacter may represent a reduction in its prevalence, although it is difficult to know whether this is a consequence of inappropriate testing whilst on PPI therapy, the socioeconomics of our cohort or due to HP patient positive patients treated in primary care rather than referred for endoscopy. Improved use of guidelines and dialogue between primary and secondary care should improve patient selection for the endoscopic investigation of dyspepsia. Disclosure of Interest None Declared. References Dyspepsia: management of dyspepsia in adults in primary care, 2004 BSG: Dyspepsia management guidelines, 2002

Background In the diagnostic work-up of spondyloarthritis (SpA), imaging of the SI-joints by MRI (MRI-SIJ) is an important step. One study showed that in HLA-B27+ patients and male patients it might be useful to repeat an MRI after one or two years 1 . It is not known if repeating an MRI after a shorter period than 1 year is useful. Objectives To investigate whether it is useful to repeat an MRI after 3 months in the diagnostic process for SpA. Methods Patients with chronic back pain (n=157) (≥3 months, ≤2 years, onset 2 , blinded for the time-sequence. If 2/3 reads were positive, the MRI-SIJ was marked as positive. Univariate and multivariate regression analyses were performed to investigate which variables (IBP, elevated CRP, MRI-status at baseline, gender, HLA-B27-status and age at onset) could predict a positive MRI-SIJ at 3 months. Results Only patients with complete MRI data are included in this analysis (n=90). In the univariate analysis, a positive MRI-SIJ at baseline was the strongest predictor of a positive MRI-SIJ over time (OR 49.5, 95% CI 11.9-206.7, p Conclusions We confirmed that a positive MRI-SIJ at baseline is a very strong predictor for a positive MRI-SIJ after 3 months. In patients with a negative MRI-SIJ at baseline, male gender and HLA-B27 are predictive of a later positive MRI-SIJ. In this group of patients with short symptom duration, variation in MRI-SIJ positivity occurred in 10% of the patients over a very short period of only 3 months. A positive change of MRI-SIJ has led to a different classification in 2.2% (n=2) of the patients. More data are needed to decide if it is necessary to repeat MRI, and if so, with what time interval. References Van Onna M. ARD 2011;70:1981-5. Rudwaleit M. ARD 2009;68:1520-7 Disclosure of Interest None Declared

Intramural gas in stomach is a rare finding, but differential diagnosis of this condition into gastric emphysema and emphysematous gastritis is clinically important because of vastly different aetiologies and prognosis. Emphysematous gastritis is caused by gas producing micro-organisms inside the stomach wall and is a potentially fatal condition, while, on the other hand, gas enters stomach wall through mucosal breach in the case of gastric emphysema and prognosis is usually good with complete resolution. To date, no case has been reported in the literature showing gas in the stomach wall in a patient with acute calculus cholecystitis. We present a case of a young man with upper abdominal pain, and who, upon diagnostic work up was diagnosed with acute calculus cholecystitis with associated intramural gas in the stomach with no known aetiological factors to be positive. Conservative management with close observation resulted in complete symptomatic resolution.

Background WHO defined cerebral malaria (CM) in 1990 as a clinical syndrome of Plasmodium falciparum infection with unrousable coma not attributable to another cause. This has been broaden by adding altered consciousness, severe anemia, and respiratory distress without laboratory confirmation in order to curtail mrtality in children. This has resulted in overdiagnosis and overlooking other serious alternatives plus overburdening the scarce resources. Aims To analyze the situation in Sudan by studying children admitted with clinical CM and do all the possible diagnostic work up in order to reach definitive diagnosis. Patients and methods Patients belonged t the main hospitals in the capital Khartoum admitting to well organized emergency departments. Clinical and laboratory data were collected from children over 1 month of age admitted with clinical CM between April and November 2011. Patients were investigated for CM, acute bacterial meningitis (ABM) and Herpes encephalitis (HE). Results One hundred and four children fulfilled the study criteria. CM was clinically diagnosed in 38 patients but only 5 were pure CM. Sixty three were suspected for ABM but 15 were confirmed cases. HE was defenitively diagnosed in only one case. There were 5 cases of mixed infection and the rest were unknown and presumed encephalitis due to viruses other than Herpes simplex. Conclusion CM was clinically over-diagnosed in our study. It is advisable to do all the necessary investigations, particularly a thoruogh blood film examinatiom, beforediagnosing CM. It is recommended to study cases that resemble CM for more detailed viruses disease.

Background “Gluten intolerance” is commonly diagnosed and often confused in the public mind with coeliac disease. Authors in Western Australia recently demonstrated an approximately 5% rate of coexistence of eosinophilic oesophagitis (EO) with villous atrophy. We asked whether our population was similar. Methods We performed a retrospective chart review of all those with gastroscopy and small-bowel biopsy and a subsequent diagnosis of CD in children less than 16 years of age between 1 April 2003 and the 31st of June 2011. Main results 239 gastroduodenoscopies were reviewed. Biopsy of both the oesophagus and duodenum was available in 231 patients. There were 124 patients positive for coeliac disease, 105 negative, and 10 indeterminate. 14 of 231 were positive for EO, and 4 of the 126 CD patients were also positive for EO. Two of the four CD + EO patients were rescoped during the time interval, and both were in remission for changes of CD, although both still had changes of EO evident. There were 7 CD patients reported with other forms of oesophageal inflammation. Histologically of our four patients with EO and villous atrophy, at least three have potentially allergic changes instead of full-blown CD. Conclusion There have been recent suggestions that serological and other tests may render the small bowel biopsy unnecessary in the management of CD. We note that EO is associated with villous atrophy in 3 to 4% cases. Serology and symptomatology presenting as coeliac disease continues to warrant detailed investigation, including endoscopic work up.

Background Early diagnosis and management of intestinal malrotation can potentially prevent the devastating complications associated with midgut volvulus. Atypical presentation of intestinal malrotation in older children frequently leads to a significant delay in diagnosis. Methods A 6-year-old boy presented with a five year history of hiccups, then vomiting after laughing. Sadly, he had resorted to avoiding laughter. Barium studies demonstrated intestinal malrotation, therefore a Ladd’s procedure was performed and he made a good recovery. The case prompted a literature search for aetiology, diagnosis and management of malrotation in children outside of the neonatal period. Results We present a review of this literature, including findings that diagnosis of intestinal malrotation in the older child is frequently delayed. One study demonstrated a mean delay to diagnosis of 1.7 years. Vague abdominal symptoms including chronic abdominal pain, intermittent non-bilious vomiting, diarrhoea and failure to thrive have been associated with malrotation, but hiccups and laughter have not previously been described. Recent review of diagnostic imaging recommended ultrasound as the investigation of choice, and may advocate its use in the work up of children presenting with non-specific abdominal symptoms. Although debated in the literature, a Ladd’s procedure is recommended for all children, even if asymptomatic. Conclusion Children with intestinal malrotation present us with a diagnostic challenge, but a low threshold of suspicion in patients presenting with vague abdominal symptoms, including intractable hiccups or vomiting, may ensure these children receive the timely surgical intervention.

Aim To prospectively assess staff prediction of culture positivity, clinical signs noted and suggested duration of antibiotic therapy required at the time of septic screen in premature infants suspected of having late onset sepsis. Methods This was a prospective study involving anonymous staff questionnaires filled out by both nursing and medical staff at the time of septic screens performed for suspected late onset sepsis in the neonatal intensive care unit (NICU) of Rotunda Maternity Hospital, Dublin from October 2009 to 2010. Eligibility criteria was defined as premature infants ( 5 days old undergoing septic work up for suspicion of infection. Prospective review of all blood, urine and CSF cultures obtained from the neonates. Staff opinion on the likelihood of positive BC was correlated with laboratory results and treatment course. Results Total of 60 surveys collected in the twelve month period. Information is available from 56 septic work ups carried out on 37 infants during twelve month period on infants who fulfilled the criteria. Doctors correctly guessed if the infant was septic or not at the time of work up 58.3% compared to 56.3 % of nursing staff. There was no stasticial significance between C-reactive protein, white cell or neutrophils counts between positive and negative cultures. Conclusion Experienced doctors and nurses were unable to accurately predict which neonate would have a positive culture. This highlights the difficulty in the NICU setting of judging correctly who is septic in very low birth weight infants.

Introduction PET CT is a non-invasive imaging modality that is widely used in the imaging work up of malignant disease. It has been postulated that due to 18 FDG accumulation in adenomatous polyps, PET CT using 18 FDG may detect early premalignant colonic lesions. The aim of our study was to assess the performance of 18 FDG PET CT in the detection of significant colonic lesions namely adenomas or villous adenomas >1 cm in size and to assess whether endoscopy in all patients with focal FDG colonic uptake on PET CT is justified by the detection rate. Methods A retrospective review of patients who had 18 FDG PET CT at the Pennine Acute Hospitals NHS Trust, Manchester as part of their staging for various cancers between February 2007 and October 2011 was conducted by a review of the reports of the examinations. Results 1553 patients between the ages of 17 and 93 years (median age 55 years) had 18 FDG PET CT performed during this period. Increased focal FDG uptake in the colon was detected in 179 of 1553 patients studied (11.5%). Endoscopic evaluation was performed in 71 (39.7%) of these patients, flexible sigmoidoscopy in 25 (35.2%) and colonoscopy in 46 (64.8%). Non-malignant pathology was found in 45 of 179 patients (25.1%); 17 (9.5%) were tubulovillous adenomas; 6 (3.4%) had villous adenomas; 9 (5.0%) were tubular adenomas; 4 (2.2%) hyperplastic polyps; 11 (6.1%) were normal colonic tissue and 1 (0.6%) was active inflammatory bowel disease. From the patients with increased 18 FDG uptake in the colon, 19 (10.6%) were subsequently found to have adenocarcinoma on histology. This represents 26.8% of the 71 patients who received endoscopic evaluation. Conclusion The presence of focal colonic 18 FDG uptake on PET CT scan justifies endoscopic evaluation in all patients where treatment would be clinically appropriate. Competing interests None declared.

Introduction EUS-FNA allows access to the posterior mediastinum and tissue acquisition under real-time ultrasound guidance through the oesophageal wall. There is ample evidence for effectiveness of EUS-FNA in staging lung cancer but data on its utility in the diagnostic work up of sarcoidosis is limited. The aim of this study was to report our experience of mediastinal EUS-FNA as a whole and its diagnostic yield in sarcoidosis in particular. Methods The study included all patients who underwent mediastinal EUS-FNA in our institution from January 2008 to December 2011. Data on patient demographics, mediastinal lesion characteristics and EUS-FNA details were collected from endoscopy reports. Cytology reports and microbiology culture results were analysed. Final clinical diagnoses made during the follow-up were obtained from medical records. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of mediastinal EUS-FNA for individual diagnoses. Results 195 patients (n=195, males 65%, mean age 58.6) underwent mediastinal EUS-FNA during the study period. Mean size of the lesions was 15.82 mm (range 3.9–43) in short axis and 28.23 mm (range 8–60) in long axis. Sub-carinal lymph nodes (LN) were the commonest (145/195, 70.3%) target lesions. Mean number of needle pass was 3.18 (range 1–6) and 22G (53.5%) was the commonest needle used. There were no procedure related complications or deaths. Of the 195 patients, FNAs were positive for malignancy in 61 (61/195, 31.2%), sarcoidosis in 40 (20.5%) and tuberculosis (TB) in 15 (7.6%) patients. Of the 64 (31.7%) cases where FNA was reported normal, 42 (65.6%) were accurate and 22 (34.3%) were inaccurate (final diagnosis: 8 cancer, 9 sarcoidosis and 5 TB). In 4 (2%) patients, FNA showed other diagnoses (3 anthracotic LNs, 1 sinus histiocytosis). Abstract PWE-221 table 1 Overall and condition specific results of mediastinal EUS-FNA. Conclusion Our large series on mediastinal EUS-FNA shows that it is an important and useful tool for the assessment of mediastinal lymphadenopathy of unknown aetiology and has overall high sensitivity (≈80%) and high specificity (≈94%). For sarcoidosis in particular, sensitivity (≈83%) and specificity (≈99%) of EUS-FNA is comparable to those for cancer. Competing interests None declared.