The European Alliance of Associations for Rheumatology recently defined difficult to treat (D2T) rheumatoid arthritis (RA) and provided points to consider in its management. This review summarises the key concepts of D2T-RA that underpinned this recent guidance. D2T-RA is primarily characterised by failure of at least two different mechanism of action biologic/targeted synthetic disease-modifying antirheumatic drug (DMARDs) with evidence of active/progressive disease. The basis for progressive disease, however, is not limited to clear inflammatory joint pathology, capturing wider contributors to treatment cycling such as comorbidity, obesity and fibromyalgia. This means D2T-RA comprises a heterogeneous population, with a proportion within this exhibiting bona fide treatment-refractory disease. The management points to consider, however, emphasise the importance of checking for the presence of inflammatory pathology before further treatment change. This review suggests additional considerations in the definition of D2T-RA, the potential value in identifying D2T traits and intervening before the development of D2T-RA state and the need for real world evidence of targeted synthetic DMARD in this population to compare to recent trial data. Finally, the review asks whether the presence of D2T-RA implies a failure to treat effectively from the outset, and the need for pharmacological and non-pharmacological management approaches to address the wider D2T-RA population effectively.

Insect damage to, and sub-optimal harvesting practices of the Papaver somniferum poppy are associated with contamination of its seeds with opium alkaloids. Consumption of poppy seeds has been linked to opium-like overdose symptoms, such as reduced consciousness and respiratory depression. However, acute cardiotoxicity secondary to ingestion of contaminated poppy seeds has not been reported previously. We report a case of a 21-year-old man who presented with severe biventricular dysfunction and cardiogenic shock following consumption of homemade poppy seed tea. We highlight the importance of prompt recognition of the myocardial effects of opiates along with the more common respiratory and neurological effects. In this case, the acute cardiotoxicity was fully reversed with high-dose naloxone, milrinone and noradrenaline. In addition, we recommend offering high-level care due to the possibility that specialist cardiac services may be required. Ergo, early transfer to an appropriate centre is recommended.

Background/Aims Limited therapeutic efficacy and ‘difficult to treat’ (D2T) characteristics mean some rheumatoid arthritis (RA) patients cycle through multiple therapies to achieve their treatment targets. The aim of this study was to evaluate for subgroups of refractory RA (RefRA) in a real-world population and describe D2T characteristics. Methods Patients on their third or more targeted therapy were identified from the electronic health record (EHR) at Manchester Royal Infirmary. Demographic and clinic information were obtained. Raised disease activity was identified as DAS28ESR>3.2. Findings of power Doppler joint synovitis on ultrasound (PDUS) if undertaken within a month of clinical assessment. These data were used to categorise patients as raised disease activity and PD positive (persistent inflammatory RefRA, PIRRA) or raised disease activity in the absence of PD (non-inflammatory RefRA, NIRRA). Descriptive analyses were used to describe the characteristics in the two groups. Missing data were counted as negative observations. Results 82 patients who were on a third advanced therapy or higher were identified. 41/82 (50%) had raised disease activity and 32/41 (78%) had MSUS performed. 18/32 (56%) of these were PIRRA and 14/32 (44%) were NIRRA. Table 1 details demographic and clinical characteristics in the two groups as well as the controlled RefRA population. The PIRRA group had more erosive disease [13/18 (72%) PIRRA vs 8/14 (57%) NIRRA] and smoking history [9/18 (50%) of PIRRA vs 5/14 (35%) of NIRRA]. The PIRRA group also had greater levels of co-morbidity but previous bDMARD toxicity was comparable between the two groups. Whilst the DAS28ESR was higher in the PIRRA group, there were only marginal differences in the tender and swollen joint counts and CRP compared to NIRRA. The controlled RefRA population as expected showed notably lower DAS28-ESR and individual components although more similar to the PIRRA group with regards to comorbidity. Conclusion Just over half of the ref-RA cohort with raised disease activity had MSUS-detected synovitis and may be regarded as PIRRA. The PIRRA group had higher disease activity although joint counts and even acute phase were comparable. Higher smoking history and comorbidity appear to distinguish PIRRA and NIRRA in this cohort. Disclosure G. Rogers: None. Y. Tan: None. R. Shukla: None. R. Gorodkin: None. B. Parker: None. I. Bruce: None. J. Humphreys: None. A. Barton: None. K. Hyrich: None. E. Bruce: None. P. Ho: None. M.H. Buch: None.

Background/Aims The COVID-19 pandemic has disrupted healthcare delivery and provision of medical education and training worldwide. We assessed the impact of the COVID-19 pandemic on rheumatology training experience in the Northwest and Merseyside deaneries of England. Methods Rheumatology trainees from the Northwest and Merseyside deaneries were issued links to an anonymous web-based survey on their training experience between August 2020 to April 2021, during the 2nd wave of the Covid-19 pandemic. Results 34 of 42 trainees completed the survey. 31 were in clinical training: 13 (42%) in a pure rheumatology post and 18 (58%) in a dual post with general medicine. Most trainees attended 3-4 clinics per week (58%), with 23% attending ≤2 clinics and 19% attending 5 clinics. The proportion of face-to-face clinics ranged from 20% to 100% (median 60%). The reduced face-to-face clinical experience was not due to trainees’ needs to shield. The range of proportion of phone consultations was 0% to 80% (median 40%). Remote consultations were conducted by telephone only for 26 (84%) trainees and by video or phone for 3 (10%). The durations for both face-to-face and virtual consultations were ranged similarly at 15 to 45 minutes (median 30minutes) for new cases and 15 to 30 minutes (median 20 minutes) for follow-ups. Only 5 (16%) trainees felt confident with assessing new patients by remote consultation. 8 (26%) trainees had some form of formal training in a virtual consultation. However, only 4 (13%) reported being “aware” of how to guide a patient through self-examination of the joints, 17 (55%) trainees were “somewhat aware”, and 10 (32%) were “not aware”. 20 (65%) trainees reported reliance on radiological and serological investigations rather than clinical skills during remote consultations. Development of skills for patient communication, joint injections, time management, and prescribing immune-suppressive medications were mainly hampered. The majority of trainees agreed that virtual educational programs had improved opportunities for attendance at structured deanery teaching sessions. Conclusion The impact of the COVID-19 pandemic on rheumatology training has been significant both in terms of current rheumatology education programme delivery and training requirements. Our regional survey shows less than a third of trainees had formal training in conducting remote consultations resulting in low levels of confidence in assessing patients remotely. Less face-to-face patient contact negatively impacted clinical and procedural skills development. Restructuring the rheumatology curricula to include training in rheumatology-specific remote consultations and ensuring clinical and procedural competencies by including novel support modalities like simulation sessions may be options for consideration going forwards. Delivery of some structured teaching sessions through the virtual platform is here to stay. Disclosure E.P. Chua: None. Y. Tan: None. L.K. Mercer: None. S. Wig: None.