Geraldine Mary McCarthy

Background and Objectives: Despite evidence demonstrating the advantages of rheumatology-led point-of-care (POC) polarised light microscopy (PLM), it remains underutilised in many hospital settings. We aimed to identify barriers to its use and assess typical caseloads of crystal arthropathy, diagnostic methods and frequency of rheumatology-led POC PLM in practice in Ireland. We also assessed reliance on laboratory-led crystal analysis and the turnaround time for results to be reported. Solutions to improve implementation of rheumatologist-led POC PLM were also explored. Material and Methods: We surveyed 29 rheumatologists registered to the Irish Society of Rheumatology via SurveyMonkey, between May and October 2024. Textual responses were categorised into key themes, and word clouds were generated using Tagcrowd to visualise thematic content. Results: Fifty-five percent of respondents faced challenges using POC PLM for crystal analysis. Common barriers included lack of access to a microscope, lack of a polarising light function and lack of training in performing and interpreting of PLM. Fifty-two percent of rheumatologists highlighted the critical need for accessible and functional microscopes. Ninety-two percent of respondents relied on in-house laboratory crystal analysis. Thirty-two percent received inaccurate or incomplete results from laboratory reports and 28% of respondents reported delays in sample analysis from the laboratory. Laboratory turnaround was 1–2 days for 43% of rheumatologists and 3–5 days for 33%. Sixty-nine percent had not received training on PLM and 48% emphasised the need for improved education on POC PLM, including improved integration into the national rheumatology training. Conclusions: Rheumatology-led POC PLM remains underutilised despite its clinical advantage primarily due to equipment and training deficits. Addressing these barriers through improved infrastructure, education and equipment is essential to ensure effective and timely care for patients with crystal arthropathy.

When, as a junior doctor, Dorian Haskard made a presentation on a patient with gout to the Medical Staff Round at the London Hospital in 1981, he was told that gout was ‘yesterday’s disease and academically dead’

Introduction: Ireland's Health Service Executive is developing a new national integrated low back pain (LBP) pathway spanning primary and secondary care to improve LBP healthcare. Clinical pathways are frequently employed to optimise clinical outcomes and resource use but are challenging to implement. Context‐specific implementation planning, leveraging implementation science and its conceptual frameworks, should inform successful implementation.Aim: To explore General Practitioner (GP) perceptions of the new LBP pathway, using their on‐the‐ground knowledge to assess barriers and facilitators to implementation with the goal of developing tailored implementation strategies.Methods: Qualitative data will be collected through semi‐structured one‐to‐one interviews with a purposive sample of GPs. Data analysis will be guided by Framework Analysis with initial open coding followed by mapping to the domains and constructs of the Consolidated Framework for Implementation Science and Proctor's implementation outcomes of acceptability, appropriateness and feasibility. Potential implementation strategies will be devised from the identified determinants of implementation.Conclusion: System‐wide changes and improvements in healthcare are difficult to accomplish. The rationale and design of a pre‐implementation study with key stakeholders is outlined with the view of informing optimal implementation of Ireland's new national integrated LBP pathway in primary care settings.

Background: The gold standard for crystal arthritis diagnosis relies on the identification of either monosodium urate (MSU) or calcium pyrophosphate (CPP) crystals in synovial fluid. With the goal of enhanced crystal detection, we adapted a standard compensated polarized light microscope (CPLM) with a polarized digital camera and multi-focal depth imaging capabilities to create digital images from synovial fluid mounted on microscope slides. Using this single-shot computational polarized light microscopy (SCPLM) method, we compared rates of crystal detection and raters’ preference for image. Methods: Microscope slides from patients with either CPP, MSU, or no crystals in synovial fluid were acquired using CPLM and SCPLM methodologies. Detection rate, sensitivity, and specificity were evaluated by presenting expert crystal raters with (randomly sorted) CPLM and SCPLM digital images, from FOV above clinical samples. For each FOV and each method, each rater was asked to identify crystal suspects and their level of certainty for each crystal suspect and crystal type (MSU vs. CPP). Results: For the 283 crystal suspects evaluated, SCPLM resulted in higher crystal detection rates than did CPLM, for both CPP (51%. vs. 28%) and MSU (78% vs. 46%) crystals. Similarly, sensitivity was greater for SCPLM for CPP (0.63 vs. 0.35) and MSU (0.88 vs. 0.52) without giving up much specificity resulting in higher AUC. Conclusions: Subjective and objective measures of greater detection and higher certainty were observed for SCPLM over CPLM, particularly for CPP crystals. The digital data associated with these images can ultimately be incorporated into an automated crystal detection system that provides a quantitative report on crystal count, size, and morphology.

Introduction Healthcare systems are struggling to deliver high-quality low back pain (LBP) care. In 2012 specialist physiotherapist-led musculoskeletal (MSK) triage services were introduced in Irish hospitals to expedite patient care and alleviate pressure on elective orthopaedic/ rheumatology consultant clinics. Specialist physiotherapists have expertise to inform health service improvement and reform, but their perspectives of LBP healthcare delivery have received scant attention. Objectives To explore specialist physiotherapists’ perspectives on LBP care in Ireland, the barriers and facilitators to quality LBP care and the development of MSK interface services in primary care settings. Design Cross-sectional observational study using an anonymous electronic survey with thematic framework analysis of response data from open-ended questions. Participants Thirty-four clinical specialist physiotherapists in Irish MSK triage services. Results Thematic analysis resulted in six overarching themes, grouped into two categories. One category pertained to LBP healthcare in Ireland with the following three themes: 1) Inadequate health services for patients with LBP; 2) Need for defined LBP clinical pathways; 3) Need for a multisectoral approach to spine health. Themes in the second category, pertaining to the development of community-based MSK interface services, were: 4) Concern regarding isolation from secondary care services; 5) Unrealistic expectations of MSK triage; 6) Improved communication and collaboration with primary care services. Conclusion Specialist physiotherapists have concerns regarding LBP health services and persistence of a biomedical, secondary care-led approach. They advocate for investment in primary care multi-disciplinary teams, enhanced integration across primary and secondary care, development of a national clinical pathway and a multisectoral approach.

Calcium-containing crystal deposition diseases are a common cause of pain and disability but remain relatively under-investigated. No drug has been identified that can prevent deposition or effect dissolution of either calcium pyrophosphate (CPP) or basic calcium phosphate (BCP) crystals. In comparison to the field of gout and urate biology, published research in relation to calcium crystal deposition diseases in 2022 was relatively modest in quantity. In CPP deposition (CPPD) disease, progress was made mainly in epidemiology, imaging, surgical management and Gitelman’s syndrome. In relation to BCP crystals, the effect on tenocytes in vitro was explored and results indicate that BCP crystals likely reduce tendon matrix integrity via their interaction with tenocytes. The involvement of calcification in the progression of osteoarthritis (OA) was elegantly demonstrated contributing to further discovery of the process of OA progression. There was a paucity of mechanistic and genetic studies in calcium crystal deposition diseases published in 2022, nor any breakthrough in therapy, showing that there is abundant scope for investigation under these themes in the future.