Screening utility and acceptability of the Kiswahili-pGALS (paediatric Gait, Arms, Legs, Spine) at a tertiary referral hospital in Kenya-A diagnostic accuracy study

BACKGROUND

Paediatric rheumatic diseases cause considerable disease burden to children and their families (Moorthy LN, Peterson MGE, Hassett AL, et al, Pediatric Rheumatology 8:20, 2010). Delayed diagnosis is a significant determinant of severity and mortality attributed to these conditions (Foster HE, Eltringham MS, Kay LJ, et al, Arthritis Care Res 57(6):921-7, 2007). pGALS is a simple clinical tool used to assess joints and identify musculoskeletal (MSK) conditions in school-going children to enable early referral to paediatric rheumatologists.

OBJECTIVES

This study aimed to translate and determine the diagnostic accuracy and acceptability of a Kiswahili version of the pGALS screening tool among Kiswahili-speaking children.

METHODS

The pGALS screening questions were translated into Kiswahili according to the World Health Organisation (WHO) standard for translation of a tool. The validity of the Kiswahili PGALS was ascertained and acceptability rated (time taken, discomfort). Using systematic random sampling, we enrolled children aged 5-16 years presenting at the Aga Khan University Hospital's (AKUH) emergency department in Kenya, who spoke Kiswahili and had symptoms suggestive of an MSK condition. Those already under follow-up at the paediatric rheumatology service at AKUH were excluded. MSK assessment was undertaken by two resident doctors using the newly translated Kiswahili-pGALS and findings were compared with a paediatric rheumatologist examination ('gold-standard') on the same day, and who was blinded to the pGALS findings. We analysed demographic details of the participants and determined the diagnostic accuracy by cross tabulation of the index test results by the results of the reference standard.

RESULTS

One hundred children with a median age of nine years (IQR 7-11) were enrolled. The sensitivity and specificity of the Kiswahili-pGALS screening tool were 76.8% (95%CI 63.6-87.0%) and 40.0% (95%CI 23.9-57.9%), respectively. The diagnostic accuracy was 62.7% (95%CI 52.1-72.1%), area under the ROC was 0.58 (95%CI 0.48-0.68). The median time to perform the Kiswahili-pGALS was 5.0 min (IQR 3.5-6.0 min). Ninety percent of the guardians found the practice of Kiswahili-pGALS to have none, or only some discomfort.

CONCLUSIONS

The Kiswahili-pGALS's was found to be a useful screening tool to aid early identification of MSK conditions in Kiswahili-speaking settings. However, the low specificity implies that relatively large number of false positives would still need to be reviewed by a rheumatologist if the tool is adapted for use.

09 Validation of the francophone version of pGALS with the Delphi approach

Background

The pediatric Gait, Arms, Legs, and Spine (pGALS) is a practical quick musculoskeletal assessment to increase awareness of the joint disease, facilitate early recognition of joint problems, and prompt referral to specialist teams to optimize clinical outcomes. pGALS has been shown to be practical and useful, with excellent acceptability by children and their parents. Its use was limited in French-speaking countries because of the lack of the francophone version.

Objectives

To describe the steps of the translation of the pGALS francophone version using the Delphi approach.

Methods

Delphi method is the consensus-building method, providing the consensual opinion of the experts. For each translated item of the pGALS, the experts assessed the relevance using a scale ranging from 1 to 9 (not relevant-completely relevant). Then median was calculated giving for each item the position of the group: disagree (if the median < 3), equivocal (median between 4–6) and agreement (median >7). The degree of the convergence with the group was assessed to clarify this result: the group’s opinion is consensual if 70% of the responses were within the range of the median; otherwise, it’s “not consensual”. For the no consensual and no relevant item, the experts propose a comment to reformulate the sentence.

Results

Three native speakers were invited to translate the English form of the pGALS into the francophone language. The different propositions were mixed in a consensual way by a children’s musculoskeletal specialist. The version was validated according to the Delphi method. Six experts (pediatricians and rheumatologists) from different French-speaking countries were interviewed during 3 rounds by electronic survey individually and anonymously. After each round: the median, consensus, and comments of every item are collected and a meeting with experts was held to analyze the results. During the first meeting, we were consensual and we had an agreement on 82% of the items (28 items were validated, and 6 items were reformulated). Then the form was reformulated using the results of the preliminary rounds: opinions of the experts and their proposals during the last meeting). We were in agreement and we validated the remaining six-item during the second meeting. In the last round, we obtain a consensual version of pGALS.

Conclusion

Our approach contributed to the consensual translation of the francophone version of pGALS. This tool is now ready to be used as a basic clinical skill. More research is mandatory to assess its sensibility and specificity in screening musculoskeletal disorders.

Efficacy, Immunogenicity and Safety of Vaccination in Pediatric Patients With Autoimmune Inflammatory Rheumatic Diseases (pedAIIRD): A Systematic Literature Review for the 2021 Update of the EULAR/PRES Recommendations

Background

In 2011, the first European League Against Rheumatism (EULAR) vaccination recommendations for pediatric patients with autoimmune inflammatory rheumatic diseases (pedAIIRD) were published. The past decade numerous new studies were performed to assess the safety, efficacy and immunogenicity of vaccinations in pedAIIRD. A systematic literature review (SLR) was therefore performed to serve as the basis for the updated 2021 EULAR/PRES recommendations.

Methods

An SLR was performed according to the standard operating procedures for EULAR-endorsed recommendations. Primary outcomes were efficacy, immunogenicity and safety of vaccination in pedAIIRD. The search was performed in Medline, Embase and the Cochrane Library and included studies published from November 2010 until July 2020.

Results

The SLR yielded 57 studies which were included for critical appraisal and data extraction. Only 8 studies described the occurrence of vaccine-preventable infections after vaccination (efficacy), none of these studies were powered to assess efficacy. The majority of studies assessed (humoral) immune responses as surrogate endpoint for vaccine efficacy. Studies on non-live vaccines showed that these were safe and in general immunogenic. Biologic disease-modifying antirheumatic drugs (bDMARDs) in general did not significantly reduce seroprotection rates, except for B-cell depleting therapies which severely hampered humoral responses. Four new studies on human papilloma virus vaccination showed that this vaccine was safe and immunogenic in pedAIIRD. Regarding live-attenuated vaccinations, level 1 evidence of the measles mumps rubella (MMR) booster vaccination became available which showed the safety of this booster for patients treated with methotrexate. In addition, level 3 evidence became available that suggested that the MMR and varicella zoster virus (VZV) vaccination for patients on low dose glucocorticosteroids and bDMARDs might be safe as well.

Conclusions

The past decade, knowledge on the safety and immunogenicity of (live-attenuated) vaccines in pedAIIRD significantly increased. Data on efficacy (infection prevention) remains scarce. The results from this SLR are the basis for the updated EULAR/PRES vaccination recommendations in pedAIIRD.

A systematic review of the nutritional status of adults experiencing homelessness

OBJECTIVES

To identify, appraise, and describe studies focussing on the nutritional characteristics of people experiencing homelessness (PEH).

STUDY DESIGN

Systematic (narrative) review.

METHODS

We identified full-text studies of any design and in the English language of adults (≥18 years) fulfilling the European Typology criteria for homelessness, based in community or hospital settings, and which report nutritional measures. Five electronic databases, 13 grey literature sources, reference lists, and forward citations were searched. Data on study characteristics and nutrition measures were collected and synthesised narratively. Risk of bias was assessed using relevant checklists for each study type.

RESULTS

A total of 1130 studies were identified and retrieved. After screening, six studies were included for review: three cross-sectional studies; two case-control studies; and one randomised control trial, involving a total of 1561 participants from various settings including shelters, drop-in centres, hospitals, and hostels. All included studies were from high-income countries. Studies reported a range of nutrition measures including anthropometry (e.g., body mass index (BMI)), serum micronutrients and biomarkers, and dietary intake. Between 33.3% and 68.3% of participants were overweight or obese; 3.5%-17% were underweight; and low blood levels of iron, folate, vitamins C, D, and B12, and haemoglobin were prevalent. PEH consumed high amounts of dietary fats and alcohol, and low amounts of fruits and vegetables compared with national guidelines and housed individuals. There was moderate to high risk of selection and measurement bias and confounding in included studies.

CONCLUSIONS

A majority of PEH are within unhealthy BMI ranges and are deficient in serum micronutrients and nutritional biomarkers. Studies using large data sets that examine multiple aspects of nutrition are needed to describe the nutritional characteristics of PEH.

REGISTRATION

This systematic review is based on a prespecified protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42021218900).

POS1292 REAL-WORLD EFFECTIVENESS OF ETANERCEPT AND ADALIMUMAB IN CHILDREN AND YOUNG PEOPLE WITH JUVENILE IDIOPATHIC ARTHRITIS (JIA) WITHOUT UVEITIS

Background:

Biologic therapies have revolutionised treatment pathways and outcomes for patients with juvenile idiopathic arthritis (JIA). Although there is a choice of approved TNF inhibitors available as a first biologic, there lacks data to inform treatment choices in clinical practice.

Objectives:

To compare short-term outcomes on etanercept and adalimumab in children and young people with JIA without uveitis, including drug survival, arthritis disease activity and function ability at 1 year.

Methods:

All patients starting a first biologic (etanercept/adalimumab including biosimilars) from 2010 in the UK JIA biologic registers (BCRD and BSPAR ETN) were included. Those with systemic JIA or with any history of uveitis were excluded. Data were collected at start of therapy, 6 months, 1 year, and then annually, including patient demographic, disease activity and drug therapy. In this analysis, drug survival and arthritis disease activity / function ability at 1 year (range 3-15 months) were investigated; comparing between therapies using logistic / linear regression, adjusted for propensity deciles.

Results:

There were 550 patients with outcome data available (to 30 Sept 2020); 384 etanercept, 166 adalimumab. At registration, 68% female, median age 12 years old (IQR 8-14), median disease duration 1 year (IQR 1-4), 72% on concomitant methotrexate. Disease activity was similar between both therapies at baseline and one year. At one year, 70% were still on biologic therapy; most stopping therapy for ineffectiveness (45%), adverse events (31%), or patient / family choice (15%). Inactive disease and minimal disease activity was achieved in 26% and 46% respectively, 48% achieved a minimally clinical important improvement in their functional ability (CHAQ improvement >0.13).

All PatientsAdalimumabEtanerceptN550166384Females68%59%71%Age (years), median (IQR)12 (8-14)12 (10-14)11 (8-14)Disease duration (years), median (IQR)1 (1-4)1 (0-3)1 (1-4)ILARPersistent oligo9%6%11%Extended oligo20%14%23%RF negative37%32%39%RF positive11%11%12%Psoriatic5%8%4%Enthesitis-related16%27%11%Undifferentiated1%2%1%Concomitant oral steroids16%20%15%Concomitant methotrexate72%84%66%Follow-up time, yearsMedian (IQR)2.5 (1.4-3.8)2.1 (1.2-3.1)3.0 (1.6-4.0)Min-Max0.4 - 8.20.4 - 7.30.4 - 8.2Drug SurvivalStill on drug at one year70%67%71%Still on drug at two years47%50%46%CHAQBaseline, mean (SE)0.9 (0.04)0.8 (0.06)1.0 (0.04)One Year, mean (SE)0.7 (0.03)0.5 (0.06)0.7 (0.04)Change, mean (SE)-0.2 (0.04)-0.2 (0.06)-0.2 (0.04)Regression coef (95% CI)--0.09 (-0.2, 0.04)RefPD Adjusted coef (95% CI)--0.08 (-0.2, 0.07)RefMCID (CHAQ)Proportion achieved48%48%48%OR (95% CI)-1.0 (0.6, 1.5)RefPD Adjusted OR (95% CI)-1.2 (0.8, 1.9)RefJADASBaseline, mean (SE)14 (0.4)14 (0.7)14 (0.4)One Year, mean (SE)5 (0.3)4 (0.5)6 (0.3)Change, mean (SE)-9 (0.4)-9 (0.7)-8 (0.5)Regression coef (95% CI)--1.1 (-2.3, -0.01)*RefPD Adjusted coef (95% CI)--1.0 (-2.8, 0.8)RefInactive Disease (JADAS<1)Proportion achieved26%32%24%OR (95% CI)-1.5 (1.0, 2.4)RefPD Adjusted OR (95% CI)-1.5 (0.9, 2.4)RefMinimal Disease Activity (MDA) [excludes enthesitis-related JIA]N=473N=121N=352Proportion achieved46%49%45%OR (95% CI)-1.2 (0.8, 1.9)RefPD Adjusted OR (95% CI)-1.2 (0.8, 2.0)Ref

Childhood Health Assessment Questionnaire (CHAQ), confidence interval (CI), International League Against Rheumatism (ILAR), interquartile range (IQR), odds ratio (OR), propensity decile (PD), rheumatoid factor (RF), standard error (SE). *p<0.05

Conclusion:

This is the first comparative effectiveness analysis of adalimumab and etanercept within UK children receiving TNFi therapies for JIA. Despite large patient numbers, there was no evidence of difference between adalimumab and etanercept regarding arthritis disease control or treatment persistence. For children without uveitis, both adalimumab and etanercept can be considered as effective treatment options for children and young people with JIA.

Disclosure of Interests:

None declared

[From the bench to the clinic: The challenge of translating platelet production in vitro]

Platelet transfusions, which are currently totally dependent on altruistic donations, are absolutely necessary to the treatment of patients with thrombocytopenia following trauma, surgery or other pathologies (especially malignancies). Producing platelets in vitro represent a major technological and scientific breathrough that would address logistical issues (supply chain, stock holding…) and medical concerns (compatibility and biosafety). The translation of this innovation will need to be accompanied by rigorous quality control, harmonised between laboratory when it comes to functionality and biosafety for use in the clinic.

Stress and well-being of unpaid carers supporting claimants through disability benefit assessments

This study assessed the subjective well-being and perceived stress of unpaid carers of disability benefit claimants. A total of 129 carers from the UK were surveyed between July and September 2017, using a cross-sectional design. Carers, who provided unpaid support to sick or disabled friends, family or neighbours in a non-professional capacity, reported here as unpaid carers, were asked to complete a web-based questionnaire comprising of the Perceived Stress-10-item Scale (PSS-10), the Personal Wellbeing Index-Adult (PWI-A), sociodemographic characteristics, the time they spent caring per day and the number of Personal Independence Payment and Work Capability Assessment interviews prepared for and attended by the person they cared for. Hierarchical regression analyses were performed to assess the effects of the number of benefit assessments on stress and well-being scores, controlling for carers' sociodemographic characteristics and the time they spent caring. Analyses revealed that the number of times that claimants were exposed to benefit assessments significantly and negatively predicted unpaid carers' well-being and was positively related to their stress levels. After controlling for sociodemographic characteristics and hours supporting per day, benefit assessments predicted 8.1% of perceived stress and 4.3% of well-being variance. Being a female unpaid carer of a disability benefit claimant negatively predicted 7.5% of well-being variance. The results offered unique evidence of the negative psychological effects of disability benefit assessments upon unpaid carers, while adding to the evidence of female carers facing increased risks of psychological distress.

Comparing Proxy, Adolescent, and Adult Assessments of Functional Ability in Adolescents With Juvenile Idiopathic Arthritis

Objective

In pediatric research, investigators rely on proxy reports of outcome, such as the proxy‐completed Childhood Health Assessment Questionnaire (C‐HAQ), to assess function in juvenile idiopathic arthritis (JIA). As children mature, they may self‐complete the adult HAQ or the unvalidated adolescent‐specific C‐HAQ. It is unclear how these measures compare and whether they are directly interchangeable. The present study was undertaken to compare agreement between the proxy‐completed C‐HAQ, adolescent‐specific C‐HAQ, and the HAQ at initial presentation to pediatric rheumatologic care and 1 year following the first presentation in adolescents with JIA.

Methods

Adolescents ages 11–17 years participating in the Childhood Arthritis Prospective Study (CAPS), a UK multicenter inception cohort, were included. In a CAPS substudy, adolescents self‐completed the adolescent‐specific C‐HAQ and the HAQ, and proxies simultaneously completed the proxy‐completed C‐HAQ at baseline and 1 year. Correlation and agreement between scores were assessed at baseline. Agreement and ability to similarly classify clinically important changes over time were assessed at 1 year following initial presentation to rheumatologic care.

Results

A total of 107 adolescents (adolescent‐specific C‐HAQ and HAQ) or their proxies (proxy‐completed C‐HAQ) had completed all 3 measures at baseline. Median age at diagnosis was 13 years, and 61% were female. Although the 3 scores demonstrated strong correlations (r > 0.8), they were not completely interchangeable, with agreement ranging between 70% and 80%. There was similar agreement between the changes in scores between baseline and 1 year. Using proxy‐completed C‐HAQ minimum clinically important cutoffs, the adolescent‐specific C‐HAQ and the HAQ similarly classified 80% to 90% of adolescents as having improved or worsened.

Conclusion

While there is relatively high agreement and similar classification of change between HAQ and the 2 C‐HAQ scores, these are not completely interchangeable. This impacts the comparison of function when measured in different ways over the lifespan.

OP0259-PARE WORLD YOUNG RHEUMATIC DISEASES (WORD) DAY: THE FIRST INTERNATIONAL AWARENESS DAY FOR PAEDIATRIC RHEUMATIC DISEASES

Background:

There is a lack of awareness of paediatric rheumatic diseases (PRDs), among the public, and certain groups of healthcare professionals, such as general practitioners [1]. To help improve awareness and understanding of PRDs, World Young Rheumatic Diseases Day (WORD Day) was established in 2019.

Objectives:

The aim of WORD Day, which took place on 18 March 2019, was to raise awareness of PRDs, while informing young people, families, healthcare professionals, teachers, and the public about the importance of timely referral plus early diagnosis and access to appropriate treatment and support.

Methods:

A steering committee was established for the inaugural campaign. An external agency was appointed to provide digital support, with an official social media campaign launching in December 2018. Social media analytics were used to measure the impact of official social media platforms. A range of branded materials were also made available (Fig 1), including an official campaign video. In addition, a specific engagement activity (#ButtonChallenge2019) was launched. This challenged participants to button up a piece of clothing while wearing gloves, to simulate the difficulties that young people with PRDs face undertaking daily activities. As part of the campaign launch, a list of suggested activities were provided, along with template press releases.

Results:

Several face-to-face and virtual events took place globally on or around WORD Day 2019, with 34 countries reporting events (Fig 2). Examples of events included lectures, social gatherings and media appearances. An official WORD Day tweet chat was also hosted. Regarding social media impact, between December 2018 and March 2019, a total of 2,585 and 660 individuals followed the official Facebook and Twitter accounts, respectively. Facebook posts were seen 646,000 times since the start of the campaign, with over 60,000 of Facebook reach from posts published on 18 March 2019 exclusively. A total of 270,800 impressions were observed on Twitter. The official #WORDDay2019 hashtag was seen by 533,955 unique accounts on 18 March 2019 alone, with 3,334,699 impressions. Posts with the hashtag were retweeted 1,112 times on WORD Day, with a total of 1,568 tweets recorded that day. With regards to the #ButtonChallenge2019, the challenge video was viewed for 6,700 minutes and received participation from across the world. Compared to the industry benchmark, the average engagements per post for WORD Day-related content was significantly higher compared to other medical and non-for-profit social media pages.

Conclusion:

WORD Day 2019 was the first international campaign focused solely on PRDs. Organic and paid social media content aided the dissemination of the WORD Day message, with Facebook proving to be the most popular social platform. Despite a wealth of different content published, authentic materials, namely video content, proved to be the most popular with users, particularly when it featured material designed by and with young people with PRDs. It was demonstrated that awareness events can often be resource-light and easily implemented across a range of diverse countries. It is anticipated that the global reach of WORD Day will increase over time as the campaign becomes more established.

References:

[1]Egert Y et al. Children and young people get rheumatic disease too. The Lancet Child & Adolescent Health. 2019;3(1):8-9.

Acknowledgments:

PReS for their financial support.

Disclosure of Interests:

Simon Stones Consultant of: I have been a paid consultant for Envision Pharma Group and Parexel. This does not relate to this abstract., Speakers bureau: I have been a paid speaker for Actelion and Janssen. These do not relate to this abstract., Eve Smith: None declared, Sammy Ainsworth: None declared, Veerle Buys: None declared, Wendy Costello: None declared, Yona Egert: None declared, Helen Foster: None declared, Lovro Lamot: None declared, Berent J. Prakken: None declared, Christiaan Scott: None declared

CAPTURE-JIA: a consensus-derived core dataset to improve clinical care for children and young people with juvenile idiopathic arthritis

Objectives

Data collected during routine clinic visits are key to driving successful quality improvement in clinical services and enabling integration of research into routine care. The purpose of this study was to develop a standardized core dataset for juvenile idiopathic arthritis (JIA) (termed CAPTURE-JIA), enabling routine clinical collection of research-quality patient data useful to all relevant stakeholder groups (clinicians, service-providers, researchers, health service planners and patients/families) and including outcomes of relevance to patients/families.

Methods

Collaborative consensus-based approaches (including Delphi and World Café methodologies) were employed. The study was divided into discrete phases, including collaborative working with other groups developing relevant core datasets and a two-stage Delphi process, with the aim of rationalizing the initially long data item list to a clinically feasible size.

Results

The initial stage of the process identified collection of 297 discrete data items by one or more of fifteen NHS paediatric rheumatology centres. Following the two-stage Delphi process, culminating in a consensus workshop (May 2015), the final approved CAPTURE-JIA dataset consists of 62 discrete and defined clinical data items including novel JIA-specific patient-reported outcome and experience measures.

Conclusions

CAPTURE-JIA is the first ‘JIA core dataset’ to include data items considered essential by key stakeholder groups engaged with leading and improving the clinical care of children and young people with JIA. Collecting essential patient information in a standard way is a major step towards improving the quality and consistency of clinical services, facilitating collaborative and effective working, benchmarking clinical services against quality indicators and aligning treatment strategies and clinical research opportunities.

P05 A national survey of clinical practice of corticosteroid use in newly diagnosed or flaring cases of juvenile idiopathic arthritis across the UK

Background

Background Corticosteroids (CS) are widely used for rapid-action or induction treatment in children and young people (CYP) with juvenile idiopathic arthritis (JIA). Given a lack of evidence base on CS induction regimen for CYP with JIA, and since criteria for choosing CS are based on healthcare professional (HCP) preference, further research is needed (1).

Methods

A national electronic survey was undertaken among HCPs across the UK as part of the Steroid Induction Regimen for Juvenile Idiopathic Arthritis (SIRJIA) study. We aimed to establish the opinions of HCPs current practice regarding the clinical criteria for commencing CS treatment

Results

A total of 39 (24%) responses were received from 162 HCPs. These included 22 (56%) NHS consultants, five (13%) grid trainees, eight (21%) clinical nurse specialists and four other HCPs (10%).

The most common treatments newly diagnosed JIA or a disease flare were intra-articular IACS or a combination of DMARDs and IAS (except for systemic JIA and oligoarticular JIA). The majority of HCPs 17 would treat new and flaring CYP the same with 53% choosing a different regime or not answering.

The key criteria HCPs used for commencing CS and choosing route of administration were rapid induction of remission (31 (89%)), high disease activity (31 (89%)), severity of systemic JIA (30 (86%)) and level of inflammation (28 (80%)), see Table 1. The main determinants of route of administration was disease severity disease subtype.

The majority of HCPs (52-72%) would consider entering CYP with JIA into a trial randomising to modes of administration.

P14 Table 1 Reasons of CS Choice Number N = 39 Percentage % High Disease Activity 35 89.7 Rapid induction of remission 34 87.18 Severity of Systemic JIA 34 87.18 Level of inflammation 32 82.5 Severe Uveitis 30 76.92 JIA subtype 27 68.21 Targeting Specific Joints 26 66.67 Level of Disability 18 46.15 Level of pain 16 41.03 Long-standing Disease 11 28.1 Patient reluctance to take DMARDS 8 20.5

Conclusion

The results from this national survey of clinical practice showed varying practices in the management of new CYP with JIA and those that are flaring. The majority of HCPs who completed this survey, indicated that they would be prepared to consider entering CYP into a trial that randomised to the four CS delivery methods.

Conflicts of Interest

The authors declare no conflicts of interest.

P27 A scoping review to support the development of pGALSplus: a multi-professional tool and educational resource

Poster presentation Tuesday 8 October

Background

Musculoskeletal (MSK) problems in children and young people (CYP) are common. The majority will present to healthcare professionals in the community but it can be challenging to identify those with serious disease requiring onward referral. pGALS (paediatric Gait, Arms, Legs and Spine) was developed as a simple, quick MSK clinical assessment to discern abnormal joints, initially within paediatric rheumatology and later targeted at non-specialists. Anecdotally, pGALS can detect joint and functional problems in CYP with other serious conditions, but alone is unlikely to be specific enough. It is unknown whether a pGALSplus assessment is practical. Our aim was to scope the literature about MSK assessments applicable to CYP used in clinical practice, focusing on evidence of validity in the context of diagnosis and assessment of juvenile idiopathic arthritis (JIA), mucopolysaccharidoses (MPS), Muscular dystrophy (MD) and developmental coordination disorder (DCD) to develop an extended pGALS.

Methods

Scoping review using the Newcastle University Library search tool (which includes several databases) and Google Scholar, and consulting NICE guidance/pathways. Search terms included dyspraxia, paediatric MSK assessment, screening tools, balance, and rheumatology, assessment tools for MD, MPS, and JIA. Studies cited within relevant articles uncovered through searches were also checked. The search was conducted between 1 October and 1 December 2018. Publication date was limited to post-1998, language did not constitute as exclusion criteria unless translation was unavailable.

Results

32 journal articles were deemed appropriate, describing specific assessment or screening tools in the context of diagnosis of our target conditions. Within DCD, motor co-ordination test batteries aid diagnosis as part of specialist assessment, but are regarded as too lengthy for the purpose of screening; a questionnaire may be useful as a first-step diagnostic tool, along with an assessment of static balance (found to be significantly worse in children with DCD). In paediatric rheumatology, pGALS is the only validated screening tool to discern normal from abnormal. Other tools to assess health and wellbeing, disability and function are validated in the context of established disease only. For neuromuscular conditions the North Star Ambulatory Assessment is valid, reliable and practical as a functional assessment, and includes activities that are necessary to remain functionally ambulant. With regards to MPS, searches did not reveal specific MSK tests, but evidence suggests that skeletal malformations and joint problems were the most frequently presenting signs. pGALS performs well to identify abnormal joints with restriction within an MPS group.

Conclusion

This review supports the development of pGALSplus; a toolkit to facilitate identification and assessment of CYP with potentially serious MSK disease. pGALSplus will be targeted at community-based clinicians and will likely include physical examination, questionnaire(s) and appropriate adjuncts. Our group is currently developing pGALSplus, aiming to describe feasibility and acceptability, and develop educational and training resources, aimed at multi-professionals.

Conflicts of Interest

The authors declare no conflicts of interest.

The prevention and treatment of glucocorticoid-induced osteopaenia in juvenile rheumatic disease: A randomised double-blind controlled trial

BACKGROUND

Children and young people (CYP) with chronic rheumatic conditions; Juvenile Idiopathic Arthritis, Juvenile Systemic Lupus Erythematosus, Juvenile Dermatomyositis and Juvenile Vasculitis, treated with steroids, have low bone density, increased fracture risk and are likely to have suboptimal peak bone mass. There is currently no evidence base for the management of steroid-induced bone loss in children with rheumatic diseases.

METHODS

We undertook a multi-centre double dummy double-blind randomised placebo controlled trial to investigate whether the bisphosphonate risedronate was superior to alfacalcidol or calcium and vitamin D supplementation in the prevention and treatment of steroid-induced osteopaenia in these children. Patients were stratified and randomised in a 1:1 ratio, into: placebo; alfacalcidol; risedronate. The primary outcome was the change in lumbar spine bone mineral density z score (LSaBMDz) measured by dual energy x-ray absorptiometry at one year. Secondary outcome was fracture rate.

RESULTS

Two hundred and seventeen patients were recruited to the study. Seventy seven placebo, 71 alfacalcidol, and 69 risedronate. Highly statistically significant differences were observed in the change in LSaBMDz between the placebo and risedronate groups; 0.274, 95% CI (0.061, 0.487) (p < 0.001) and between the risedronate and the alfacalcidol groups; 0.326 95% CI (0.109, 0.543) (p < 0.001). The difference observed between the alfacalcidol and placebo group was not statistically significant.Highly statistically significant differences were seen in the change in Total Body Less Head aBMD-Z Score between the placebo and risedronate groups (p < 0.01) but not between the alfacalcidol and risedronate groups. No significant differences in fracture frequency, adverse or serious adverse reactions were observed between the groups.

CONCLUSIONS

Children and adolescents receiving steroids for rheumatic diseases benefit from prophylactic treatment with bisphosphonates to increase LSaBMD. Alfacalcidol is ineffective.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Protective parents and permissive children: what qualitative interviews with parents and children can tell us about the feasibility of juvenile idiopathic arthritis trials

BACKGROUND

Patient recruitment can be very challenging in paediatric studies, especially in relatively uncommon conditions, such as juvenile idiopathic arthritis (JIA). However, involving children and young people (CYP) in the design of such trials could promise a more rapid trajectory towards making evidence-based treatments available. Studies involving CYP are advocated in the literature but we are not aware of any early stage feasibility studies that have qualitatively accessed the perspectives of parents and CYP with a long term condition to inform design and conduct of a trial. In the context of a feasibility study to inform the design of a proposed randomised controlled trial of corticosteroid induction regimen in JIA, we explored families' perspectives on the proposed trial and on JIA trials generally.

METHODS

We analysed interviews with 27 participants (8 CYP aged 8-16 years and 19 parents) from four UK paediatric rheumatology centres. CYP had recently received corticosteroids to treat JIA. Audio-recorded interviews were transcribed and analysed thematically, drawing on the Framework Method.

RESULTS

Both parents and CYP were capable of engaging with the logic of the proposed trial but pointed to challenges with its design. Treatment preferences influenced willingness to participate in the proposed trial. The preferences of older children and their parents often differed, with CYP being more willing to participate in the proposed trial than parents. Families' current treatment preferences were largely informed by past positive and negative treatment experiences. Some participants also indicated that their treatment preferences were influenced by those of their clinicians.

CONCLUSION

Previous research has typically focused on deficits in patients' understandings of trials. We found that both parents and CYP understood trial concepts and were able to identify potential flaws in the proposed trial. We propose recommendations to optimise the design of a planned corticosteroid induction regimen trial in JIA. Accessing both parents' and CYP's perspectives helps to identify and address recruitment challenges, which will ultimately optimise informed consent and future recruitment.

Depressive symptoms, pain and disability for adolescent patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study

Objectives

To determine if depressive symptoms assessed near diagnosis associate with future measures of pain, disability and disease for adolescent patients diagnosed with JIA.

Methods

Data were analysed from JIA patients aged 11–16 years recruited to the Childhood Arthritis Prospective Study, a UK-based inception cohort of childhood-onset arthritis. Depressive symptoms (using the Mood and Feelings Questionnaire; MFQ), active and limited joint count, disability score (Childhood Health Assessment Questionnaire), pain visual analogue scale and patient’s general evaluation visual analogue scale were collected. Associations between baseline measures (first visit to paediatric rheumatologist) were analysed using multiple linear regression. Linear mixed-effect models for change in the clinical measures of disease over 48 months were estimated including MFQ as an explanatory variable.

Results

Data from 102 patients were analysed. At baseline, median (IQR) age was 13.2 years (11.9–14.2 years) and 14.7% scored over the MFQ cut-off for major depressive disorder. At baseline, depressive symptoms significantly associated with all clinical measures of disease (P ⩽ 0.01). High baseline depressive symptoms scores predicted worse pain (P ⩽ 0.005) and disability (P ⩽ 0.001) 12 months later but not active and limited joint counts.

Conclusions

Adolescent patients with JIA and depressive symptoms had more active joints, pain and disability at the time of their first specialist appointment. The associations between baseline depression and both pain and disability continued for at least one year, however, this was not the case for active joint count.

Long-Term Outcomes Following Achievement of Clinically Inactive Disease in Juvenile Idiopathic Arthritis: The Importance of Definition

Objective

Potential targets for treat‐to‐target strategies in juvenile idiopathic arthritis are minimal disease activity (MDA) and clinically inactive disease (CID). We undertook this study to compare short‐ and long‐term outcomes following achievement of MDA and CID on the 10‐joint clinical Juvenile Arthritis Disease Activity Score (cJADAS10) and following achievement of CID on Wallace et al's preliminary criteria.

Methods

Children recruited to the Childhood Arthritis Prospective Study, a UK multicenter inception cohort, were selected if they were recruited prior to January 2011 and diagnosed as having oligoarthritis or rheumatoid factor–negative or –positive polyarthritis. One year following diagnosis, children were assessed for MDA on the cJADAS10 and for CID on both Wallace et al's preliminary criteria and the cJADAS10. Associations were tested between those disease states and functional ability, absence of joints with limited range of motion, psychosocial health, and pain at 1 year and annually to 5 years.

Results

Of 832 children, 70% were female and the majority had oligoarthritis (68%). At 1 year, 21% had achieved CID according to both definitions, 7% according to Wallace et al's preliminary criteria alone, and 16% according to the cJADAS10 alone; 56% had not achieved CID. Only 10% of children in the entire cohort achieved MDA without also achieving CID. Achieving either early CID state was associated with a greater absence of joints with limited range of motion. However, only CID according to the cJADAS10 was associated with improved functional ability and psychosocial health. Achieving CID was superior to achieving MDA in terms of short‐ and long‐term pain and the absence of joints with limited range of motion.

Conclusion

CID on the cJADAS10 may be preferable as a treatment target to CID on Wallace et al's preliminary criteria in terms of both feasibility of application and long‐term outcomes.

Abstract P1-03-10: Breast tumour kinase and its role in mTOR signalling

Background: The development of distal metastases and the acquisition of resistance to chemotherapeutic agents are one of the leading causes of cancer related death in breast cancer patients. There is both a scientific and clinical need to understand the alterations in cellular signalling pathways that could contribute to chemotherapeutic resistance in breast cancer, thereby identifying novel targets for therapy. The intracellular tyrosine kinase Brk/PTK6 enhances coupling of ErbB signalling to PI3K/Akt and we hypothesise that Brk plays a role in chemo-resistance and activation of downstream effectors such as mTOR.

Methods: The protein and activation levels of mTOR pathway components and expression levels of Brk, in both Taxol-sensitive and resistant breast cancer cells, were examined by western blotting and immunofluorescence. Brk transfected cells were treated with BEZ-235 for 72 hours and relative cell numbers determine by MTT assay. Immunoprecipitation studies were carried out on lysates from T47D cells, transfected to express FLAG-tagged Brk, with ANTI-FLAGM2 agarose beads. Sequence alignment was done using the NCBI BLAST Tool.

Results: We found that mTOR signalling was up-regulated in the Taxol-resistant cell line compared to parental Taxol-sensitive cells. This up-regulation was also accompanied by increased Brk levels. Transfection of a Brk-negative breast cancer cell line, MDA-MB-468 with wild-type Brk resulted in increased levels of both mTOR and, to a lesser extent, the downstream signalling component GβL at the protein level compared to cells transfected with vector only. Levels of the mTOR inhibitor DEPTOR were also decreased in response to Brk expression and mTOR co-precipitated in FLAG-Brk pull downs using FLAG M2 beads.

The Taxol resistant cells also showed altered responses to the mTOR inhibitor RAD-001/everolimus. Interestingly, sequence alignment revealed that there are common amino acid motifs between Brk and the mTOR regulatory molecule DEPTOR.

Conclusions: These data implicate Brk in up-regulating mTOR expression and indicate that Brk may influence mTOR signalling in the development of Taxol resistance. It is possible that Brk could substitute for DEPTOR in mTOR complexes providing a mechanism for elevated mTOR signalling in many breast cancers.

Citation Format: Harvey A, Foster H, Thorpe M, Karteris E. Breast tumour kinase and its role in mTOR signalling [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-03-10.

Temporomandibular Joint Involvement in Association With Quality of Life, Disability, and High Disease Activity in Juvenile Idiopathic Arthritis

OBJECTIVE

To evaluate the demographic, disease activity, disability, and health-related quality of life (HRQOL) differences between children with juvenile idiopathic arthritis (JIA) and their healthy peers, and between children with JIA with and without clinical temporomandibular joint (TMJ) involvement and its determinants.

METHODS

This study is based on a cross-sectional cohort of 3,343 children with JIA and 3,409 healthy peers, enrolled in the Pediatric Rheumatology International Trials Organisation HRQOL study or in the methotrexate trial. Potential determinants of TMJ involvement included demographic, disease activity, disability, and HRQOL measures selected through univariate and multivariable logistic regression.

RESULTS

Clinical TMJ involvement was observed in 387 of 3,343 children with JIA (11.6%). Children with TMJ involvement, compared to those without, more often had polyarticular disease course (95% versus 70%), higher Juvenile Arthritis Disease Activity Score (odds ratio [OR] 4.6), more disability, and lower HRQOL. Children with TMJ involvement experienced clearly more disability and lower HRQOL compared to their healthy peers. The multivariable analysis showed that cervical spine involvement (OR 4.6), disease duration >4.4 years (OR 2.8), and having more disability (Childhood Health Assessment Questionnaire Disability Index >0.625) (OR 1.6) were the most important determinants for TMJ involvement.

CONCLUSION

Clinical TMJ involvement in JIA is associated with higher disease activity, higher disability, and impaired HRQOL. Our findings indicate the need for dedicated clinical and imaging evaluation of TMJ arthritis, especially in children with cervical spine involvement, polyarticular course, and longer disease duration.

Transitional care for rheumatic conditions in Europe: current clinical practice and available resources

OBJECTIVE

To assess European pediatric rheumatology providers' current clinical practices and resources used in the transition from child-centered to adult-oriented care.

METHODS

European pediatric rheumatologists were invited to complete a 17-item anonymized e-survey assessing current transition practices, transition policy awareness, and needs in advance of the publication of EULAR/PReS recommendations on transition.

RESULTS

The response rate was 121/276 (44%), including responses from 115 centers in 22 European Union countries. Although 32/121 (26%) responded that their centers did not offer transition services, the majority (99%) agreed that a formalized process in transitioning patients to adult care is necessary. A minority (<30%) of respondents stated that they have a written transition policy although 46% have an informal transition process. Designated staff to support transitional care were available in a minority of centers: nurse (35%), physiotherapist (15%), psychologist (15%), social worker (8%), and occupational therapist (2%). The existence of a designated team member to coordinate transition was acknowledged in many centers (64% of respondents) although just 36% use a checklist for young people as part of individualized transitional care.

CONCLUSION

This survey of European pediatric rheumatology providers regarding transitional care practices demonstrates agreement that transitional care is important, and wide variation in current provision of transition services exists.

How common is clinically inactive disease in a prospective cohort of patients with juvenile idiopathic arthritis? The importance of definition

Objectives

Many criteria for clinically inactive disease (CID) and minimal disease activity (MDA) have been proposed for juvenile idiopathic arthritis (JIA). It is not known to what degree each of these criteria overlap within a single patient cohort. This study aimed to compare the frequency of MDA and CID across different criteria in a cohort of children with JIA at 1 year following presentation.

Methods

The Childhood Arthritis Prospective Study recruits children at initial presentation to paediatric or adolescent rheumatology in seven UK centres. Children recruited between October 2001 and December 2013 were included. The proportions of children with CID and MDA at 1 year were calculated using four investigator-defined and eight published composite criteria. Missing data were accounted for using multiple imputation under different assumptions.

Results

In a cohort of 1415 children and adolescents, 67% patients had no active joints at 1 year. Between 48% and 61% achieved MDA and between 25% and 38% achieved CID using published criteria. Overlap between criteria varied. Of 922 patients in MDA by either the original composite criteria, Juvenile Arthritis Disease Activity Score (JADAS) or clinical JADAS cut-offs, 68% were classified as in MDA by all 3 criteria. Similarly, 44% of 633 children with CID defined by either Wallace's preliminary criteria or the JADAS cut-off were in CID according to both criteria.

Conclusions

In a large JIA prospective inception cohort, a majority of patients have evidence of persistent disease activity after 1 year. Published criteria to capture MDA and CID do not always identify the same groups of patients. This has significant implications when defining and applying treat-to-target strategies.

The mammalian dynein-dynactin complex is a strong opponent to kinesin in a tug-of-war competition

Kinesin and dynein motors transport intracellular cargos bidirectionally by pulling them in opposite directions along microtubules, through a process frequently described as a 'tug of war'. While kinesin produces 6 pN of force, mammalian dynein was found to be a surprisingly weak motor (0.5-1.5 pN) in vitro, suggesting that many dyneins are required to counteract the pull of a single kinesin. Mammalian dynein's association with dynactin and Bicaudal-D2 (BICD2) activates its processive motility, but it was unknown how this affects dynein's force output. Here, we show that formation of the dynein-dynactin-BICD2 (DDB) complex increases human dynein's force production to 4.3 pN. An in vitro tug-of-war assay revealed that a single DDB successfully resists a single kinesin. Contrary to previous reports, the clustering of many dyneins is not required to win the tug of war. Our work reveals the key role of dynactin and a cargo adaptor protein in shifting the balance of forces between dynein and kinesin motors during intracellular transport.

Development of a Paediatric Musculoskeletal Skills Workshop for Canadian Medical Students

BACKGROUND: Musculoskeletal (MSK) complaints in children account for up to 30% of visits to general practitioners. Doctors who see children with MSK complaints are often not confident in assessing them and MSK exams are poorly documented in medical records. There has been little published literature describing the logistics of teaching MSK skills in a group setting (which is how medical students are commonly taught). At our center, no MSK examination skills were previously taught during the undergraduate paediatrics clerkship.

OBJECTIVES: 1) To develop a hands-on, paediatric MSK workshop for medical students with direct observation and feedback. 2) To evaluate student/faculty satisfaction with the workshop. 3) To develop an MSK workshop protocol as a resource for medical educators.

DESIGN/METHODS: A 1-hour interactive workshop was designed for students to practice the paediatric Gait, Arms, Legs and Spine (pGALS) screening MSK exam. Students are given pre-reading, videos and pGALS checklists. Workshops include live demonstrations and videos/images of abnormal MSK findings for pGALS practice. Students practice pGALS with their peers with staff supervision(up to 5 physicians present)and receive feedback. All students complete a post-workshop evaluation. Teachers also complete a post-workshop evaluation discussing what went well and areas for improvement.

RESULTS: Workshops are delivered every 2 months for 25 students (5 iterations completed). Feedback has been positive (median rating 4.5 on a 5-point Likert scale) for all areas evaluated: objectives, handouts, preparation time, discussion, resources, etc. Comments include: “Helpful and applicable to personal clinical practice,” and, “The hands-on practice was really appreciated, as was the chance to get feedback.” Workshops have been modified according to faculty/student evaluations, resulting in a workshop protocol (organizational template) for future workshop leaders including a teaching checklist, preparation timeline, and PowerPoint to be modified by instructors as they wish.

CONCLUSION: The paediatric MSK workshop has been a welcome addition to our undergraduate paediatrics clerkship curriculum. We aim to further develop our workshop by explicitly including applied anatomy, e.g., land-marking for joints. We also aim to make our workshop protocol available on Paediatric Musculoskeletal Matters,www.pmmonline.org, as a resource for other medical educators. Further work will include evaluating its uptake, use and applicability by users in different contexts, and modifying it for different levels of learners, e.g., paediatricians.

Influence of past breast feeding on pattern and severity of presentation of juvenile idiopathic arthritis

This analysis aimed to study the influence of breast feeding on the pattern and severity of juvenile idiopathic arthritis (JIA) at presentation. The association between ever versus never breast feeding and disease severity at onset was compared in 923 children with JIA recruited to the UK Childhood Arthritis Prospective Study at first presentation to rheumatology. Fifty six per cent of children were ever breast fed (median 3.7 months). Breastfed children reported a lower median age at onset, a lower Childhood Health Assessment Questionnaire (CHAQ), a measure of disease severity, lower parent general evaluation scores and lower pain at presentation. There was a trend towards a higher proportion of breastfed children with rheumatoid factor-negative polyarthritis, but lesser enthesitis-related and psoriatic arthritis. There was a statistically significant inverse association between breast feeding and high CHAQ, even after adjusting for differences in socioeconomic status (adjusted OR 0.61 (95% CI 0.39 to 0.95)). Further work to understand the reasons behind these associations is required.

Can Seeding in the Clinic Reach a Wide Audience? A Proof of Concept Study on Spreading a Health Message About Juvenile Idiopathic Arthritis Using a Shareable Online Video

Background

Shareable online video offers the potential for spreading a health message across online and real world social networks. Seeding a message in a clinical setting may be advantageous.

Objective

To investigate the potential of an online video to spread a health message about juvenile idiopathic arthritis (JIA) when delivered or seeded in a clinical setting and investigate factors that influence sharing behavior.

Methods

Multimethod proof of concept study. Concepts for two different styles of video were developed using focus groups and interviews and reviewed by an online market research panel. We compared dissemination of the two videos from two specialist pediatric rheumatology clinics in NHS Hospitals. Participants were 15 patients, family members, and clinical staff with knowledge of JIA at concept stage; 300 market research panel members in development stage; and 38 patients and their parents or guardians in the seeding stage. Newly diagnosed patients with JIA and/or parents or guardians were invited to view and share an online video with a health message about JIA across real-life and electronic social networks. Main outcome measures were viewing statistics, sharing behavior and patterns, and participant feedback.

Results

Of 38 patients and/or their parents or guardians given links, 26 visited the video webpage and shared the link, 2 visited and did not share, and 10 did not visit. Most links were viewed and shared within a few days. A total of 3314 pageviews were recorded with a mean of 89.6 pageviews per link (range 0-1245). Links were accessed from 26 countries, with most viewers in the United Kingdom (82.5%). Mothers were the most active group of sharers.

Conclusions

Distribution of a video link in a clinical setting may be an effective way to spread a health message. Parents or guardians of children with JIA are more likely to share a link than young people. Dissemination depends on a small number of active sharers, the content of the video, and the willingness of participants to share health information about themselves.

Trial Registration

UK Clinical Research Network Study Portfolio ID (UKCRN): 13747; http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=13747 (Archived by WebCite at http://www.webcitation.org/6eeXlMmM6).