The right care, every time: improving adherence to evidence-based guidelines

Guidelines are integral to reducing variation in paediatric care by ensuring that children receive the right care, every time. However, for reasons discussed in this paper, clinicians do not always follow evidence-based guidelines. Strategies to improve guideline usage tend to focus on dissemination and education. These approaches, however, do not address some of the more complex factors that influence whether a guideline is used in clinical practice. In this article, part of the Equipped Quality Improvement series, we outline the literature on barriers to guideline adherence and present practical solutions to address these barriers. Examples outlined include the use of care bundles, integrated care pathways and quality improvement collaboratives. A sophisticated information technology system can improve the use of evidence-based guidelines and provide organisations with valuable data for learning and improvement. Key to success is the support of an organisation that places reliability of service delivery as the way business is done. To do this requires leadership from clinicians in multidisciplinary teams and a system of continual improvement. By learning from successful approaches, we believe that all healthcare organisations can ensure the right care for each patient, every time.

The Influence of Patient-Reported Joint Manifestations on Quality of Life in Fabry Patients

Fabry disease, a lysosomal storage disorder, is a rare inborn error of metabolism caused by deficiency of the enzyme alpha galactosidase A and resulting accumulation of globotriaosylceramide. The symptoms of Fabry disease are heterogeneous including renal failure, cardiac hypertrophy, and stroke and may not be well recognized by non-specialist physicians. Patients with milder, later onset of disease often have a delay in diagnosis.Fabry patients may suffer significant neuropathic pain in the extremities (acroparasthesia) but the degree to which musculoskeletal symptoms contribute to total pain and disability is unknown. Here, we present a questionnaire study focusing on joint manifestations and their impact on daily life of patients with Fabry disease.Seventy-seven patients with Fabry disease and age-matched healthy controls (49 female and 28 male) took part in a survey focused on joint problems, pain, disability, and quality of life. Joint pain and swelling were reported by 43% of male and 39% of female Fabry patients. Analysis by age group showed higher prevalence of joint problems and decreased quality of life, in terms of mobility, activity, pain, and anxiety, in Fabry patients younger than 50 years compared to healthy controls. Female Fabry patients had higher fatigue scores compared to control subjects. Fabry patients reported problems with vigorous daily activities and gripping.Musculoskeletal symptoms are common in Fabry patients and contribute to overall pain and decreased quality of life. Awareness of Fabry disease by physicians may be raised to ensure timely diagnosis of this rare disease.

Comparing the WeeFIM and PEDI in neurorehabilitation for children with acquired brain injury: A systematic review

INTRODUCTION

We sought to compare the suitability of the Functional Independence Measure for Children (WeeFIM) and the Pediatric Evaluation of Disability Inventory (PEDI) as outcome measures in rehabilitation of children with acquired brain injury (ABI).

METHODS

We performed a systematic review of the evidence base using five databases. PRISMA guidelines were adhered to and the review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42015025370).

RESULTS

Twenty-six retrospective studies were included. Twelve studies utilized the PEDI, thirteen studies the WeeFIM, and one study included both. Statistically significant responsiveness was demonstrated for both the WeeFIM and PEDI, although significant ceiling effects were detected. Evidence of clinically significant responsiveness was limited to one center utilizing the PEDI.

CONCLUSION

Although requiring licensing to use, the WeeFIM is more suitable for the inpatient setting, is quicker to administer and showed minimal ceiling effects compared to the PEDI counterpart.

Rheumatic immune-related adverse events of checkpoint therapy for cancer: case series of a new nosological entity

Immunotherapy of cancer with checkpoint inhibitors has been associated with a spectrum of autoimmune and systemic inflammatory reactions known as immune-related adverse events (irAEs). Rheumatic irAEs are infrequently reported and extensively described. Here, we report our experience over an 18-month period with 15 patients evaluated in the rheumatology department for rheumatic irAEs. We identified 13 patients without pre-existing autoimmune disease (AID) who subsequently developed rheumatic irAEs, and two with established AID referred pre-emptively. irAEs encountered included: inflammatory arthritis, sicca syndrome, polymyalgia rheumatica-like symptoms and myositis. All cases required glucocorticoids, and three required a biological agent. Rheumatic irAEs led to temporary or permanent cessation of immunotherapy in all but five patients. One patient with pre-existing AID experienced a flare after starting immunotherapy. Our findings underscore that rheumatic irAEs are complex, at times require additional immunosuppressive therapy, and may influence ongoing immunotherapy regimens for the primary disease. Similar irAEs will be increasingly seen as checkpoint inhibitors adopted as standard of care in the community.

Fifteen-minute consultation: safety assessment prior to discharge of patient admitted for self-harm

Paediatricians often admit young people who have self-harmed, as advised by the National Institute for Health and Care Excellence guidelines. A full psychosocial assessment is essential to understand the underlying needs and risks. In this paper we focus on what the discharging doctor needs to know to arrange for a safe discharge. This involves reviewing the admission notes for red flags. We also give advice on the verbal and non-verbal communication skills needed to contain both the doctor's and the patient's difficult feelings.

Educational needs of health professionals working in rheumatology in Europe

Objective

To explore the availability of postgraduate education for health professionals (HPs) working in rheumatology in Europe, and their perceived educational needs and barriers for participation in current educational offerings.

Methods

Structured interviews were conducted with national representatives of rheumatology HPs' organisations and an online survey among individual HPs was disseminated through existing European League Against Rheumatism (EULAR) networks (10 languages including English). These comprised questions on: availability of postgraduate education, familiarity with EULAR and its educational offerings, unmet needs regarding the contents and mode of delivery and potential barriers to participate in education (0–10 scales).

Results

According to 17 national representatives, postgraduate rheumatology education was most common for nurses, physical and occupational therapists. There were 1041 individuals responding to the survey, of whom 48% completed all questions. More than half (56%) were familiar with EULAR as an organisation, whereas <25% had attended the EULAR congress or were familiar with EULAR online courses. Educational needs regarding contents were highest for ‘inflammatory arthritis’ and ‘connective tissue diseases’ and regarding modes of delivery for ‘courses organised in own country’ and ‘online courses’. Important barriers to participation included lack of ‘resources’, ‘time’ and ‘English language skills’. Overall, there was considerable variation in needs and barriers among countries.

Conclusions

There is a lack of postgraduate rheumatology education for HPs in most countries. There are opportunities to raise awareness regarding EULAR educational offerings and to develop courses provided in HPs' own country, tailored to national needs and barriers and taking language barriers into consideration.

EULAR/PReS standards and recommendations for the transitional care of young people with juvenile-onset rheumatic diseases

To develop standards and recommendations for transitional care for young people (YP) with juvenile-onset rheumatic and musculoskeletal diseases (jRMD). The consensus process involved the following: (1) establishing an international expert panel to include patients and representatives from multidisciplinary teams in adult and paediatric rheumatology; (2) a systematic review of published models of transitional care in jRMDs, potential standards and recommendations, strategies for implementation and tools to evaluate services and outcomes; (3) setting the framework, developing the process map and generating a first draft of standards and recommendations; (4) further iteration of recommendations; (5) establishing consensus recommendations with Delphi methodology and (6) establishing standards and quality indicators. The final consensus derived 12 specific recommendations for YP with jRMD focused on transitional care. These included: high-quality, multidisciplinary care starting in early adolescence; the integral role of a transition co-ordinator; transition policies and protocols; efficient communications; transfer documentation; an open electronic-based platform to access resources; appropriate training for paediatric and adult healthcare teams; secure funding to continue treatments and services into adult rheumatology and the need for increased evidence to inform best practice. These consensus-based recommendations inform strategies to reach optimal outcomes in transitional care for YP with jRMD based on available evidence and expert opinion. They need to be implemented in the context of individual countries, healthcare systems and regulatory frameworks.

Diagnostic criteria for cryopyrin-associated periodic syndrome (CAPS)

Cryopyrin-associated periodic syndrome (CAPS) is a rare, heterogeneous disease entity associated with NLRP3 gene mutations and increased interleukin-1 (IL-1) secretion. Early diagnosis and rapid initiation of IL-1 inhibition prevent organ damage. The aim of the study was to develop and validate diagnostic criteria for CAPS. An innovative process was followed including interdisciplinary team building, item generation: review of CAPS registries, systematic literature review, expert surveys, consensus conferences for item refinement, item reduction and weighting using 1000Minds decision software. Resulting CAPS criteria were tested in large cohorts of CAPS cases and controls using correspondence analysis. Diagnostic models were explored using sensitivity analyses. The international team included 16 experts. Systematic literature and registry review identified 33 CAPS-typical items; the consensus conferences reduced these to 14. 1000Minds exercises ranked variables based on importance for the diagnosis. Correspondence analysis determined variables consistently associated with the diagnosis of CAPS using 284 cases and 837 controls. Seven variables were significantly associated with CAPS (p<0.001). The best diagnosis model included: Raised inflammatory markers (C-reactive protein/serum amyloid A) plus ≥two of six CAPS-typical symptoms: urticaria-like rash, cold-triggered episodes, sensorineural hearing loss, musculoskeletal symptoms, chronic aseptic meningitis and skeletal abnormalities. Sensitivity was 81%, specificity 94%. It performed well for all CAPS subtypes and regardless of NLRP3 mutation. The novel approach integrated traditional methods of evidence synthesis with expert consensus, web-based decision tools and innovative statistical methods and may serve as model for other rare diseases. These criteria will enable a rapid diagnosis for children and adults with CAPS.

Integrating primary and secondary care for children and young people: sharing practice

OBJECTIVE

To share innovative practice with enough detail to be useful for paediatricians involved in planning services.

DESIGN

A review of practice, adopting a realist approach.

SETTING

We collected detailed information about five initiatives which were presented at two meetings in July and October 2014 and telephone interviews between July and November 2014 with key informants, updating information again in February 2015.

RESULTS

The five case studies involved three clinical commissioning groups (CCGs): Islington CCG and Southwark and Lambeth CCG in London and Taunton CCG in the Southwest. All five initiatives involved acute paediatric units. We heard about four distinct types of services designed to bring paediatric expertise into primary care and/or improve joint working between paediatricians and primary care professionals: telephone multidisciplinary team, hospital at home, general practitioner (GP) outreach clinics, and advice and guidance. We defined four common ways that initiatives might work: promoting shared responsibility; upskilling GPs; establishing relationships between paediatricians and primary healthcare professionals; and by taking specialist care to the patient.

CONCLUSIONS

We derived common aims and mechanisms and generated programme (mid-level) theory for each integrated care initiative about how they might work. These descriptions of what is being done can inform debate about which interventions should be prioritised for wider implementation. There is an urgent need for evaluation of these interventions and more indepth research into how mechanisms and their effectiveness could be assessed.

Structured, supported feeding admissions for restrictive eating disorders on paediatric wards

BACKGROUND

Restrictive eating disorders in young people are increasingly requiring admission to the hospital and can be a challenge to manage on acute general paediatric wards.

METHODS

We have developed a joint working model with Child and Adolescent Mental Health services (CAMHS) using short, structured, supported feeding admissions to supplement outpatient treatment in high risk or 'stuck' cases.

RESULTS

We have successfully managed the majority of young people in the community avoiding lengthy, expensive, specialist CAMHS eating disorder inpatient unit admissions (tier 4). Local ward admissions are easier to manage and the attitudes of nursing and medical staff towards these young people have changed.

DISCUSSION

Joint working between paediatric and CAMHS teams enables shorter, more manageable local ward admissions, reducing the need for tier-4 units.

EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome

Objectives

Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS).

Methods

Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus.

Results

Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease.

Conclusions

Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.

EULAR revised recommendations for the management of fibromyalgia

OBJECTIVE

The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'.

METHODS

A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations.

RESULTS

2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability).

CONCLUSIONS

These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

The quality of life of home-ventilated children and their primary caregivers plus the associated social and economic burdens: a prospective study

BACKGROUND

Despite the obvious challenges faced by families caring for children on home ventilation, there is surprisingly little research into the details of their daily lives. In particular, little is known about the quality of life of the child and caregiver plus the associated social and economic burdens of care.

METHODS

We prospectively studied 90 families enrolled in a paediatric home ventilation service in British Columbia. In the clinic, we recorded demographic information, patient acuity score and quality of life for patient and caregiver using standardised questionnaires. Parents then monitored social and financial costs of care at home over the subsequent 8 weeks. These data were collected by telephone at 1 and 2 months.

RESULTS

Most children led rich active lives. Camping trips, wheelchair sports and foreign travel were the norm, not the exception. Over 90% assessed the burden of care as mild or moderate. Government support covers medical expenses and home nursing (median 32 h/week, IQR 0-62.5 h). Monthly unreimbursed family expenses were low (median $87.7, IQR $15.3-$472). Despite this, nearly 25% of primary caregivers assessed burden of care as severe and over 50% had chronic illnesses requiring daily medication (principally depression, anxiety and arthritis). Quality of life for children or caregivers did not correlate with income or education.

INTERPRETATION

Home ventilation of complex children is a successful strategy but it places significant strain on the primary caregiver. Specific attention to the physical and mental health of the caregiver should be an integral part of the management of home-ventilated children.

TRIAL REGISTRATION NUMBER

NCT01863992.

Management of ulcerative colitis

Ulcerative colitis (UC) in children is increasing. The range of treatments available has also increased too but around 1 in 4 children still require surgery to control their disease. An up-to-date understanding of treatments is essential for all clinicians involved in the care of UC patients to ensure appropriate and timely treatment while minimising the risk of complications and side effects.

Child Health General Practice Hubs: a service evaluation

OBJECTIVE

To evaluate the impact of an integrated child health system.

DESIGN

Mixed methods service evaluation.

SETTING AND PATIENTS

Children, young people and their families registered in Child Health General Practitioner (GP) Hubs where groups of GP practices come together to form 'hubs'.

INTERVENTIONS

Hospital paediatricians and GPs participating in joint clinics and multidisciplinary team (MDT) meetings in GP practices, a component of an 'Inside-Out' change known as 'Connecting Care For Children (CC4C)'.

MAIN OUTCOME MEASURES

Cases seen in clinic or discussed at MDT meetings and their follow-up needs. Hospital Episode data: outpatient and inpatient activity and A&E attendance. Patient-reported experience measures and professionals' feedback.

RESULTS

In one hub, 39% of new patient hospital appointments were avoided altogether and a further 42% of appointments were shifted from hospital to GP practice. In addition, there was a 19% decrease in sub-specialty referrals, a 17% reduction in admissions and a 22% decrease in A&E attenders. Smaller hubs running at lower capacity in early stages of implementation had less impact on hospital activity. Patients preferred appointments at the GP practice, gained increased confidence in taking their child to the GP and all respondents said they would recommend the service to family and friends. Professionals valued the improvement in knowledge and learning and, most significantly, the development of trust and collaboration.

CONCLUSIONS

Child Health GP Hubs increase the connections between secondary and primary care, reduce secondary care usage and receive high patient satisfaction ratings while providing learning for professionals.

Therapeutic and diagnostic outcomes of a standardised, comprehensive care pathway for patients with systemic sclerosis

Objectives

To determine the outcomes, including number of medical interventions and initiation of immunosuppressive treatment of a standardised, comprehensive, diagnostic care pathway for patients with systemic sclerosis (SSc). Patient characteristics associated with need for medical interventions and with need for immunosuppressive treatment were determined.

Methods

Data were routinely gathered in connection with a 2-day care pathway combining multidisciplinary care and complete diagnostic work-up of organ involvement in SSc. The number of patients in whom the pathway resulted in medical interventions, and/or initiation of immunosuppressives was recorded. Patient characteristics and diagnostic tests results were compared between patients with and without medical interventions, and patients with and without initiation of immunosuppressives by means of multivariable logistic regression analyses.

Results

During a period of 44 months, 226 patients with SSc were referred to the care pathway. They included 186 (82%) women with mean age of 54 (SD 14.5) years, and median disease duration of 4 years (range 1–11); 73 (32%) of them had diffuse cutaneous SSc. Medical interventions were initiated in 191 (85%) patients, including initiation of immunosuppressive treatment in n=49 (22%). Presence of telangiectasias and higher erythrocyte sedimentation rate were associated with any medical intervention. Of commonly available variables, lower age, higher skin score and absence of anticentromere antibody were associated with initiation of immunosuppressives.

Conclusions

A standardised comprehensive 2-day care pathway for patients with SSc resulted in additional diagnostic or therapeutic interventions in 85% of the patients, regardless of SSc subtype and disease duration. In 22% of the patients, immunosuppressive treatment was initiated.

Management of developmental speech and language disorders: Part 1

The identification of developmental problems in a child's acquisition of speech, language and/or communication is a core activity in child surveillance. These are common difficulties with up to 15% of toddlers being 'late talkers' and 7% of children entering school with persisting impairments of their language development. These delays can confer disadvantages in the long term, adversely affecting language, cognition, academic attainment, behaviour and mental health. All children presenting with significant speech and language delay should be investigated with a comprehensive hearing assessment and be considered for speech and language therapy assessment. Socioeconomic adversity correlates with delayed language development. Clinical assessment should confirm that the presentation is definitely not acquired (see part 2) and will also guide whether the difficulty is primary, in which there are often familial patterns, or secondary, from a very wide range of aetiologies. Symptoms may be salient, such as the regression of communication in <3-year-olds which 'flags up' autism spectrum disorder. Further investigation will be informed from this clinical assessment, for example, genetic investigation for sex aneuploidies in enduring primary difficulties. Management of the speech and language difficulty itself is the realm of the speech and language therapist, who has an ever-increasing evidence-based choice of interventions. This should take place within a multidisciplinary team, particularly for children with more severe conditions who may benefit from individualised parental and educational supports.

Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team

AIM

To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand.

METHODS

Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010.

RESULTS

Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%).

CONCLUSIONS

The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death.

Antenatal magnesium sulfate: Neuro-protection for preterm infants

The neuro-protective effect of antenatal magnesium sulfate on very preterm infants has been demonstrated in good-quality randomised controlled trials and meta-analyses. Magnesium administered prior to preterm delivery crosses over to the foetal circulation and acts via several pathways to reduce perinatal neuronal damage. Meta-analysis of the trial data indicates that antenatal magnesium sulfate reduces the risk of cerebral palsy by one-third, and results in one fewer case in every 50 women treated. Treatment is associated with discomfort and flushing in some women, but maternal side-effects are mostly transient and manageable. Magnesium sulfate has also been found to be without any serious adverse consequences in newborn infants. Consensus recommendations and guidelines have been developed and implemented internationally, and endorsed by the UK Royal College of Obstetricians and Gynaecologists. However, magnesium sulfate for neuro-protection of very preterm infants has not yet become established widely in UK practice. Paediatricians, neonatologists and advocacy groups for preterm infants and their families could contribute to raising awareness and engage in dissemination activities and implementation initiatives to develop local protocols for adoption of this safe, effective and cost-effective intervention to reduce the burden of cerebral palsy in children born very preterm.

Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial

Objectives

The Educational Needs Assessment Tool (ENAT) is a self-completed questionnaire, which allows patients with arthritis to prioritise their educational needs. The aim of this study was to evaluate the effects of needs-based patient education on self-efficacy, health outcomes and patient knowledge in people with rheumatoid arthritis (RA).

Methods

Patients with RA were enrolled into this multicentre, single-blind, parallel-group, pragmatic randomised controlled trial. Patients were randomised to either the intervention group (IG) where patients completed ENAT, responses of which were used by the clinical nurse specialist to guide patient education; or control group (CG) in which they received patient education without the use of ENAT. Patients were seen at weeks 0, 16 and 32. The primary outcome was self-efficacy (Arthritis Self Efficacy Scale (ASES)-Pain and ASES-Other symptoms). Secondary outcomes were health status (short form of Arthritis Impact Measurement Scale 2, AIMS2-SF) and patient knowledge questionnaire-RA. We investigated between-group differences using analysis of covariance, adjusting for baseline variables.

Results

A total of 132 patients were recruited (IG=70 and CG=62). Their mean (SD) age was 54 (12.3) years, 56 (13.3)  years and disease duration 5.2 (4.9) years, 6.7 (8.9) years for IG and CG, respectively. There were significant between-group differences, in favour of IG at week 32 in the primary outcomes, ASES-Pain, mean difference (95% CI) −4.36 (1.17 to 7.55), t=−2.72, p=0.008 and ASES-Other symptoms, mean difference (95% CI) −5.84 (2.07 to 9.62), t=−3.07, p=0.003. In secondary outcomes, the between-group differences favoured IG in AIMS2-SF Symptoms and AIMS2-SF Affect. There were no between-group differences in other secondary outcomes.

Conclusions

The results suggest that needs-based education helps improve patients’ self-efficacy and some aspects of health status.

Trial registration number

ISRCTN51523281.

Detection of clinically manifest and silent synovitis in the hands and wrists by fluorescence optical imaging

Objectives

The correct identification of synovitis is critical for achieving optimal therapy results. Fluorescence optical imaging (FOI) is a novel modality based on the use of an intravenous fluorophore, which enables fluorescent imaging of the hands and wrists with increased focal optical signal intensities in areas of high perfusion and/or capillary leakage. The study objective was to determine the diagnostic utility of FOI in detecting apparent and clinically non-apparent active synovitis.

Methods

Bilateral hand and wrist joints (n=872) of 26 patients with inflammatory arthritis assessed by standard clinical examination, musculoskeletal ultrasound (MSUS) and FOI were studied. Synovitis was defined as tender and swollen joints on clinical examination, presence of synovial thickening and intra-articular Doppler signals on MSUS, and abnormal focal optical signal intensities on FOI, respectively. Subclinical synovitis was defined as being clinically non-apparent, but positively inflamed on MSUS.

Results

Depending on the standard used to define inflammation, FOI ranged from 73–83% sensitive and 83–95% specific for detecting manifest synovitis. For detecting clinically silent synovitis, the sensitivity, specificity and positive and negative predictive values of FOI were 80%, 96%, 77% and 97%, respectively.

Conclusions

The high degree of agreement between MSUS and FOI suggest its use in clinical practice, especially when MSUS is not available, in order to identify synovitis earlier and with greater confidence. FOI may be particularly useful in identifying patients with clinically non-apparent joint inflammation of the hands and/or wrists.

Socioeconomic inequities in perceived health among patients with musculoskeletal disorders compared with other chronic disorders: results from a cross-sectional Dutch study

OBJECTIVES

To explore the impact of socioeconomic factors on physical and mental health of patients with musculoskeletal disorders (MSKDs) and compare it across patients with other disorders.

METHODS

A representative sample of the Dutch population (n=8904) completed a survey on sociodemographics, physician-diagnosed (co-) morbidities, and physical (physical component summary, PCS) and mental (mental component summary, MCS) subscales of SF-12 (outcome variables). Regression models were computed first in the total group of patients with MSKDs, with education, age, gender, origin and place of residence as independent variables, and, second, in individuals expected to have paid work, adding a variable on social status. Models were repeated for five other subgroups of chronic disorders (cardiovascular (CVD), diabetes, cancer, mental and respiratory) and for healthy individuals.

RESULTS

MSKDs confirmed by a physician were reported by 1766 (20%) participants (mean age 59 years, 38% male), 547 (6%) respondents reported to have diabetes, 1855 (21%) CVD, 270 (3%) cancer, 526 (6%) mental disorders, 679 (8%) respiratory disorders and 4525 (51%) did not report any disease. In patients with MSKDs, (primary school vs university education (-5.3 (PCS) and -3.3 (MCS)) and having a state subsidy vs paid work (-5.3 (PCS) and -4.7 (MCS)) were consistently associated with worse physical and mental health. Gender was only relevant for PCS (female vs male -2.1). Comparable differences in health by education and social status were observed in the other diseases, except for cancer.

CONCLUSIONS

Education and social status in MSKD have the same strong and independent association with health as in other chronic diseases. These health gradients are unfair and partly avoidable, and require consorted attention and action in and outside healthcare.

Kabuki syndrome: clinical and molecular diagnosis in the first year of life

OBJECTIVE

To review the clinical and molecular genetic characteristics of 16 patients presenting a suspected diagnosis of Kabuki syndrome (KS) in the first year of life, to evaluate the clinical handles leading to a prompt diagnosis of KS in newborns. Clinical diagnosis of KS can be challenging during the first year of life, as many diagnostic features become evident only in subsequent years.

METHODS

All patients were clinically investigated by trained clinical geneticists. A literature review was performed using the Pubmed online database and diagnostic criteria suggested by DYSCERNE-Kabuki Syndrome Guidelines (2010) were used (a European Network of Centres of Expertise for Dysmorphology, funded by the European Commission Executive Agency for Health and Consumers (DG Sanco), Project 2006122). Molecular analysis of the known causative genes of KS, KMT2D/MLL2 and KDM6A, was performed through MiSeq-targeted sequencing platform. All mutations identified were validated by Sanger sequencing protocols.

RESULTS

Mutations in KMT2D gene were identified in 10/16 (62%) of the patients, whereas none of the patients had KDM6A mutations. Facial dysmorphisms (94%), feeding difficulties (100%) and hypotonia (100%) suggested the clinical diagnosis of KS. No significative differences in terms of facial features were noticed between mutation positive and negative patients of the cohort. Brachydactyly, joint laxity and nail dysplasia were present in about 80% of the patients. Other congenital anomalies were most commonly present in the mutated group of patients, including left-sided cardiac abnormalities, skeletal, renal and anorectal malformations and hypertricosis.

CONCLUSIONS

We present an overview of patients with KS diagnosed during the first year of life. Early diagnosis is serviceable in terms of clinical management and for targeted genetic counselling.

Prolonged school non-attendance in adolescence: a practical approach

Prolonged school non-attendance in adolescence poses a significant public health concern. Adverse outcomes for adolescents who have missed out on the social and academic benefits of high school include mental health disorders and economic, social and relationship difficulties that may persist into adulthood. Healthcare professionals are often consulted in cases of prolonged school non-attendance. Diagnosis and management of specific physical and mental health problems must be the health professional's initial priority, with the subsequent development of a management plan to assist with school reintegration. Using a specific framework, an understanding of the factors contributing to a young person's school non-attendance can be developed. Intervention leading to a successful return to school has the potential to lower the risk of associated long-term adverse health outcomes.

Social circumstances and medical complications in children with intestinal failure

Although most children discharged on home parenteral nutrition (HPN) will achieve enteral autonomy, some remain parenteral nutrition dependent; those who develop life-threatening complications may undergo small bowel transplantation (SBTx). The aim of this study was to investigate the relationship between social circumstances, compliance and complications.

SUBJECTS AND METHODS

An observational study in 2008-2012 on 64 children (34 HPN, 30 SBTx) from three units (two regional gastroenterology; one transplant). Social circumstances were assessed routinely as part of discharge planning; adherence by families to home care management was scored, and episodes of catheter-related blood stream infection and graft rejection were recorded for 2 years and related to compliance and social circumstances.

RESULTS

A quarter of families had a disadvantaged parent: non-English speaking (n=11), unable to read (n=5), physical disability (n=3), mental health problems disclosed (n=10); 20% children were cared for by a lone parent. Discharge home was delayed by social factors (n=9) and need for rehousing (n=17, 27%). 17/34 (50%) of HPN and 12/30 (40%) of transplant families were assessed as fully adherent. 10 families were assessed as non-adherent, eight were subject to child protection review and care was taken over by another family member (n=3) or foster parents (n=2). The risk of catheter-related blood stream infection was increased by parental disadvantage and age <3 years (p<0.05). Poor compliance was associated with complications in HPN and SBTx recipients.

CONCLUSIONS

Children receiving complex home care may be socially isolated and measures to support improved compliance such as increased community support, social care involvement and respite care may improve outcomes.

Use of formal advance care planning documents: a national survey of UK Paediatric Intensive Care Units

OBJECTIVE

Advance Care Planning (ACP) is nationally a core element of adult and paediatric palliative care strategies. It is defined as a process of discussion between an individual, their care providers and those close to them, about future care. Formal procedures and processes can help with some of the most difficult elements of communication related to ACP. The majority of children who die do so in a Paediatric Intensive Care Unit (PICU). This survey aimed to identify and compare paediatric ACP documents that are in use within UK hospitals with a PICU.

DESIGN

Email survey of lead clinicians from UK PICUs (n=28).

RESULTS

24 (86%) questionnaires were returned. 14 (58%) responded that formal ACP documents were currently in use within their hospital trust. Of the remainder, 2 (8%) detailed plans to launch local ACP documents in the near future, 1 (4%) had a 'Children and Young Persons Deterioration Management (CAYPDM) Document' and 3 (12%) listed rapid discharge and extubation pathways. 6 (25%) provided details of the document in use. They varied widely in terms of their presentation, content and intended use with some having been developed locally and others having been adopted across regions.

CONCLUSIONS

There is variation around the UK in the existence of formal ACP documents for paediatric patients with palliative care needs, as well as variation in the type of document that is used. Consideration of a national policy should be informed by further review and evaluation of these documents, as well as current practice in ACP.

A review of causes of Stevens-Johnson syndrome and toxic epidermal necrolysis in children

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening conditions almost exclusively attributed to drugs. The incidence in children is lower than in adults and has a better outcome. Mycosplama pneumoniae infection may be involved in some cases of paediatric SJS. The main etiologic factors for both SSJ and TEN are sulphonamides and anticonvulsants, followed by penicillins and non-steroidal anti-inflammatory drugs. In rare instances, paracetamol is the only suspected drug. By contrast with adults, allopurinol, oxicams and nevirapine are not identified as causative agents in children, probably due to differences in drug prescriptions. The only aspects of treatment that have been proved to improve survival are the rapid withdrawal of the suspected offending drugs and an optimal supportive therapy with emphasis in nutritional support, accompanied by management of denuded skin areas. The use of specific therapies remains controversial.

Diagnostic radiation exposure in children with spinal dysraphism: an estimation of the cumulative effective dose in a cohort of 135 children from The Netherlands

OBJECTIVE

Based on the assumption that children with spinal dysraphism are exposed to a large amount of ionising radiation for diagnostic purposes, our objective was to estimate this exposure, expressed in cumulative effective dose.

DESIGN

Retrospective cohort study.

SETTINGS

The Netherlands.

PATIENTS

135 patients with spinal dysraphism and under 18 years of age treated at our institution between 1991 and 2010.

RESULTS

A total of 5874 radiological procedures were assessed of which 2916 (49.6%) involved ionising radiation. Mean cumulative effective dose of a child with spinal dysraphism during childhood was 23 mSv, while the individual cumulative effective dose ranged from 0.1 to 103 mSv. Although direct radiography accounted for 81.7% of examinations, the largest contributors to the cumulative effective dose were fluoroscopic examinations (40.4% of total cumulative effective dose).

CONCLUSIONS

Exposure to ionising radiation and associated cancer risk were lower than expected. Nevertheless, the use of ionising radiation should always be justified and the medical benefits should outweigh the risk of health detriment, especially in children.

The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA).

METHODS

In a multicentre pragmatic randomised controlled trial, the assessment of clinical effects followed a non-inferiority design, while patient satisfaction and cost assessments followed a superiority design. Participants were 181 adults with RA randomly assigned to either NLC or rheumatologist-led care (RLC), both arms carrying out their normal practice. The primary outcome was the disease activity score (DAS28) assessed at baseline, weeks 13, 26, 39 and 52; the non-inferiority margin being DAS28 change of 0.6. Mean differences between the groups were estimated controlling for covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation (NHS and healthcare perspectives) estimated cost relative to change in DAS28 and quality-adjusted life-years (QALY) derived from EQ5D.

RESULTS

Demographics and baseline characteristics of patients under NLC (n=91) were comparable to those under RLC (n=90). Overall baseline-adjusted difference in DAS28 mean change (95% CI) for RLC minus NLC was -0.31 (-0.63 to 0.02) for PP and -0.15 (-0.45 to 0.14) for ITT analyses. Mean difference in healthcare cost (RLC minus NLC) was £710 (-£352, £1773) and -£128 (-£1263, £1006) for PP and ITT analyses, respectively. NLC was more cost-effective with respect to cost and DAS28, but not in relation to QALY utility scores. In all secondary outcomes, significance was met for non-inferiority of NLC. NLC had higher 'general satisfaction' scores than RLC in week 26.

CONCLUSIONS

The results provide robust evidence to support non-inferiority of NLC in the management of RA.

TRIAL REGISTRATION

ISRCTN29803766.

Development of healthcare quality indicators for rheumatoid arthritis in Europe: the eumusc.net project

BACKGROUND

Eumusc.net (http://www.eumusc.net) is a European project supported by the EU and European League Against Rheumatism to improve musculoskeletal care in Europe.

OBJECTIVE

To develop patient-centred healthcare quality indicators (HCQIs) for healthcare provision for rheumatoid arthritis (RA) patients.

METHODS

Based on a systematic literature search, existing HCQIs for RA were identified and their contents analysed and categorised referring to a list of 16 standards of care developed within the eumusc.net. An international expert panel comprising 14 healthcare providers and two patient representatives added topics and during repeated Delphi processes by email ranked the topics and rephrased suggested HCQIs with the preliminary set being established during a second expert group meeting. After an audit process by rheumatology units (including academic centres) in six countries (The Netherlands, Norway, Romania, Italy, Austria and Sweden), a final version of the HCQIs was established.

RESULTS

56 possible topics for HCQIs were processed resulting in a final set of HCQIs for RA (n=14) including two for structure (patient information and calculation of composite scores), 11 for process (eg, access to care, assessments, and pharmacological and non-pharmacological treatments) and one for outcome (effect of treatment on disease activity). They included definitions to be used in clinical practice and also by patients. Further, the numerators and the denominators for each HCQI were defined.

CONCLUSIONS

A set of 14 patient-centred HCQIs for RA was developed to be used in quality improvement and bench marking in countries across Europe.

Expert consensus for performing right heart catheterisation for suspected pulmonary arterial hypertension in systemic sclerosis: a Delphi consensus study with cluster analysis

OBJECTIVE

To establish an expert consensus on which criteria are the most appropriate in clinical practice to refer patients with systemic sclerosis (SSc) for right heart catheterisation (RHC) when pulmonary hypertension (PH) is suspected.

METHODS

A three stage internet based Delphi consensus exercise involving worldwide PH experts was designed. In the first stage, a comprehensive list of domains and items combining evidence based indications and expert opinions were obtained. In the second and third stages, experts were asked to rate each item selected in the list. After each of stages 2 and 3, the number of items and criteria were reduced according to a cluster analysis.

RESULTS

A literature search and the opinions of 47 experts participating in Delphi stage 1 provided a list of seven domains containing 142 criteria. After stages 2 and 3, these domains and tools were reduced to three domains containing eight tools: clinical (progressive dyspnoea over the past 3 months, unexplained dyspnoea, worsening of WHO dyspnoea functional class, any finding on physical examination suggestive of elevated right heart pressures and any sign of right heart failure), echocardiography (systolic pulmonary artery pressure >45 mm Hg and right ventricle dilation) and pulmonary function tests (diffusion lung capacity for carbon monoxide <50% without pulmonary fibrosis).

CONCLUSIONS

Among experts in pulmonary arterial hypertension-SSc, a core set of criteria for clinical practice to refer SSc patients for RHC has been defined by Delphi consensus methods. Although these indications are recommended by this expert group to be used as an interim tool, it will be necessary to formally validate the present tools in further studies.

A vasculitis centre based management strategy leads to improved outcome in eosinophilic granulomatosis and polyangiitis (Churg-Strauss, EGPA): monocentric experiences in 150 patients

OBJECTIVE

To evaluate a vasculitis centre based management strategy for eosinophilic granulomatosis and polyangiitis (Churg-Strauss, EGPA).

METHODS

A retrospective cohort study at a vasculitis referral centre was performed. All EGPA patients admitted from 1990 to 2009 were included. A structured interdisciplinary work-up for proof of diagnosis, Disease Extent Index and Birmingham Vasculitis Activity Score was performed. Immunosuppressive therapy was initiated and regularly adapted. Treatment targets were induction and maintenance of remission according to definitions given by the European League Against Rheumatism and the European Vasculitis Study Group. Outcomes were mortality, rate of remission, relapses, adverse events and prednisolone-dose.

RESULTS

Out of 269 patients with suspected EGPA 150 fulfilled the inclusion criteria. Of those, 104 had more than one follow-up visit resulting in a mean follow up of 53±4.9 months. By using additional data sources the follow-up concerning survival was extended to 92±5 month. Severe organ manifestations occurred at heart (46%), kidney (18%) and lungs (10%). Cyclophosphamide was used in 107 patients (71%). The prednisolone-doses of all patients were within the targeted range (i.e. ≤7.5 mg) in 69% of the total follow-up time; the median dose at end of follow-up was 5mg/d. The 10-year survival rate was 89% resulting in mortality comparable to the general population (SMR 1.29). Only patients with cardiac failure associated with EGPA had an increased mortality (SMR 3.06).

CONCLUSIONS

Regular re-evaluation and target-orientated adaption of therapy may lead to normalization of life expectancy and attenuation of disease progression. Continued centre based interdisciplinary treatment should be standard of care.