Psychological characteristics of caregivers of pediatric patients with chronic rheumatic disease in relation to treatment adherence

Benefits of Integrated Social Care in the Management of Patients With Inborn Errors of Metabolism

The current cornerstone of the management of many small-molecule inborn errors of metabolism (IEMs) is a combination of dietary therapy and medication, with evidence for improved clinical outcomes. However, the burden imposed on patients and families is substantial. Many families also have to manage this burden in conjunction with other medical, psychosocial, and financial stressors. Adherence to the recommended treatment can therefore be extremely challenging, sometimes leading to sustained derangement of biochemical parameters and/or clinical deterioration. The treating team needs to work with the family to determine an individualized optimal management strategy, with targets that can be pragmatically achieved. This paper focusses on the role of social care in assisting patients with a range of different small-molecule IEMs, as well as their families and the medical team. We provide six case vignettes that illustrate how social care involvement, in addition to enhanced psychosocial support from the clinical team, resulted in improved outcomes. This included assisting with adjustment to a new diagnosis, exploring and addressing barriers to treatment adherence, and provision of 'early help' community supports. In some instances where this was not sufficient and risk of harm to the child was considered significant, social care involvement facilitated graded escalation from a "child in need" approach to formal child protection measures. We identified challenges in engaging social workers external to the metabolic team. This included a need for greater education about the medical condition and the risks associated with undertreatment, lack of protected time for metabolic case management, and a lack of preventative involvement of social workers during the initial hospitalization (impacting on patient rapport). We advocate for the integration of social care within the metabolic team as part of a more holistic model of care.

The Bender-Gestalt Test: A Systematic Review

The Bender-Gestalt test (Bender test), since its appearance, has been widely used to analyze visuomotor functions, perception and cognitive processes. However, it is often used in a variety of other contexts. The aim of this research is to study the use of the Bender test and the Bender-II, based on the results of studies conducted between 2013 and 2023. The search was carried out using inclusion and exclusion criteria and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The databases consulted were Medline, Embase and SciELO (Scientific Electronic Library Online), with no language restrictions. Study selection criteria included three steps: title, abstract and full text. The heterogeneity of study results precluded meta-analysis. Sixty-two articles were retrieved through the electronic search, and after reviewing abstracts and reading full texts, 25 articles were considered to meet our inclusion criteria. Among these, studies reveal that the Bender test is particularly useful for diagnosing neurodegenerative disorders such as dementia and Alzheimer's disease. In particular, several studies have demonstrated its effectiveness in assessing visuomotor functions and visual perception, with mixed results regarding its sensitivity and specificity. Key findings include improved detection of cognitive impairment in the early stages of Alzheimer's disease and a strong association between test performance and patients' neuropsychological status. In conclusion, although the Bender test is widely recognized and used in various clinical populations, its use remains subject to certain limitations. The main criticism concerns subjectivity in interpreting results and the variability of scores depending on cultural factors and the age of the individual.

Caregiver experiences and needs in pediatric rheumatic disease: a mixed-methods systematic review protocol

INTRODUCTION

Understanding the genuine experiences and requirements of caregivers and implementing targeted interventions can have a positive impact on the physical and mental well-being of caregivers with children diagnosed with rheumatic diseases, ultimately reducing their burden and enhancing their quality of life. While there has been a gradual increase in research in this area in recent years, there remains a gap in the evidence that comprehensively and systematically reflects the actual experiences and needs of caregivers. We will employ a mixed-methods approach to evaluate the real-life experiences and requirements of caregivers for children diagnosed with rheumatic diseases to provide insights for both research and clinical interventions. METHODS AND ANALYSIS: All types of studies (quantitative, qualitative, and mixed-methods) involving caregivers of children aged 0 to 18 with rheumatic diseases will be included. We will conduct a comprehensive search across multiple databases, including MEDLINE (PubMed), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL), CNKI, WanFang, and VIP, as well as the grey literature, to identify primary studies published in either English or Chinese since 2000. Two independent reviewers will conduct the selection process and cross-check the data extraction. The focus of interest will be on understanding the experiences and needs of caregivers for pediatric rheumatic disease patients. In our systematic review, we will employ the 2018 version of the Mixed Methods Assessment Tool (MMAT) to evaluate study quality, and we will apply a convergent integration approach to synthesize the data.

ETHICS AND DISSEMINATION

Ethical approval is not needed, as no primary data will be collected. The results will be made available through a peer-reviewed publication.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 42023465302.

A qualitative study exploring experiences of treatment in paediatric rheumatology - children's, young people's, parents' and carers' perspectives

BACKGROUND

There is limited literature in paediatric rheumatology describing holistic lived experiences of medical treatment from perspectives of children and young people (CYP) and their parents or carers (PC). This is important as it could have implications for adherence. This study aimed to explore treatment experiences of CYP and PC in a paediatric rheumatology service.

METHODS

Participants were recruited at a day-case unit for intravenous infusions at a tertiary paediatric rheumatology centre. Joint qualitative semi-structured interviews with CYP and PC were used to collect data. Data were transcribed, quality checked and thematically analysed using NVivo 12.4 to identify findings.

RESULTS

Thirty-two participants (15 CYP between the ages of 6 and 16 years, 17 PC) took part in interviews lasting 41 min and 43 s, on average. Participants described experiences using infliximab, followed by tocilizumab and abatacept. Participants experienced a wave, oscillating between positive and negative trajectories. Experiences of medical treatments were described as temporary, eventually changing and leading to treatment changes or cessation. Behaviours were influenced through somatic factors (pain, function), social factors (advice from health professionals, encouragement from friends, family and teachers, practicality of using treatment in relation to school, work and finance) and cognitive factors (fear of needles, fear of specific medications, beliefs about necessity).

CONCLUSIONS

Collectively, findings demonstrate experiences of medical treatment reflect the nature of many paediatric rheumatology conditions, oscillating between periods of positive and negative trajectories. Somatic, social and cognitive experiences can be positive, when treatment is considered 'successful'. Negative somatic, social or cognitive experiences led to behaviours such as treatment non-adherence. A limitation of the study is interviews were conducted jointly with CYP and PC, which may have influenced what participants were willing to say in front of one another however this does mean findings relate to both CYP and PC and so could be suitable targets for interventions to improve adherence.

The evaluation of depression and anxiety levels of mothers of patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome and familial Mediterranean fever

OBJECTIVE

Periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome and familial Mediterranean fever (FMF) are autoinflammatory disorders typically characterized by recurrent fever attacks. These recurrent fever attacks can lead to depression and anxiety in mothers of these patients. This study aimed to compare the depression and anxiety levels in mothers of PFAPA and FMF patients.

METHODS

This study is a cross-sectional observational study. 48 mothers of children with FMF and 70 mothers of children with PFAPA participated in the study. Mothers in these two groups were compared in terms of anxiety and depression by using the validated Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI).

RESULTS

Depression and anxiety scores of mothers were found to be similar in FMF and PFAPA groups. Moderate or high level of anxiety was seen in 32% of mothers of patients with PFAPA and 27% of mothers of patients with FMF. 23% of mothers of patients with PFAPA were evaluated as having moderate or severe depression, and 18% of mothers of patients with FMF were evaluated as having moderate depression. There was no statistically significant difference between the duration, frequency of attacks, recurrent hospitalizations, sociodemographic characteristics, and inventory scores.

CONCLUSION

Depression and anxiety scores of mothers with children diagnosed with FMF and PFAPA are similar. These two diseases affect families psychosocially at similar levels. It is important to provide psychosocial support to families.

Factors associated with medication adherence among children with rheumatic diseases

Introduction: Failure to take medications regularly leads to poorer health outcomes. The Pediatric Rheumatology Adherence Questionnaire (PRAQ) is an effective tool for assessing medication adherence in rheumatic patients. Therefore, we aimed to determine the factors associated with poor medication adherence among children with rheumatic diseases. Methods: This was a cross-sectional study. Patients with rheumatic diseases who had taken at least one medication and had been followed up at our pediatric rheumatology clinic were included in the study, together with their caregivers. Patients with poor medication adherence were characterized as those who had taken less than 80% of their prescribed drugs, as determined using the pill count method. The original PRAQ was translated and validated in Thai language and was completed by caregivers and literate patients over age 13 years. Interviewing for additional problems with taking medications was conducted. We performed descriptive and logistic regression analyses. Results: From 210 patients, 52.86% had juvenile idiopathic arthritis (JIA), and 46.19% had connective tissue diseases. The mean patient age was 14.10 ± 4.74 years, with a median (interquartile range) disease duration of 4.33 (2.08-6.98) years. PRAQ scores in the group with poor adherence were significantly higher than scores in the group with good adherence (11.00 ± 3.47 vs. 9.51 ± 3.16, p = 0.004). Enthesitis-related arthritis (ERA) (odds ratio [OR] 9.09, 95% confidence interval [CI] 1.25-66.18; p = 0.029) and polyarticular JIA (OR 6.43, 95% CI 1.30-31.75; p = 0.022) were associated with poor treatment adherence. Disease duration ≥5 years (OR 3.88, 95% CI 1.17-12.87; p = 0.027), active disease (OR 6.49, 95% CI 1.76-23.99; p = 0.005), PRAQ scores ≥12 (OR 6.48, 95% CI 1.76-23.82; p = 0.005), forgetting to take medications (OR 14.18, 95% CI 4.21-47.73; p < 0.001), and unawareness about the importance of the medicines (OR 44.18, 95% CI 11.30-172.73; p < 0.001) were predictors of poor drug adherence. Conclusion: In the present study, poor medication adherence was found in one-fourth of children with rheumatic illnesses, particularly those with ERA, polyarticular JIA, longer disease duration, active disease, and high PRAQ scores. The most frequent reasons for inadequate medication adherence were forgetfulness and unawareness about the importance of disease control and consistency with treatment.

Hydroxychloroquine and immunosuppressant adherence patterns and their association with subsequent hospitalization rates among children with systemic lupus erythematosus

OBJECTIVES

Using a representative sample of children with systemic lupus erythematosus (SLE) in the United States, we characterized prescription claim-based hydroxychloroquine and immunosuppressant adherence estimates and evaluated their concurrent and predictive validity.

METHODS

We identified children ages 5-18 with SLE in the Truven Health MarketScan® Commercial and Medicaid claims databases (2013-2018). Among new users of hydroxychloroquine and immunosuppressant medications, we calculated proportion of days covered (PDC) over 365 days to estimate adherence by user group (mycophenolate, azathioprine, methotrexate, and any immunosuppressant use). Agreement between adherence estimates was evaluated with intraclass correlation coefficients (ICC) and kappa statistics. Separate negative binomial regression models were used to estimate associations between (a) hydroxychloroquine, (b) immunosuppressant, or (c) concurrent immunosuppressant/hydroxychloroquine non-adherence and subsequent hospitalizations, adjusted for baseline demographics, disease severity, and healthcare utilization.

RESULTS

Among 423 new hydroxychloroquine/immunosuppressant users, 63% were Medicaid recipients. Sufficient adherence (PDC≥80%) ranged from 33 to 45% for immunosuppressants vs. 51-52% for hydroxychloroquine. Agreement between hydroxychloroquine and immunosuppressant adherence was modest overall, but better for mycophenolate (ICC 0.55) than methotrexate (0.27). Hydroxychloroquine non-adherence was associated with a 2.9-fold higher incidence of subsequent hospitalizations (95% CI [1.2-7.1]), whereas immunosuppressant and concurrent non-adherence were associated with 5.9 [2.4-14.6] and 5.6-fold [2.0-15.5] increased incidence, respectively. Use of concurrent adherence improved upon estimation of hospitalization risk compared to hydroxychloroquine adherence, but not immunosuppressant adherence alone.

CONCLUSIONS

Hydroxychloroquine adherence is an imperfect proxy for adherence to other lupus medications among children with SLE, and therefore assessing immunosuppressant adherence concurrently adds value to hydroxychloroquine adherence assessments. Prescription claims-based immunosuppressant adherence measures are predictive of acute care utilization and may inform population management strategies.

Predictors of adherence to positive airway pressure therapy in children: a systematic review and meta-analysis

BACKGROUND

While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children.

METHODS

Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed.

RESULTS

We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence.

CONCLUSION

In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.