OA32 Minimally invasive, ultrasound-guided tissue biopsies of synovial tissue in children with Juvenile Idiopathic Arthritis for research: a feasibility study

Introduction/Background

When investigating disease mechanisms, site-specific differences in immune cell phenotype and function have highlighted the need to analyse cellular and molecular mechanisms at the tissue site directly. In adults, the ability to obtain synovial tissue biopsies using ultrasound-guided techniques, combined with advanced tissue analytics, has revolutionised our understanding of the cellular ecosystem that operates within the joint and how it contributes to disease. However, a similar approach in paediatric disease is lacking.

Description/Method

Aims: 1) To describe the protocol for undertaking minimally invasive ultrasound-guided synovial tissue biopsies in children and young people with arthritis, for the purpose of research, alongside routine clinical care. 2) To investigate whether high-quality synovial tissue can be obtained that is suitable for downstream applications including single cell profiling technologies, histology and digital spatial profiling.

Treatment-naïve children with a diagnosis of Juvenile Idiopathic Arthritis, who were being referred for a corticosteroid joint injection were recruited from two large UK Paediatric Rheumatology centres. We established a workflow pipeline for performing synovial tissue biopsies in child and young people with arthritis, using standardised procedures for biopsy and sample processing. Procedures were performed by experienced paediatric interventional radiologists with experience of joint biopsy for diagnostic purposes. Following a general anaesthetic, required as part of routine clinical care and the establishment of sterility, synovial fluid was aspirated. Needle-biopsies were undertaken from the same needle insertion site and subsequently corticosteroid was injected into the joint. Thickened synovium was graded via ultrasonography. Participating families completed questionnaires prior to and following synovial biopsy.

Discussion/Results

11 participants were recruited to the study over a nine month period, with a median age of 7 years (range 1-16 years); 91% were female. Samples obtained included core synovial biopsies, paired synovial fluid and peripheral blood. Synovial tissue fragments were processed for histology by formalin fixation and cryopreserved for downstream applications, including RNA sequencing and cell culture. Quality control indices included histological analysis to ensure the biopsied material was characteristically synovium and to grade the severity of inflammation. No significant complications were reported; however, one child had a mild haemarthrosis controlled with cold saline wash out and cold compresses.

Key learning points/Conclusion

Obtaining biopsies of synovial tissue in children with Juvenile Idiopathic Arthritis for the purpose of research, alongside clinical care is feasible. Analysis of tissue direct from the site of inflammation with single-cell RNA sequencing in children is achievable.

Fathers of children with a disability: health, work, and family life issues

PURPOSE

Fathers in families raising children with disabilities are under-researched. Fathers' perspectives can be better accommodated in childhood disability services that operate on a family-centred paradigm if their perspectives are understood. This study aimed to investigate the perspectives of fathers on caring and family life, work, and health.

METHODS

A mixed-methods design with an online questionnaire included open-ended questions and three instruments: Depression Anxiety Stress Scales (DASS); Health Promoting Activities Scale (HPAS-M); Fathers of Children with Developmental Challenges (FCDC) Scale.

RESULTS

Fathers (n = 33) reported high depressive (58%), anxiety (37%), and stress symptoms (61%). Fathers reported low participation in health-promoting activity with less than weekly: planning health activities (58%); solo physical activity (26%); social activity (3%); time relaxing (16%). Sixty-four percent worked full-time, although work was reported to be challenged by family responsibilities. Fathers described directly caring for their children although service interactions were low and delegated to mothers.

CONCLUSIONS

Fathers in this study reported stress, mental health issues, and low participation in healthy activity. Fathers experienced challenges related to career progression and job choices due to family responsibilities. Providing individualised and responsive support to fathers of a child with a disability would better support the family unit.IMPLICATIONS FOR REHABILITATIONFathers of children with a disability in this study experienced high mental health symptoms.Fathers were involved with their child's care at home but had low service interactions suggesting that service providers need to discover new ways to better engage fathers.Fathers experienced challenges to participation in paid work secondary to care responsibilities for their child with a disability and resulting needs of their family.Services that better support fathers are important to promote better health and wellbeing and support families.

Cutaneous sequelae of a national health crisis: Obesity and the skin

Background

The global obesity pandemic has far‐reaching health consequences and has become a major global health challenge. The worldwide prevalence of obesity nearly doubled between 1980 and 2008 and based on the latest estimates in the European Union, obesity affects up to 30% of adults. As a consequence of this rising prevalence of obesity, there has been an increase in the frequency of certain disease of the skin.

Objectives

We review the cutaneous sequelae of obesity, firstly describing the physiological consequences of increased adiposity in the skin and secondly examining the dermatoses associated with obesity.

Controlled choice, not choice and control: Families' reflections after one year using the National Disability Insurance Scheme

INTRODUCTION

At least 40 percent of children with cerebral palsy and their families rely on access to allied health services, assistive technology, and require funding and expertise to achieve skills and participate in daily life. Implementation of the National Disability Insurance Scheme (NDIS) has resulted in a shift to public funding and emphasis on choice and control of services, support and assistive technology to promote social and economic participation. Families of children with cerebral palsy are invested in scheme success and their subjective experiences require consideration if the NDIS is to meet participation targets.

OBJECTIVE

The aim of this research was to explore the experiences of families with a child with cerebral palsy, who have been in receipt of the NDIS for 12 months, comparisons to previous funding systems, and recommendations for the NDIS going forward.

METHODS

Purposive sampling was utilised within one specialised paediatric setting. All families received occupational therapy intervention for their child. A qualitative approach using semi structured interviews was employed. Braun and Clarke's six phases of thematic analysis was utilised to analyse the data and explore participants lived experiences.

FINDINGS

Eight (n = 8) mothers of children with cerebral palsy were interviewed. Three overarching themes were derived from the data: Equipment impacts on all areas of life; Frustration navigating the National Disability Insurance Scheme; and Gratitude, hope and suggestions.

CONCLUSION

Families reported challenges navigating the NDIS including administrative challenges and extensive wait times for assistive technology, as well as gratefulness for increased opportunities for support. Occupational therapists and other allied health professionals can assist by: being proactive in service delivery and advocating for the needs of individual families and children; and finding ways to increase the preparedness of the NDIS to better understand the needs of children with cerebral palsy and their families.

Evaluation of the UK Public Health Skills and Knowledge Framework (PHSKF): implications for international competency frameworks

Background

The value of competency frameworks for developing the public health workforce is widely acknowledged internationally. However, there is a lack of formal evaluations of such frameworks. In the UK, the Public Health Skills and Knowledge Framework (PHSKF) is a key tool for the public health workforce across the UK, and this study presents the evaluation of the PHSKF 2016 version, with the aim of reflecting on implications for international public health competency frameworks.

Methods

A sequential explanatory design was employed. An online survey (n = 298) was completed with stakeholders across the four UK nations and different sectors. This was followed by 18 telephone interviews with stakeholders and survey completers. Quantitative results were analysed descriptively; qualitative transcripts were analysed with thematic analysis.

Results

Most respondents had used the PHSKF occasionally or rarely, and most users found it useful (87%) and easy to use (82%). Main purposes of use included team/workforce development (e.g. setting of standards) and professional development (e.g. identify professional development opportunities). Some positive experiences emerged of uses of the PHSKF to support organisational redevelopments. However, 23% of respondents had never used the framework. Areas for improvement included greater clarity on purpose and audience, the need for more support from employers and for clear career progression opportunities, and stronger links with other competency frameworks.

Conclusions

The development of a digital version of the PHSKF, together with improving buy-in from the workforce and employers could make an important contribution towards UK public health workforce development. Further evaluation and shared learning internationally of the implementation of public health competency frameworks would support global public health workforce development.

School success and participation for students with cerebral palsy: a qualitative study exploring multiple perspectives

PURPOSE

This qualitative study investigated perceived successful school experiences for students with cerebral palsy in Australia. Participation and appropriate support in school are complex concepts, although few studies have investigated all stakeholders' perspectives.

METHODS

Phenomenology informed the study that centered on the concept of a successful school experience. In-depth interviews occurred with students (n = 7), parents (n = 11), teachers (n = 10), school principals (n = 9) and allied health practitioners (n = 10) to gain the perspective from multiple vantage points. Specific research questions, interview guides and demographic questionnaires were configured for each group. Interviews were analyzed thematically within and between groups.

RESULTS

Three key themes emerged: Collaborative partnerships between families, schools and outside organizations; School culture and attitude is key; and, allied health practitioners are part of home and school teams.

CONCLUSIONS

Student and school success was impacted substantially by the capacity of adults in the student's life to collaborate - family, school professionals and allied health practitioners. An inclusive school culture was crucial to students with cerebral palsy. All parties needed to prioritize promotion of an open and positive school culture built around problem-solving inclusive practices. Involved people, such as allied health practitioners, bring knowledge and skills that are not otherwise readily available in school environments. Implications for rehabilitation Students with cerebral palsy have high needs at school and allied health practitioners have a role advocating for, educating and providing support to students within the school. Teachers of students with cerebral palsy need education, training and support from allied health practitioners. The need for allied health and rehabilitation services continues for children and youth with cerebral palsy outside of school and across the schooling years. School professionals; allied health practitioners; families and students can work together to improve the student experience.

Complementary, Alternative, and Mainstream Service use Among Families with Young Children with Multiple Disabilities: Family Costs to Access Choices

ABSTRACT Families raising a young child with multiple disabilities are charged with significant responsibilities such as learning about their child's condition and navigating mainstream and alternative services. Aim: Describe service choices, costs, out of pocket expenses, and the impact on families. Methods: Survey design using a custom questionnaire was used to collect extensive retrospective and current data. Purposive sampling (N = 29) occurred from one early intervention facility specialized in servicing children with cerebral palsy (CP) and, or multiple disabilities in Australia. Descriptive statistics were used for analysis of data. Results: Twenty-three (79%) families reported caring for a child with CP. Twenty-three families reported using at least one complementary/alternative intervention. Out-of-pocket amounts were reported including: chiropractic services (10 families); naturopathy (9 families); point percussion therapy (7 families), and Chinese medicine (6 families). Expenses resulted in families reporting forgoing clothing items, family entertainment, recreation/hobbies for parents (55%); family holidays (59%); time for parents alone (66%); and health services for parents (38%). Conclusions: Families of young children with multiple disabilities select a wide range of services for their child, with consequential out of pocket expenses. Early intervention professionals can be an important resource for families as they evaluate their choices and select interventions for their child.

Young children with cerebral palsy: families self-reported equipment needs and out-of-pocket expenditure

BACKGROUND

Costs to families raising a child with cerebral palsy and complex needs are direct and indirect. This study investigated the self-reported real-life costs, equipment needs, and associated characteristics of children who had the highest equipment and care needs.

METHOD

The purposive sample (n = 29) were families with a child with cerebral palsy: gross motor function levels 5 (n = 20), level 4 (n = 5), level 3 (n = 4); complex communication needs (n = 21); medical needs (n = 14); hearing impairment (n = 5) and visual impairment (n = 9). Participants completed a specifically designed survey that included the Assistance to Participate Scale. Equipment and technology purchases were recorded in the areas of positioning, mobility, transport, home modifications, communication, splinting and orthoses, self-care, technology, communication devices, medical, adapted toys/leisure items and privately hired babysitters/carers. Descriptive and inferential statistics were used to analyse the data.

RESULTS

Families had purchased up to 25 items within the areas described. The highest median number of items were recorded for positioning (15 items), mobility devices (9 items) and adapted toys/leisure items (9 items). Median costs were highest for home modifications (AUD$23000), transport (AUD$15000), splints and orthoses (AUD$3145), paid carers (AUD$3080), equipment for toileting/dressing/bathing (AUD$2900) and technical/medical items ($2380). Children who needed more parental assistance to participate in play and recreation also required significantly more equipment overall for positioning, communication, self-care and toys/leisure.

CONCLUSIONS

The equipment needs of young children with complex disability are extensive and out-of-pocket expenses and parental time to support participation in play/recreation excessive. Substantial financial support to offset costs are crucial to better support families in this life situation.

The use of zolpidem in the treatment of progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is a debilitating progressive neurodegenerative disorder for which there is no proven pharmacological treatment. Zolpidem immediate release formulation has been reported to show short-term improvements in motor function and voluntary saccadic eye movements, but the benefits were not sustained. A 61-year-old man with a 4-year history of PSP was observed over 6 months to have sustained improvement in motor function, pseudobulbar symptoms and ocular motility 2 months after commencing zolpidem controlled release (CR) formulation. He was admitted to hospital and a detailed neurological and functional assessment recorded on video after withdrawal of zolpidem CR, and again following re-introduction of the medication. Within 1 hour of administration of 25mg zolpidem CR the patient had a dramatic improvement in fine motor skills, dexterity, speed and fluidity of movement, facial and vocal expression, oropharyngeal coordination and function and pursuit, and voluntary saccadic eye movements. These improvements were observed for 4 hours to 5 hours post-dose and were reproducible on subsequent withdrawal and re-challenging. We found that zolpidem CR, a gamma aminobutryic acid (GABA)ergic agonist of the benzodiazepine type 1 receptor, caused sustained improvement in motor and ocular symptoms in a patient with PSP over 6 months. Further studies are needed to determine the potential roles of GABA neurotransmission in PSP.

The outcome of Direct Current Cardioversion (DCC) for the treatment of Atrial Fibrillation (AF) in a district general hospital in Ireland

BACKGROUND

Direct current cardioversion (DCC) is a method to control persistent AF, to facilitate a reduction in stroke risk. Although this is a frequently performed procedure, there are no available published data regarding its outcome in an Irish setting.

AIMS

To determine the short- and long-term outcome of DCC, factors predicting a successful outcome, and its safety.

METHODS

Data relating to each DCC were collected retrospectively from patient notes over a 6.3 year-period, and subsequently entered into a Microsoft Access database before subsequent statistical analysis.

RESULTS

Forty-five consecutive unselected patients were identified, in which 59 DCCs were performed. Sinus rhythm (SR) was achieved immediately after DCC in 54/59 (91%) patients. There was a significant positive correlation between patient body weight and the energy level required to achieve SR (p=0.0001). No thromboembolic complications were noted. After a mean follow-up time of 12 +/- 13.7months, 30/45 (67%) had maintained SR. After univariate analysis, a number of important factors predictive of maintenance of SR at follow-up were identified.

CONCLUSION

DCC was found to be an effective method for short- and long-term control of AF, without thromboembolic complications, and patients with a favourable long-term outcome after DCC could conceivably be predicted on the basis of a methodical history, careful examination, simple investigations and pharmacological variables.

Alternative work scheduling for professional social workers

The authors present some practical evidence that the changing nature of today's work force requires innovative alternatives to traditional scheduling based on the 9 to 5, five-day workweek. They support alternative work scheduling (AWS) as an updated and promising approach. Described is their experience with a two-year AWS pilot project in the Social Work Service of an urban medical center, with their focus upon the processes of negotiating, programming, and implementing the concepts of "flex-time," "compressed workweek," and "job sharing." Informal assessment indicates strongly positive responses from the participating social workers, other members of the health care team, and the consumers of the services.

Metal resistance and accumulation in bacteria

Recent research on the ecology, physiology and genetics of metal resistance and accumulation in bacteria has significantly increased the basic understanding of microbiology in these areas. Research has clearly demonstrated the versatility of bacteria to cope with toxic metal ions. For example, certain strains of bacteria can efficiently efflux toxic ions such as cadmium, that normally exert an inhibitory effect on bacteria. Some bacteria such as Escherichia coli and Staphylococcus sp. can volatilize mercury via enzymatic transformations. It is also noteworthy that many of these resistance mechanisms are encoded on plasmids or transposons. By expanding the knowledge on metal-resistance and accumulation mechanisms in bacteria, it may be possible to utilize certain strains to recover precious metals such as gold and silver, or alternatively remove toxic metal ions from environments or products where their presence is undesirable.

Radiologic characteristics of primitive neuroectodermal tumors in children

Radiographic findings are reviewed in 31 children with primitive neural ectodermal tumors seen at the Hospital for Sick Children from 1962 through 1983. Seventeen children were initially evaluated with computed tomography (CT). Ten of these had both CT studies and angiography. The tumors were large, irregular, typically iso- to hyperdense, and showed dense, heterogeneous contrast enhancement. Cysts were present in 65% and calcifications in 71% of cases. The angiographic findings were nonspecific, ranging from avascular to markedly vascular. Although these tumors were usually found in the cerebral hemisphere, particularly the frontal lobes, two cases are included of tumors arising elsewhere: one in the pineal and one in the suprasellar region. Epidemiologic data are reviewed.