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Md Yusof MY, Smith EMD, Ainsworth S, Armon K, Beresford MW, Brown M, Cherry L, Edwards CJ, Flora K, Gilman R, Griffiths B, Gordon C, Howard P, Isenberg D, Jordan N, Kaul A, Lanyon P, Laws PM, Lightsone L, Lythgoe H, Mallen CD, Marks SD, Maxwell N, Moraitis E, Nash C, Pepper RJ, Pilkington C, Psarras A, Rostron H, Skeates J, Skeoch S, Tremarias D, Wincup C, Zoma A, Vital EM. Management and treatment of children, young people and adults with systemic lupus erythematosus: British Society for Rheumatology guideline scope. Rheumatol Adv Pract 2023; 7:rkad093. [PMID: 38058676 PMCID: PMC10695902 DOI: 10.1093/rap/rkad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/20/2023] [Indexed: 12/08/2023] Open
Abstract
The objective of this guideline is to provide up-to-date, evidence-based recommendations for the management of SLE that builds upon the existing treatment guideline for adults living with SLE published in 2017. This will incorporate advances in the assessment, diagnosis, monitoring, non-pharmacological and pharmacological management of SLE. General approaches to management as well as organ-specific treatment, including lupus nephritis and cutaneous lupus, will be covered. This will be the first guideline in SLE using a whole life course approach from childhood through adolescence and adulthood. The guideline will be developed with people with SLE as an important target audience in addition to healthcare professionals. It will include guidance related to emerging approved therapies and account for National Institute for Health and Care Excellence Technology Appraisals, National Health Service England clinical commissioning policies and national guidance relevant to SLE. The guideline will be developed using the methods and rigorous processes outlined in 'Creating Clinical Guidelines: Our Protocol' by the British Society for Rheumatology.
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Affiliation(s)
- Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Eve M D Smith
- Department of Women’s and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | | | - Kate Armon
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michael W Beresford
- Department of Women’s and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | | | - Lindsey Cherry
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Christopher J Edwards
- Musculoskeletal Research Unit, NIHR Southampton Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Kalveer Flora
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Rebecca Gilman
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Natasha Jordan
- Department of Adolescent Rheumatology, St James’s Hospital and Children’s Health Ireland, Dublin, Ireland
| | - Arvind Kaul
- Department of Rheumatology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Peter Lanyon
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Laws
- Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Liz Lightsone
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Christian D Mallen
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Elena Moraitis
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Department, University College of London Great Ormond Street Institute of Child Health, London, UK
| | - Clare Nash
- Pharmacy Department, Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Ruth J Pepper
- Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Antonios Psarras
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Heather Rostron
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jade Skeates
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Skeoch
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | - Chris Wincup
- Department of Clinical and Academic Rheumatology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Asad Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Charras A, Haldenby S, Smith EMD, Egbivwie N, Olohan L, Kenny JG, Schwarz K, Roberts C, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Modgil G, Pilkington C, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Beresford MW, Hedrich CM. Panel sequencing links rare, likely damaging gene variants with distinct clinical phenotypes and outcomes in juvenile-onset SLE. Rheumatology (Oxford) 2023; 62:SI210-SI225. [PMID: 35532072 PMCID: PMC9949710 DOI: 10.1093/rheumatology/keac275] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Juvenile-onset systemic lupus erythematosus (jSLE) affects 15-20% of lupus patients. Clinical heterogeneity between racial groups, age groups and individual patients suggests variable pathophysiology. This study aimed to identify highly penetrant damaging mutations in genes associated with SLE/SLE-like disease in a large national cohort (UK JSLE Cohort Study) and compare demographic, clinical and laboratory features in patient sub-cohorts with 'genetic' SLE vs remaining SLE patients. METHODS Based on a sequencing panel designed in 2018, target enrichment and next-generation sequencing were performed in 348 patients to identify damaging gene variants. Findings were integrated with demographic, clinical and treatment related datasets. RESULTS Damaging gene variants were identified in ∼3.5% of jSLE patients. When compared with the remaining cohort, 'genetic' SLE affected younger children and more Black African/Caribbean patients. 'Genetic' SLE patients exhibited less organ involvement and damage, and neuropsychiatric involvement developed over time. Less aggressive first line treatment was chosen in 'genetic' SLE patients, but more second and third line agents were used. 'Genetic' SLE associated with anti-dsDNA antibody positivity at diagnosis and reduced ANA, anti-LA and anti-Sm antibody positivity at last visit. CONCLUSION Approximately 3.5% of jSLE patients present damaging gene variants associated with younger age at onset, and distinct clinical features. As less commonly observed after treatment induction, in 'genetic' SLE, autoantibody positivity may be the result of tissue damage and explain reduced immune complex-mediated renal and haematological involvement. Routine sequencing could allow for patient stratification, risk assessment and target-directed treatment, thereby increasing efficacy and reducing toxicity.
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Affiliation(s)
- Amandine Charras
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
| | - Sam Haldenby
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
| | - Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Naomi Egbivwie
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Lisa Olohan
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
| | - John G Kenny
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
- Teagasc Food Research Centre, Moorepark, Cork, Ireland
| | - Klaus Schwarz
- Institut for Transfusion Medicine, University Ulm, Ulm
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service Baden-Württemberg—Hessen, Ulm, Germany
| | - Carla Roberts
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children’s Hospital, Birmingham
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford
| | - Daniel P Hawley
- Department of Paediatric Rheumatology, Sheffield Children’s Hospital, Sheffield
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children’s Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne
| | - Gita Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton
| | | | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham
| | - Phil Riley
- Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Manchester
| | - Arani Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
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Schreiber K, Frishman M, Russell MD, Dey M, Flint J, Allen A, Crossley A, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice. Rheumatology (Oxford) 2022; 62:e89-e104. [PMID: 36318967 PMCID: PMC10070063 DOI: 10.1093/rheumatology/keac552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Karen Schreiber
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust , London, UK
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases , Sonderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark , Odense, Denmark
| | - Margreta Frishman
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust , London, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, King’s College London , London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust , Shropshire, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology , London, UK
| | | | - Mary Gayed
- Rheumatology, University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
| | - Kenneth Hodson
- The UK Teratology Information Service , Newcastle upon Tyne, UK
| | - Munther Khamashta
- Division of Women’s Health, Lupus Research Unit, King's College London , London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady’s Hospice and Care Service , Dublin, Ireland
| | - Sonia Panchal
- Rheumatology, South Warwickshire NHS Foundation Trust , Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital , Bath, UK
| | | | - Katherine Saxby
- Pharmacology, University College London Hospitals NHS Foundation Trust , London, UK
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust , London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham NHS Trust , Birmingham, UK
| | | | - Louise Warburton
- Shropshire Community NHS Trust , Shropshire, UK
- Primary Care and Health Sciences, Keele University , Keele, UK
| | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust , London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust , Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham , Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London , London, UK
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Price-Kuehne F, Armon K. Chronic non-bacterial osteomyelitis (CNO) in childhood: a review. Curr Pediatr Rev 2022; 19:CPR-EPUB-127239. [PMID: 36305134 DOI: 10.2174/1573396319666221027123723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/05/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory bone disorder mostly affecting children and adolescents. Although it is considered a rare disease, CNO is likely to be the single most common autoinflammatory bone disease in childhood, underdiagnosed and underreported due to a lack of awareness of the condition in both medics and patients, and the absence of validated diagnostic criteria. The exact underlying pathogenesis of CNO remains unknown, making targeted treatment difficult. This issue is exacerbated by the lack of any randomised control trials, meaning that treatment strategies are based solely on retrospective reviews and case series. This review summarises the current concepts in pathophysiology, the clinical features that help to differentiate important differential diagnoses, and an approach to the investigation and management of children with CNO. Ultimately, the timely and thorough investigation of children and young people with CNO is vitally important to exclude important mimics and initiate appropriate management that can prevent the complications of persistent inflammatory bone disease.
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Affiliation(s)
- Fiona Price-Kuehne
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Armon
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Suo C, Chia D, Toms A, Sanghrajka A, Ramanan A, Killeen O, Jacobs B, Ilea C, Mahmood K, Compeyrot-Lacassagne S, Armon K. OA33 Incidence of chronic recurrent multifocal osteomyelitis in the UK and Republic of Ireland: initial results from 13 months of surveillance study. Rheumatol Adv Pract 2022. [PMCID: PMC9515744 DOI: 10.1093/rap/rkac066.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction/Background Chronic Recurrent Multifocal Osteomyelitis (CRMO), also known as chronic nonbacterial osteomyelitis (CNO), is a rare autoinflammatory condition affecting the bones. It occurs primarily in children and teenagers and is characterised by bone pain and swelling in the absence of infection or tumour. The incidence of CRMO remains uncertain, with estimates ranging from 0.4-1 per 100,000 person years. Description/Method The primary aim of the study was to identify the incidence of CRMO in patients under the age of 16 in the United Kingdom (UK) and Republic of Ireland (ROI). Additional aims include describing the demographics, clinical features, treatment, and healthcare needs of patients with CRMO. A prospective surveillance study was undertaken via the British Paediatric Surveillance Unit. A monthly e-reporting card was sent to all registered paediatric consultants in the UK and ROI. A parallel surveillance study was sent via the British Society for Children’s Orthopaedics to identify patients managed solely by orthopaedics. A standardised questionnaire was sent to the reporting clinicians to collect further information. Discussion/Results During initial 13 months of surveillance, 168 cases were reported. 23 questionnaires were not returned (13.7% of reported cases). After de-duplication, and removal of cases outside the reporting time period and age-group, 82 confirmed and 8 probable cases were included in these interim results. The estimated incidence of CRMO is 0.605 cases/100,000 children per year. Median age at time of diagnosis was 10 years (range 3-16). 53 (58.9%) of cases were female. Median delay from symptom onset to diagnosis was 5 months and 16 patients (17.78%) had a delay of greater than 12 months. Most (48.9%) of the cases were diagnosed by paediatric rheumatology specialists. Other cases were diagnosed by orthopaedics (16.7%), general paediatricians (15.6%) or by a multidisciplinary team. 34 cases (37.8%) reported requiring hospital admission related to CRMO. The most common presenting feature was bone pain (96.67%). 34 patients (37.8%) presented with clavicular pain, and thirty-one (34.4%) had unifocal bone pain. Patients also presented with bone swelling (52.2%), joint swelling (20.0%), fever (12.2%) and general malaise (13.3%). A median of 3 radiological investigations were reported for each case, of which 61 (67.7%) cases had whole body MRI performed. Additionally, 33 cases (36.67%) had bone biopsy. At initial reporting, the most common treatment was NSAIDs (90.0%) and bisphosphonates (33.3%). Key learning points/Conclusion Our results estimate the incidence of CRMO as 0.605 cases per 100,000 person years. The study will continue to capture new CRMO cases for a further 12 months. Reported cases will be followed up for 24 months. This prospective study of all incident cases of CRMO within the UK and ROI will provide insight into the medium-term outcomes and treatment strategies used by clinicians. These results will provide a valuable baseline for further research and improvement in care for patients with CRMO.
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Affiliation(s)
- Chenqu Suo
- Department of Paediatrics, University of Cambridge , Cambridge, United Kingdom
| | - Daphne Chia
- Department of Paediatrics, University of Cambridge , Cambridge, United Kingdom
| | - Andoni Toms
- Department of Radiology, Cambridge University Hospitals , Cambridge, United Kingdom
| | - Anish Sanghrajka
- Department of Truama and Orthopaedics, Norfolk and Norwich University Hospitals , Norwich, United Kingdom
| | - Athimalaipet Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children , Bristol, United Kingdom
| | - Orla Killeen
- National Centre for Paediatric Rheumatology, Children's Health Ireland , Dublin, Ireland
| | - Benjamin Jacobs
- Royal National Orthopaedic Hospital , London, United Kingdom
| | - Cristina Ilea
- Royal National Orthopaedic Hospital , London, United Kingdom
| | - Kamran Mahmood
- Department of Rheumatology, Alder Hey Children's Hospital , United Kingdom
| | | | - Kate Armon
- Department of Paediatrics, University of Cambridge , Cambridge, United Kingdom
- Department of Paediatric Rheumatology, Cambridge University Hospitals , Cambridge, United Kingdom
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7
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Smith EMD, Egbivwie N, Jorgensen AL, Ciurtin C, Al-Abadi E, Armon K, Bailey K, Brennan M, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, Malik G, McLaren Z, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Wood F, Beresford MW, Hedrich CM. Real world treatment of juvenile-onset systemic lupus erythematosus: Data from the UK JSLE cohort study. Clin Immunol 2022; 239:109028. [PMID: 35513304 DOI: 10.1016/j.clim.2022.109028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the absence of clinical trials evidence, Juvenile-onset Systemic Lupus Erythematosus (JSLE) treatment plans vary. AIM To explore 'real world' treatment utilising longitudinal UK JSLE Cohort Study data. METHODS Data collected between 07/2009-05/2020 was used to explore the choice/sequence of immunomodulating drugs from diagnosis. Multivariate logistic regression determined how organ-domain involvement (pBILAG-2004) impacted treatment choice. RESULT 349 patients met inclusion criteria, median follow-up 4-years (IQR:2,6). Mycophenolate mofetil (MMF) was most commonly used for the majority of organ-domains, and significantly associated with renal involvement (OR:1.99, 95% CI:1.65-2.41, pc < 0.01). Analyses assessing the sequence of immunomodulators focused on 197/349 patients (meeting relevant inclusion/exclusion criteria). 10/197 (5%) solely recieved hydroxychloroquine/prednisolone, 62/197 (31%) received a single-immunomodulator, 69/197 (36%) received two, and 36/197 patients (28%) received ≥three immunomodulators. The most common first and second line immunomodulator was MMF. Rituximab was the most common third-line immunomodulator. CONCLUSIONS Most UK JSLE patients required ≥two immunomodulators, with MMF used most commonly.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK.
| | - Naomi Egbivwie
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK; Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | | | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Daniel P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Zoe McLaren
- Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Annie Ratcliffe
- Department of Paediatrics, Taunton & Somerset NHS Foundation Trust - Musgrove Park Hospital, Taunton, UK
| | - Phil Riley
- Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Arani Sridhar
- Leicester Children's Hospital, University Hospitals of Leicester NHS trust, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Fiona Wood
- Department of Paediatrics, University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
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8
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Bloxham N, Cross J, Garnett M, Bewick J, Armon K, Hook CE, Murray MJ. Hodgkin Lymphoma Presenting With Spinal Cord Compression: Challenges for Diagnosis and Initial Management. Pediatr Dev Pathol 2022; 25:168-173. [PMID: 34428078 PMCID: PMC9109237 DOI: 10.1177/10935266211033269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Hodgkin lymphoma (HL) can present with extra-nodal disease, but spinal cord compression is exceptionally rare. We describe a 15-year-old presenting with hip/back pain with normal initial examination. Persistent pain and raised inflammatory markers prompted further investigation with MRI, which revealed an epidural mass causing spinal cord compression. On examination, there was no palpable lymphadenopathy or cauda equina syndrome, but absent lower limb reflexes were noted. Following multidisciplinary discussion, it was determined that cauda equina syndrome was imminent and therefore surgical debulking was undertaken, both to prevent this complication and establish a diagnosis. At surgery, the tumor was highly vascular. Frozen section confirmed lesional material. Following surgery, and given the frozen section findings, a short course of steroids was commenced to reduce any peri-surgical edema. Unfortunately, histopathology was ultimately non-diagnostic, due to failure of immunohistochemistry on technically challenging material. Consequently, ultrasound-guided excision biopsy of a (non-palpable) cervical lymph node was performed five days later; histopathology showed typical effacement of the normal architecture and a conspicuous population of CD15/CD30-positive larger pale cells present, confirming nodular sclerosis classic HL, despite recent steroids. We review the available literature for HL presenting with spinal cord compression and describe the challenges for diagnosis and initial management in such cases.
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Affiliation(s)
- Nicola Bloxham
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Justin Cross
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Matthew Garnett
- Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jessica Bewick
- Department of Ear, Nose and Throat Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C Elizabeth Hook
- Department of Paediatric Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK,Department of Pathology, University of Cambridge, University of Cambridge, Tennis Court Road, Cambridge, UK
| | - Matthew J Murray
- Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK,Department of Pathology, University of Cambridge, University of Cambridge, Tennis Court Road, Cambridge, UK,Matthew J Murray, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, UK.
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9
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Smith EMD, Tharmaratnam K, Al-Abadi E, Armon K, Bailey K, Brennan M, Ciurtin C, Gardner-Medwin J, Haslam KE, Hawley D, Leahy A, Leone V, Malik G, McLaren Z, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Hedrich CM, Jorgensen A, Beresford MW. Attainment of Low Disease Activity and Remission Targets reduces the risk of severe flare and new damage in Childhood Lupus. Rheumatology (Oxford) 2021; 61:3378-3389. [PMID: 34894234 PMCID: PMC9348762 DOI: 10.1093/rheumatology/keab915] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Indexed: 11/14/2022] Open
Abstract
Objectives To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). Methods Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice–Williams–Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. Results LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). Conclusions This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kukatharmini Tharmaratnam
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | | | - Kirsty E Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Daniel Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Zoe McLaren
- Rheumatology Department, Aintree University Hospital, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Annie Ratcliffe
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - Philip Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children's Hospital & Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Arani Sridhar
- Leicester Children's Hospital, University Hospitals of Leicester NHS trust, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Andrea Jorgensen
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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10
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Smith EMD, Rasul S, Ciurtin C, Al-Abadi E, Armon K, Bailey K, Brennan M, Gardner-Medwin J, Haslam K, Hawley D, Lane S, Leahy A, Leone V, Malik G, Mewar D, Moots R, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Beresford MW, McCann LJ, Hedrich CM. Limited sensitivity and specificity of the ACR/EULAR-2019 classification criteria for SLE in JSLE?-observations from the UK JSLE Cohort Study. Rheumatology (Oxford) 2021; 60:5271-5281. [PMID: 33690793 PMCID: PMC8566265 DOI: 10.1093/rheumatology/keab210] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/23/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES This study aimed to test the performance of the new ACR and EULAR criteria, that include ANA positivity as entry criterion, in JSLE. METHODS Performance of the ACR/EULAR-2019 criteria were compared with Systemic Lupus International Collaborating Clinics (SLICC-2012), using data from children and young people (CYP) in the UK JSLE Cohort Study (n = 482), with the ACR-1997 criteria used as reference standard. An unselected cohort of CYP positive for ANA (n = 129) was used to calculate positive/negative predictive values of the criteria. RESULTS At both first and last visits, the number of patients fulfilling the different classification criteria varied significantly (P < 0.001). The sensitivity of the SLICC-2012 criteria was higher when compared with that of the ACR/EULAR-2019 criteria at first and last visits (98% vs 94% for first visit, and 98% vs 96% for last visit; P < 0.001), when all available CYP were considered. The ACR/EULAR-2019 criteria were more specific when compared with the SLICC-2012 criteria (77% vs 67% for first visit, and 81% vs 71% for last visit; P < 0.001). Significant differences between the classification criteria were mainly caused by the variation in ANA positivity across ages. In the unselected cohort of ANA-positive CYP, the ACR/EULAR-2019 criteria produced the highest false-positive classification (6/129, 5%). CONCLUSION In CYP, the ACR/EULAR-2019 criteria are not superior to those of the SLICC-2012 or ACR-1997 criteria. If classification criteria are designed to include CYP and adult populations, paediatric rheumatologists should be included in the consensus and evaluation process, as seemingly minor changes can significantly affect outcomes.
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Affiliation(s)
- Eve M D Smith
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
| | - Sajida Rasul
- Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Manchester
| | - Coziana Ciurtin
- Department of Rheumatology, Centre for Adolescent Rheumatology, University College London, London
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children’s Hospital, Birmingham
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford
| | - Daniel P Hawley
- Department of Paediatric Rheumatology, Sheffield Children’s Hospital, Sheffield
| | - Steven Lane
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children’s Hospital, Aberdeen
| | - Devesh Mewar
- Department of Rheumatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool
| | - Robert Moots
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk
| | | | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham
| | | | - Phil Riley
- Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Manchester
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children’s Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne
| | - Arani Sridhar
- Leicester Children’s Hospital, University Hospitals of Leicester NHS trust, Leicester
| | - Nick Wilkinson
- Department of Paediatric Rheumatology, Guy’s & St Thomas’s NHS Foundation Trust, Evelina Children’s Hospital, London, UK
| | - Michael W Beresford
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
| | - Liza J McCann
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
| | - Christian M Hedrich
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
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11
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Foley C, Armon K, Bale P. P15 A Juvenile idiopathic arthritis mimic. Rheumatol Adv Pract 2021. [PMCID: PMC8832413 DOI: 10.1093/rap/rkab068.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Case report - Introduction Juvenile idiopathic arthritis (JIA) is a diagnosis of exclusion. In a paediatric rheumatology clinic, children can present with signs and symptoms that don’t quite fit under the umbrella of JIA. When these cases present it is important that we take a thorough history and examination, and investigate as appropriate, with continual assessment to check progress and review response to treatment. This case highlights the importance of this practise, in turn enabling the correct diagnosis to be reached. This allows for more appropriate treatment choices and more specific counselling for child and family with regards to the condition and expected prognosis. Case report - Case description A 7-year-old girl was referred for paediatric rheumatology review with a 3-week history of inability to close her hands properly, and pain and swelling in hands and feet. There had been no preceding illness, trauma, or tick bites. There was no history of associated fever, rash, mouth ulcers or eye symptoms. She complained of central abdominal pain with associated constipation. Her appetite and weight were stable. No significant PMH. FHx brother - JIA. On assessment, systems exam was unremarkable. Her skin was soft with no erythema. It did not appear thickened or shiny, but there was bilateral pitting oedema to just below both knees. On musculoskeletal assessment there was notable dorsal swelling of both hands, with significant restriction of both wrists. There was pain, swelling and restriction of the fingers, elbows, knees, ankles and toes. Her neck and shoulder movements were also restricted. Limited summary of investigation An USS was performed of affected joints which showed poly-articular synovitis and tenosynovitis. There was no documented fasciitis. She was treated with three-days IV methylprednisolone (30mg/kg) and discharged on a weaning course of prednisolone. She was reviewed 3-weeks later. She was functioning better but reported on-going abdominal pain and that her arms looked thicker. The skin on her arms appeared thickened. She was unable to make a claw or fully extend fingers. Her wrists were restricted with visible wrist flexor tendons. Her pitting oedema had improved. Her inflammatory markers were normal. She proceeded to have an MRI of her right hand/wrist which confirmed a diagnosis of eosinophilic fasciitis and tenosynovitis. Case report - Discussion Following initial assessment, this 7-year-old girl was found to have significant inflammatory arthritis and tenosynovitis, abdominal pain, eosinophilia and hypo-albuminaemia. However, the clinical picture was not felt to be typical for JIA. The differential diagnosis at the time was that this could be an evolving connective tissue disease; however, the autoimmune screen was negative. Also, initially there were no abnormal skin or fascial features seen on imaging, and no other organ dysfunction or features pointing towards a specific condition. Once infection and risk of malignancy was excluded in consultation with the infectious disease and haematology teams, it was agreed that treatment was required. Pulse methylprednisolone was agreed as an appropriate first choice with a plan to review response on weaning oral steroids. When the little girl returned for review, the clinical picture had progressed to include non-tender, tightness and thickening of the forearms, with ongoing restriction in multiple joints and abdominal pain. In view of the ongoing abdominal pain, eosinophilia, low albumin and rising ALT she was discussed with the gastroenterology team who repeated an abdominal USS and performed an OGD. The USS showed a slightly enlarged spleen. The OGD was macroscopically normal. Microscopically there were some submucosal duodenal foamy macrophages, significance uncertain. The team remained suspicious that this was an eosinophilic driven inflammatory condition with musculoskeletal findings, and so an MRI of the right hand and wrist was requested. This showed an abnormal rim of high signal around the tendons and along the fascial planes of the forearm in both extensor and flexor compartments, consistent with a diagnosis of eosinophilic fasciitis. A skin and muscle biopsy were obtained which confirmed chronic inflammation and fibrosis in the fascia. These features were consistent with the suggested radiological diagnosis of eosinophilic fasciitis. She was commenced on subcutaneous methotrexate. Case report - Key learning points Eosinophilic faciitis (EF), also known as Shulman syndrome after the physician who, in 1974 was the first to report on the disorder in the medical literature, is a rare disorder. It is characterised by inflammatory infiltrate in the fascia consisting of lymphocytes, macrophages and plasma cells, with eosinophils sometimes present. The fascia is thickened 2- to 15- fold; the dermis and epidermis can be unaffected. The condition can precede, coexist or follow localised scleroderma. Clinically it can present as painful swelling with progressive induration and thickening of the skin – “peau d’orange” appearance. In paediatrics, as was the case in this little girl, skin findings are minimal or absent at presentation. Paediatric EF tends to involve extremities, often the hands and feet. There is a paucity of data for paediatric EF. In childhood onset EF there is a higher frequency of joint involvement. However, many can develop persistent cutaneous fibrosis and permanent disability. Over 30% of children also present with visceral involvement, such as mesenteric lymphadenopathy, hepatosplenomegaly and pericardial effusion. Early recognition of the condition and timely initiation of treatment improves likelihood of good response to treatment. Risk factors for persistent fibrosis include extensive disease (3—4 extremities and trunk involvement) and/or younger age at onset. There are no standardised guidelines for treatment of childhood-onset EF. However, given that children have more severe, rapidly progressive articular involvement, the expert view is that initial treatment should include combination therapy i.e., corticosteroids and methotrexate. If this treatment fails, the literature suggests instigation of alternative DMARDS, biologics or JAK inhibitors. Summary learning/discussion points include;
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Affiliation(s)
| | - Kate Armon
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Peter Bale
- Addenbrooke's Hospital, Cambridge, United Kingdom
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12
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Foley C, Armon K, Skarmoustsos F, Muthusamy B, Bale P. O26 More than meets the eye … When inflammation extends beyond the anterior chamber. Rheumatol Adv Pract 2021. [PMCID: PMC8832414 DOI: 10.1093/rap/rkab067.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Case report - Introduction The differential diagnosis of paediatric uveitis is extensive. Classification starts by determining infectious versus non-infectious causes, anatomic location and associated intra-ocular and extra-ocular features. A relatively common referral to Paediatric Rheumatology from our Ophthalmology colleagues is of a child with a diagnosis of uveitis. This case highlights the importance and benefits of multidisciplinary team working across our regional network when caring for children with complex and rare conditions. Case report - Case description An 8-year-old-girl was referred by her local ophthalmology team to the paediatric rheumatology clinic with a diagnosis of pars-planitis. She had presented to them with blurred-vision and eye-“floaters”. On review, the girl reported that she had a 4-month-history of headaches and blurred-vision, associated with dizziness. She denied any eye-pain. Corresponding to the onset of her symptoms, she had suffered with Chickenpox. Her mother felt that she had "not been right since then". She noted that she was generally quieter and more fatigued than normal. Over the course of the 4 months, she was noted to have become clumsier and was bumping into things on a regular basis. She reported increasing visual difficulties in her right eye and initially attended for an optician review. The optician was concerned and referred for urgent ophthalmology opinion. She was diagnosed with bilateral pars-planitis, commenced on oral prednisolone and referred for paediatric rheumatology and tertiary ophthalmology assessment. The headaches improved following commencement on steroids. Positive findings on systems review included occasional oral ulcers, 1—2 times-per-month. They started about 1-month prior to the onset of her chickenpox and continued for the following 3—4 months. She denied any history of genital-ulcers or skin-rash. She had new-onset muscle soreness and tiredness after activity. She also described non-specific abdominal pain since having chickenpox, but no associated change in bowel habit. Examination revealed normal skin, hair, nail and joint examination. She had a soft systolic murmur (echocardiogram normal). She had RUQ tenderness on abdominal palpation (abdominal-USS – spleen upper limit of normal. Nil else). Relevant blood and stool samples were sent as part of a uveitis work-up panel. The paediatric ophthalmologist found right-intermediate uveitis with vitreitis and peripheral retinal changes in keeping with a peripheral exudative detachment. Similar changes were seen in the peripheral retina of the left eye. The impression was of bilateral pan-uveitis with retinal involvement. A subsequent oral fluorescein angiogram showed a widespread retinal vasculitis with some occlusive changes in the right-eye, and a tuft of retinal vascular leakage at the 5-o'clock position in the left eye. Case report - Discussion The differential diagnosis for paediatric retinal vasculitis is broad. It includes collagen vascular disorders, Behçet's disease, Eales’ disease, post viral or post vaccination, acquired toxoplasmosis, multiple sclerosis, systemic immunosuppression and Henoch-Schönlein purpura. The ANA, ENAs, dsDNA, ANCA, ACE, Toxoplasma and Lyme serology were all negative for this little girl. Her inflammatory markers were also normal. She was not on any regular medications prior to her illness and had not had any recent vaccinations. She had no significant past medical or family history of note. However, the onset of her symptoms did correspond to her having chickenpox. She was subsequently found to be positive for HLA B51. In view of the ophthalmology findings and positive HLA B51, the little girl was admitted for an urgent MRI/MRI to exclude neuro- Behçets. This was reported as normal. She was treated with a three-day pulse of IV methylprednisolone and discharged on oral prednisolone 10mg OD (weight 33.4kg). At present Bechet’s retinal vasculitis remains high in the list of differentials for this little girl; however, currently she does not strictly meet the diagnostic criteria for Bechet’s disease. She has been commenced on a steroid sparing agent, azathioprine. Her follow-up plan is to be reviewed in the joint paediatric rheumatology and ophthalmology clinic in 1 months’ time. Case report - Key learning points Retinal vasculitis may occur secondary to a systemic disease or an infectious agent, or as an isolated retinal aetiology. Given that the differentials are vast, a detailed history and examination are important to identify signs and symptoms of systemic disease. Appropriate investigations should be chosen to help narrow the differentials and ensure pathology that could lead to significant morbidity and mortality is not missed. With a case such as this, close collaboration between the paediatric ophthalmologist and rheumatologist is paramount to ensure the best outcome for the patient. With regards to treatment, small case series have described a refractory nature of retinal vasculitis in paediatric patients. One study report that almost 80% of patients with paediatric idiopathic uveitis show manifestations of retinal vasculitis, which is associated with a lower probability of inflammation control resulting in a worse visual prognosis. Points for discussion
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Affiliation(s)
| | - Kate Armon
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | | | - Peter Bale
- Addenbrooke's Hospital, Cambridge, United Kingdom
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13
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Giani T, Smith EMD, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Davidson J, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Mewar D, Modgil G, Moots R, Pilkington C, Pregnolato F, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Wilkinson N, Cimaz R, Beresford MW, Hedrich CM. Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus: Data from the UK Juvenile-onset systemic lupus erythematosus cohort study. Lupus 2021; 30:1955-1965. [PMID: 34601989 PMCID: PMC8649437 DOI: 10.1177/09612033211045050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 08/19/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Juvenile-onset systemic lupus erythematosus (JSLE) is a rare autoimmune/inflammatory disease with significant morbidity and mortality. Neuropsychiatric (NP) involvement is a severe complication, encompassing a heterogeneous range of neurological and psychiatric manifestations. METHODS Demographic, clinical, and laboratory features of NP-SLE were assessed in participants of the UK JSLE Cohort Study, and compared to patients in the same cohort without NP manifestations. RESULTS A total of 428 JSLE patients were included in this study, 25% of which exhibited NP features, half of them at first visit. Most common neurological symptoms among NP-JSLE patients included headaches (78.5%), mood disorders (48.6%), cognitive impairment (42%), anxiety (23.3%), seizures (19.6%), movement disorders (17.7%), and cerebrovascular disease (14.9%). Peripheral nervous system involvement was recorded in 7% of NP-SLE patients. NP-JSLE patients more frequently exhibited thrombocytopenia (<100 × 109/L) (p = 0.04), higher C-reactive protein levels (p = 0.01), higher global pBILAG score at first visit (p < 0.001), and higher SLICC damage index score at first (p = 0.02) and last (p < 0.001) visit when compared to JSLE patients without NP involvement. CONCLUSIONS A significant proportion of JSLE patients experience NP involvement (25%). Juvenile-onset NP-SLE most commonly affects the CNS and is associated with increased overall disease activity and damage.
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Affiliation(s)
- Teresa Giani
- Rheumatology Unit, AOU Meyer, Florence, Italy
- Department of Medical
Biotechnology, University of Siena, Siena, Italy
| | - Eve MD Smith
- Department of Women’s &
Children’s Health, Institute of Life Course and Medical
Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric
Rheumatology, Alder Hey Children’s NHS Foundation
Trust Hospital, Liverpool, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children’s
Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric
Rheumatology, Cambridge University
Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric
Rheumatology, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College
London, London, UK
| | - Joyce Davidson
- Department of Paediatric
Rheumatology, Royal Hospital for Sick
Children, Edinburgh, UK
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal
Infirmary, Bradford, UK
| | - Dan P Hawley
- Department of Paediatric
Rheumatology, Sheffield Children’s
Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric
Rheumatology, Southampton General
Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric
Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Flora McErlane
- Paediatric Rheumatology, Great
North Children’s Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine,
Newcastle University, Newcastle Upon Tyne, UK
| | - Devesh Mewar
- Department of Rheumatology, Royal Liverpool University
Hospital, Liverpool, UK
| | - Gita Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - Robert Moots
- Department of Rheumatology, University Hospital
Aintree, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric
Rheumatology, Great Ormond Street
Hospital, London, UK
| | | | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS
Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric
Rheumatology, Nottingham University
Hospitals, Nottingham, UK
| | - Phil Riley
- Department of Paediatric
Rheumatology, Royal Manchester Children’s
Hospital, Manchester, UK
| | - Arani Sridhar
- Department of Paediatrics, Leicester Royal
Infirmary, Leicester, UK
| | - Nick Wilkinson
- Guy’s & St Thomas’s NHS
Foundation Trust, Evelina Children’s
Hospital, London, UK
| | - Rolando Cimaz
- ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences
and Community Health, Research Center for Adult and
Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
| | - Michael W Beresford
- Department of Women’s &
Children’s Health, Institute of Life Course and Medical
Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric
Rheumatology, Alder Hey Children’s NHS Foundation
Trust Hospital, Liverpool, UK
| | - Christian M Hedrich
- Department of Women’s &
Children’s Health, Institute of Life Course and Medical
Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric
Rheumatology, Alder Hey Children’s NHS Foundation
Trust Hospital, Liverpool, UK
| | - on behalf of the UK JSLE Cohort Study
- Rheumatology Unit, AOU Meyer, Florence, Italy
- Department of Medical
Biotechnology, University of Siena, Siena, Italy
- Department of Women’s &
Children’s Health, Institute of Life Course and Medical
Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric
Rheumatology, Alder Hey Children’s NHS Foundation
Trust Hospital, Liverpool, UK
- Department of Rheumatology, Birmingham Children’s
Hospital, Birmingham, UK
- Department of Paediatric
Rheumatology, Cambridge University
Hospitals, Cambridge, UK
- Department of Paediatric
Rheumatology, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
- Centre for Adolescent Rheumatology, University College
London, London, UK
- Department of Paediatric
Rheumatology, Royal Hospital for Sick
Children, Edinburgh, UK
- Department of Child Health, University of Glasgow, Glasgow, UK
- Department of Paediatrics, Bradford Royal
Infirmary, Bradford, UK
- Department of Paediatric
Rheumatology, Sheffield Children’s
Hospital, Sheffield, UK
- Department of Paediatric
Rheumatology, Southampton General
Hospital, Southampton, UK
- Department of Paediatric
Rheumatology, Leeds Children Hospital, Leeds, UK
- Paediatric Rheumatology, Great
North Children’s Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine,
Newcastle University, Newcastle Upon Tyne, UK
- Department of Rheumatology, Royal Liverpool University
Hospital, Liverpool, UK
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
- Department of Rheumatology, University Hospital
Aintree, Liverpool, UK
- Department of Paediatric
Rheumatology, Great Ormond Street
Hospital, London, UK
- Immunorheumatology Research
Laboratory, Auxologico Institute, Milan, Italy
- University Hospitals Bristol NHS
Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
- Department of Paediatric
Rheumatology, Nottingham University
Hospitals, Nottingham, UK
- Department of Paediatric
Rheumatology, Royal Manchester Children’s
Hospital, Manchester, UK
- Department of Paediatrics, Leicester Royal
Infirmary, Leicester, UK
- Guy’s & St Thomas’s NHS
Foundation Trust, Evelina Children’s
Hospital, London, UK
- ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences
and Community Health, Research Center for Adult and
Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
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14
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Price-Kuehne F, Close R, Armon K. Early-onset stroke and iron-deficiency anaemia in young siblings. Rheumatology (Oxford) 2021; 60:iii15-iii17. [PMID: 34137877 DOI: 10.1093/rheumatology/keab058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/14/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fiona Price-Kuehne
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rosie Close
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Armon
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Paediatrics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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15
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Close R, Bale P, Armon K. Use of non-steroidal anti-inflammatory drugs in paediatrics. Arch Dis Child Educ Pract Ed 2021; 106:47-52. [PMID: 32033990 DOI: 10.1136/archdischild-2019-317228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 01/04/2020] [Accepted: 01/14/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Rosie Close
- Department of Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Peter Bale
- Department of Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
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16
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Cooray S, Omyinmi E, Hong Y, Papadopoulou C, Harper L, Al-Abadi E, Goel R, Dubey S, Wood M, Jolles S, Berg S, Ekelund M, Armon K, Eleftheriou D, Brogan PA. Anti-tumour necrosis factor treatment for the prevention of ischaemic events in patients with deficiency of adenosine deaminase 2 (DADA2). Rheumatology (Oxford) 2021; 60:4373-4378. [DOI: 10.1093/rheumatology/keaa837] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/12/2020] [Indexed: 02/07/2023] Open
Abstract
Abstract
Objective
To evaluate the impact of anti-Tumour Necrosis Factor-α (anti-TNF) treatment on the occurrence of vasculitic ischaemic events in patients with deficiency of adenosine deaminase 2 (DADA2).
Methods
A retrospective analysis of DADA2 patients referred from six centres to Great Ormond Street Hospital for Children was conducted. Ischaemic events, vasculitic disease activity, biochemical, immunological, and radiological features were compared, before and after anti-TNF treatment.
Results
A total of 31 patients with genetically confirmed DADA2 were included in the study. The median duration of active disease activity prior to anti-TNF treatment was 73 months (inter-quartile range [IQR] 27.5–133.5 months). Twenty seven/31 patients received anti-TNF treatment for a median of 32 months (IQR 12.0–71.5 months). The median event rate of central nervous system (CNS) and non-CNS ischemic events before anti-TNF treatment was 2.37 per 100 patient-months (IQR 1.25–3.63); compared with 0.00 per 100 patient-months (IQR 0.0–0.0) post-treatment (p< 0.0001). Paediatric vasculitis activity score (PVAS) was also significantly reduced: median score of 20/63 (IQR 13.0–25.8/63) pre-treatment vs. 2/63 (IQR 0.0–3.8/63) following anti-TNF treatment (p< 0.0001), with mild livedoid rash being the main persisting feature. Anti-TNF treatment was not effective for severe immunodeficiency or bone marrow failure, which required haematopoietic stem cell transplantation (HSCT).
Conclusion
Anti-TNF treatment significantly reduced the incidence of ischaemic events and other vasculitic manifestations of DADA2, but was not effective for immunodeficiency or bone marrow failure.
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Affiliation(s)
- Samantha Cooray
- Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London
| | - Ebun Omyinmi
- Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London
| | - Ying Hong
- Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London
| | - Charalampia Papadopoulou
- Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London
| | - Lorraine Harper
- Institute of Applied Health Research, University of Birmingham
| | - Eslam Al-Abadi
- Rheumatology Department, Birmingham Women's and Children’s NHS Foundation Trust, Birmingham
| | - Ruchika Goel
- Institute of Applied Health Research, University of Birmingham
| | - Shirish Dubey
- Rheumatology Department, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Mark Wood
- Paediatric Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Stephen Jolles
- Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - Stefan Berg
- Paediatric Rheumatology, The Queen Silvia Children’s Hospital and University of Gothenburg, Gothenburg
| | | | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Despina Eleftheriou
- Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London
| | - Paul A Brogan
- Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London
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17
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Massias JS, Smith EM, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Davidson J, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Mewar D, Modgil G, Moots R, Pilkington C, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Wilkinson N, Beresford MW, Hedrich CM. Clinical and laboratory phenotypes in juvenile-onset Systemic Lupus Erythematosus across ethnicities in the UK. Lupus 2021; 30:597-607. [PMID: 33413005 PMCID: PMC7967896 DOI: 10.1177/0961203320984251] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune/inflammatory disease. Patients diagnosed with juvenile-onset SLE (jSLE), when compared to individuals with adult-onset SLE, develop more severe organ involvement, increased disease activity and greater tissue and organ damage. In adult-onset SLE, clinical characteristics, pathomechanisms, disease progression and outcomes do not only vary between individuals and age groups, but also ethnicities. However, in children and young people, the influence of ethnicity on disease onset, phenotype and outcome has not been investigated in detail. In this study, we investigated clinical and laboratory characteristics in pediatric SLE patients from different ethnic backgrounds (White Caucasian, Asian, Black African/Caribbean) accessing data from a national cohort of jSLE patients (the UK JSLE Cohort Study). Among jSLE patients in the UK, ethnicity affects both the disease’s clinical course and outcomes. At diagnosis, Black African/Caribbean jSLE patients show more “classical” laboratory and clinical features when compared to White Caucasian or Asian patients. Black African/Caribbean jSLE patients exhibit more renal involvement and more frequently receive cyclophosphamide and rituximab. Studies targeting ethnicity-specific contributors to disease expression and phenotypes are necessary to improve our pathophysiological understanding, diagnosis and treatment of jSLE.
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Affiliation(s)
| | - Eve Md Smith
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | - Joyce Davidson
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Dan P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Devesh Mewar
- Department of Rheumatology, Royal Liverpool University Hospital, Liverpool, UK
| | - Gita Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - Robert Moots
- Department of Rheumatology, University Hospital Aintree, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Phil Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Arani Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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18
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Richards C, Eleftheriou D, Armon K, Muthusamy B, Bale P. O22 An inflammatory journey from brain to skin: a case of En Coupe De Sabre scleroderma presenting with raised intracranial pressure, seizures, and uveitis. Rheumatol Adv Pract 2020. [PMCID: PMC7607343 DOI: 10.1093/rap/rkaa054.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Case report - Introduction
Scleroderma is a rare connective tissue disease characterised by thickening and hardening of the skin resulting in increased collagen production. The predominant type of childhood scleroderma is localised scleroderma (LSc) which primarily involves the skin, fascia, muscle, and bone. En coup de sabre (ECDS) is a rare subtype affecting the frontoparietal region and is characterised by a unilateral indurated streak in the shape of a sabre sword wound.
ECDS is also associated with extracutaneous features which can manifest prior to the classical skin changes. We present the case of a 7-year-old boy with ECDS presenting with neurological and ocular findings.
Case report - Case description
A seven-year-old boy presented with severe headache followed by a twenty min right sided focal seizure. He had a 3-month history of headaches associated with vomiting suggesting raised intracranial pressure and ophthalmology review revealed bilateral papilloedema. Viral studies, bacterial serology and autoimmune screen were negative. He had normal inflammatory markers. Brain MRI demonstrated left sided white matter changes, thought to be secondary to inflammation. The clinical impression was of atypical pseudotumor cerebri and Acetazolamide was commenced.
Intermittent headaches persisted, without vomiting but unilateral left uveitis was identified. This was treated with Dexamethasone eye drops and his Acetazolamide was switched to Topiramate. Further imaging excluded malignancy and MRA and MRV were negative for vasculitis and sinus thrombosis. Neuro-Behcet’s was considered in the presence of HLA-b51 positivity but he did not meet diagnostic criteria.
His parents reported a transient knee swelling and an intermittent red line on his forehead. The rest of systemic screen was negative. In the presence of raised pressure, inflammation on imaging and dexamethasone dependant uveitis, he was commenced on a weaning course of oral prednisolone.
On this treatment his papilloedema and uveitis resolved but his Topiramate dose was increased due to intermittent brief focal seizures. MRI changes remained stable. A year after first presentation, episodes of left sided facial flushing became prominent associated with an injected left eye and an asymmetrical reduction of subcutaneous depth developed. Infrared thermography revealed warmth on the left forehead in the Blaschkoid distribution. The diagnosis was revised to ECDS with neuroinflammation.
The patient was commenced on high dose steroids and Mycophenolate Mofetil (MMF). Seizures resolved, uveitis and papilloedema remain absent and his skin stabilised. Recently there has been concern regarding progression of a facial lesion on reducing to 5 mg of Prednisolone, and a further prednisolone course and optimised MMF were initiated.
Case report - Discussion
ECDS is an unusual variant of linear scleroderma but causes significant cosmetic changes. The skin lesions can be hard to treat and the choice of medication depends on response and associated extracutaneous features.
The lesion is typically erythematous during the acute inflammatory phase, before exhibiting a sunken ivory appearance. It is usually unilateral, rare below the forehead but can extend into the hairline. Asymmetrical facial development can occur.
In a large multicentre study of 750 children with LSc the prevalence and the clinical features of extracutaneous findings were identified. In 92% of cases a skin lesion was the presenting feature of disease. 4% of cases had neurological involvement. This increased to 18% in patients with ECDS. The most frequent neurological symptoms were seizures and headaches. When neuroimaging abnormalities are identified they are primarily ipsilateral to the skin lesion.
Ocular involvement is reported and in another large multicentre study of children with LSc, the involvement of the anterior segment of the eye was the second most frequent condition. Anterior uveitis was the most relevant finding.
In most patients the development of neurological symptoms follows the recognition of cutaneous disease. In our case his headaches, seizures and uveitis were the presenting feature prior to development of the scleroderma lesion. The cutaneous features were initially intermittent and transient making diagnosis challenging and classical skin changes may have been slowed by the initial course of oral prednisolone for his neurological and ocular disease. Access to infrared thermography proved to be a helpful modality to confirm the inflammatory skin lesion and affirm the diagnosis.
Case report - Key learning points
This case highlights to clinicians the importance of assessing for extracutaneous features of linear scleroderma of the face. The case further highlights that these findings, including focal seizures associated with non-specific unilateral inflammatory neurological lesions, raised intracranial pressure, and unilateral uveitis can be presenting features before the typical skin changes are visible. Intermittent erythema in a longitudinal linear distribution may be the first indication of cutaneous disease and repeated thorough cutaneous examination is vital.
Anterior uveitis can be completely unrelated to the site of LsC and is asymptomatic. Ophthalmic monitoring is recommended for all patients and is mandatory in those with lesions on the face and/or CNS involvement. ECDS should be considered in the differential for all patients presenting with unilateral anterior uveitis.
The cutaneous outcome for children with ECDS is variable and some lesions remain refractory to the most used disease modifying treatments including methotrexate and MMF. In some cases, the inflammation self terminates but loss of subcutaneous tissue and asymmetrical facial development remains. Fat transplant remains an option in for some cases. The lesions can be very disfiguring and can cause significant psychological distress and we recommend early referral to clinical psychology within the paediatric rheumatology team.
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Affiliation(s)
| | | | - Kate Armon
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | - Peter Bale
- Addenbrooke's Hospital, Cambridge, United Kingdom
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19
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Close R, Bale P, Gallagher K, Ambegaonkar G, Rossor T, Abbassi N, Armon K. P137 Growing up on biologics: a case report of development of NMDAr encephalitis in a young person with JIA on abatacept. Rheumatology (Oxford) 2020. [DOI: 10.1093/rheumatology/keaa111.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A 12-year-old female with JIA on biologic medication (IV abatacept every three weeks) presented with a first generalised tonic-clonic seizure on background of preceding headache and fatigue. The seizure self-terminated but disorientation and encephalopathy ensued. MRI brain demonstrated lesions with high signal intensity in the left periventricular and right occipital regions. The clinical picture and radiological imaging suggested a broad differential diagnosis including CNS infection, JC virus associated progressive multifocal leucoencephalomalacia (PML), acute disseminated encephalomyelitis (ADEM) and Anti-N-methyl-d-aspartate receptor (NMDAr) encephalitis. She was commenced on IV ceftriaxone, acyclovir and clarithromycin. All bloods including inflammatory markers and infection serology were unremarkable. CSF was acellular and JC virus PCR negative. NMDAr encephalitis was initially considered unlikely (pre-existing immunosuppression, abnormal MRI brain and no evidence of ovarian teratoma on abdominal MRI pelvis). However more classical clinical features developed including further seizures, significant movement disorder, cognitive dysfunction, sleep and speech dysfunction. Anti-NMDAr antibodies in both serum and CSF were positive. She made a good recovery following IV steroids, plasmapheresis and rituximab and was discharged home after a 10-week admission. NMDAr encephalitis developed three years after commencing abatacept treatment. Previous immune modulating treatment included methotrexate (since age 2 years), Etanercept (age 5-8 years) and Tocilizumab (aged 8-10 years). Flares of disease following a period of control necessitated the changes in therapy.
Methods
A literature review was conducted to explore the relationship between NMDAr encephalitis and biologic medication. A yellow card report and information request to abatacept manufacturer were also submitted.
Results
No previous cases of NMDAr encephalitis in patients on abatacept or paediatric cases related to biologic therapy are described. There are reports of adults developing NMDAr encephalitis on Adalumimab for Crohn’s disease and etanercept for rheumatoid arthritis. NMDAr encephalitis has also been described in patients on immune checkpoint inhibitors for malignant melanoma (nivolumab and ipilimumab). Known triggers of production of anti-NMDA receptor antibodies include tumours (ovarian teratoma; rarely associated in patients under 12 years) and viral infections. Developing autoimmune disorders on biologic medication is well reported, most notably psoriasis and inflammatory bowel disease. In relation to abatacept specifically, the development of anti-nuclear antibodies (ANA) and psoriasis have been described. However, patients with autoimmune disorders are known to be of increased risk for additional immune disease. A new cohort of patients are emerging who have received multiple biologic medications and the development of autoimmune conditions despite immunosuppression needs to be considered.
Conclusion
We describe the first case of NMDAr encephalitis occurring in a child on abatacept therapy, and the first case in JIA. We are unable to determine what contribution a history of autoimmune disease or immunomodulating therapy has made on its development in this case.
Disclosures
R. Close: None. P. Bale: None. K. Gallagher: None. G. Ambegaonkar: None. T. Rossor: None. N. Abbassi: None. K. Armon: None.
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Affiliation(s)
- Rosie Close
- Paediatric Rhematology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Paediatric Rhematology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Kathy Gallagher
- Paediatric Rhematology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | | | - Thomas Rossor
- Paediatric Neurology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Natalie Abbassi
- Paediatric Neurology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rhematology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
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20
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Massias JS, Smith EMD, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Davidson J, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Mewar D, Modgil G, Moots R, Pilkington C, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Wilkinson N, Beresford MW, Hedrich CM. Clinical and laboratory characteristics in juvenile-onset systemic lupus erythematosus across age groups. Lupus 2020; 29:474-481. [PMID: 32233733 PMCID: PMC7528537 DOI: 10.1177/0961203320909156] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Systemic lupus erythematous (SLE) is a systemic autoimmune/inflammatory condition. Approximately 15–20% of patients develop symptoms before their 18th birthday and are diagnosed with juvenile-onset SLE (JSLE). Gender distribution, clinical presentation, disease courses and outcomes vary significantly between JSLE patients and individuals with adult-onset SLE. This study aimed to identify age-specific clinical and/or serological patterns in JSLE patients enrolled to the UK JSLE Cohort Study. Methods Patient records were accessed and grouped based on age at disease-onset: pre-pubertal (≤7 years), peri-pubertal (8–13 years) and adolescent (14–18 years). The presence of American College of Rheumatology (ACR) classification criteria, laboratory results, disease activity [British Isles Lupus Assessment Group (BILAG) and Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) scores] and damage [Systemic Lupus International Collaborating Clinics (SLICC) damage index] were evaluated at diagnosis and last follow up. Results A total of 418 JSLE patients were included in this study: 43 (10.3%) with pre-pubertal disease onset; 240 (57.4%) with peri-pubertal onset and 135 (32.3%) were diagnosed during adolescence. At diagnosis, adolescent JSLE patients presented with a higher number of ACR criteria when compared with pre-pubertal and peri-pubertal patients [pBILAG2004 scores: 9(4–20] vs. 7(3–13] vs. 7(3–14], respectively, p = 0.015] with increased activity in the following BILAG domains: mucocutaneous (p = 0.025), musculoskeletal (p = 0.029), renal (p = 0.027) and cardiorespiratory (p = 0.001). Furthermore, adolescent JSLE patients were more frequently ANA-positive (p = 0.034) and exhibited higher anti-dsDNA titres (p = 0.001). Pre-pubertal individuals less frequently presented with leukopenia (p = 0.002), thrombocytopenia (p = 0.004) or low complement (p = 0.002) when compared with other age groups. No differences were identified in disease activity (pBILAG2004 score), damage (SLICC damage index) and the number of ACR criteria fulfilled at last follow up. Conclusions Disease presentations and laboratory findings vary significantly between age groups within a national cohort of JSLE patients. Patients diagnosed during adolescence exhibit greater disease activity and “classic” autoantibody, immune cell and complement patterns when compared with younger patients. This supports the hypothesis that pathomechanisms may vary between patient age groups.
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Affiliation(s)
- J S Massias
- School of Medicine, University of Liverpool, UK
| | - E M D Smith
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - E Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - K Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - K Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Ciurtin
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Davidson
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - K Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - D P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - A Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - V Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - F McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - D Mewar
- Department of Rheumatology, Royal Liverpool University Hospital, Liverpool, UK
| | - G Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - R Moots
- Department of Rheumatology, University Hospital Aintree, Liverpool, UK
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - A V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - S Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals Nottingham, UK
| | - P Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - A Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - N Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
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Holmes R, Armon K, Bale P. P39 Physiotherapy management of long thoracic nerve injury (LTNI) post-flu vaccine in an immunocompromised patient with vasculitis: what is the best strategy? Rheumatology (Oxford) 2019. [DOI: 10.1093/rheumatology/kez416.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
We describe the case of a 12 year-old boy with polyarteritis nodosa presenting with long thoracic nerve injury (LTNI) post flu vaccination. Polyarteritis nodosa is an inflammatory vasculitis treated with immunosuppressive medication. Children with immunosuppression require seasonal flu vaccination, and LTNI is a recognised complication, rare in children, with no incidence documented. Physiotherapy plays a role in the conservative management of LTNI, however, there is debate regarding the most effective regime.
Methods
Case description with literature review of aetiology, treatment strategies and recommendations for effective therapeutic approach.
Results
Our patient was diagnosed with polyarteritis nodosa following an admission with intra-abdominal bleed, coeliac axis thrombosis and mesenteric artery aneurysm seen on angiogram. He responded well to steroids and immunosuppressive medication. Due to the risk of infection from immune suppression, he received seasonal intra-muscular influenza vaccination to the right deltoid. There were no initial complications, however, two weeks later, burning shoulder pain and sleep disturbance were reported. There was paraesthesia in the right hand although grip strength was not impaired. Of note, the patient is left hand-dominant.
Examination revealed elevation of the right shoulder girdle and winging of the medial border of the scapula. Range of movement at the shoulder was full and pain-free. Palpation of the gleno-humeral joint line and deltoid were unremarkable. The clinical findings suggested long thoracic nerve denervation.
Physiotherapy assessment demonstrated weakness in the serratus anterior muscle and abnormal scapula movement patterns, including decreased protraction. Nerve conduction studies reported decreased activation of the long thoracic nerve. Scapula recruitment exercises were advised, as well as posture correction. After a year, scapula-humeral rhythm and strength of the scapula muscles improved.
Conclusion
Causes of scapula-winging in children include osteochondromas, exostoses and sports-related injuries. Scapula-winging associated with LTNI is a recognised complication of flu vaccine but very rarely reported in under 16-year olds.
Treatment of LTNI is poorly evidenced in the literature. However, physiotherapy including bracing to enhance proprioception, mobility exercises in supine to correct scapula position and strengthening of scapula muscles is reported. There is a lack of evidence to inform the most effective approach. The literature outlines that general gleno-humeral muscle strengthening is beneficial in improving shoulder function in LTNI. However, there is limited research investigating the specific role of scapula muscle strengthening in LTNI in children. The literature suggests that poor scapula function can impair the biomechanics of the shoulder and exercises that address scapula muscle control can improve movement patterns.
The time to recovery from LTNI is estimated between 1-2 years and maintaining muscle bulk is our challenge, as the nerve recovers.
Clinicians need to be aware of LTNI complicating flu vaccine in immuno-compromised children. We highlight the importance of physiotherapy in improving scapula biomechanics.
Conflicts of Interest
The authors declare no conflicts of interest.
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Affiliation(s)
- Rachel Holmes
- Paediatric Rheumatology, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom
| | - Kate Armon
- Paediatric Rheumatology, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter Bale
- Paediatric Rheumatology, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom
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Millington GWM, Dobson J, Holden S, Waters G, Puvanachandra N, Close R, Bale P, Armon K. Sporadic Blau syndrome treated with adalimumab. Clin Exp Dermatol 2019; 44:811-813. [DOI: 10.1111/ced.14016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2019] [Indexed: 11/26/2022]
Affiliation(s)
- G. W. M. Millington
- Department of Dermatology Norfolk and Norwich University Hospital Norwich UK
| | - J. Dobson
- Department of Dermatology Norfolk and Norwich University Hospital Norwich UK
| | - S. Holden
- Department of Clinical GeneticsCambridge University Hospitals CambridgeUK
| | - G. Waters
- Department of Cellular PathologyNorfolk and Norwich University Hospital NorwichUK
| | - N. Puvanachandra
- Department of Ophthalmology Norfolk and Norwich University Hospital Norwich UK
| | - R. Close
- Department of Paediatric Rheumatology Cambridge University Hospitals Cambridge UK
| | - P. Bale
- Department of Paediatric Rheumatology Cambridge University Hospitals Cambridge UK
| | - K. Armon
- Department of Paediatric Rheumatology Cambridge University Hospitals Cambridge UK
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23
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Smith EMD, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Davidson J, Gardner-Medwin J, Haslam K, Hawley D, Leahy A, Leone V, McErlane F, Mewar D, Modgil G, Moots R, Pilkington C, Ramanan A, Rangaraj S, Riley P, Sridhar A, Wilkinson N, Beresford MW, Hedrich CM. Outcomes following mycophenolate mofetil versus cyclophosphamide induction treatment for proliferative juvenile-onset lupus nephritis. Lupus 2019; 28:613-620. [DOI: 10.1177/0961203319836712] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Juvenile-onset systemic lupus erythematosus (JSLE) is more severe than adult-onset disease, including more lupus nephritis (LN). Despite differences in phenotype/pathogenesis, treatment is based upon adult trials. This study aimed to compare treatment response, damage accrual, time to inactive LN and subsequent flare, in JSLE LN patients treated with mycophenolate mofetil (MMF) versus intravenous cyclophosphamide (IVCYC). Methods UK JSLE Cohort Study participants, ≤16 years at diagnosis, with ≥4 American College of Rheumatology criteria for SLE, with class III or IV LN, were eligible. Mann–Whitney U tests, Fisher's exact test and Chi-squared tests were utilized for statistical analysis. Results Of the patients, 34/51 (67%) received MMF, and 17/51 (33%) received IVCYC. No significant differences were identified at 4–8 and 10–14 months post-renal biopsy and last follow-up, in terms of renal British Isles Lupus Assessment Grade scores, urine albumin/creatinine ratio, serum creatinine, ESR, anti-dsDNA antibody, C3 levels and patient/physician global scores. Standardized Damage Index scores did not differ between groups at 13 months or at last follow-up. Inactive LN was attained 262 (141–390) days after MMF treatment, and 151 (117–305) days following IVCYC ( p = 0.17). Time to renal flare was 451 (157–1266) days for MMF, and 343 (198–635) days for IVCYC ( p = 0.47). Conclusion This is the largest study to date investigating induction treatments for proliferative LN in children, demonstrating comparability of MMF and IVCYC.
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Affiliation(s)
- EMD Smith
- Department of Women and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - E Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - K Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - K Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals, Oxford, UK
| | - C Ciurtin
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Davidson
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - J Gardner-Medwin
- Department of Paediatric Rheumatology, NHS Greater Glasgow and Clyde (Yorkhill Division), Glasgow, UK
| | - K Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - D Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - A Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - V Leone
- Department of Paediatric Rheumatology, Leeds General Infirmary, Leeds, UK
| | - F McErlane
- Department of Paediatric Rheumatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - D Mewar
- Department of Rheumatology, Royal Liverpool University Hospital, Liverpool, UK
| | - G Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - R Moots
- Department of Rheumatology, University Hospital Aintree, Liverpool, UK
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - A Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - S Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - P Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - A Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - N Wilkinson
- Guy's and St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - M W Beresford
- Department of Women and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - C M Hedrich
- Department of Women and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Bale P, Easton V, Bacon H, Jerman E, Watts L, Barton G, Clark A, Armon K, MacGregor AJ. The effectiveness of a multidisciplinary intervention strategy for the treatment of symptomatic joint hypermobility in childhood: a randomised, single Centre parallel group trial (The Bendy Study). Pediatr Rheumatol Online J 2019; 17:2. [PMID: 30621718 PMCID: PMC6325876 DOI: 10.1186/s12969-018-0298-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/10/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Joint hypermobility is common in childhood and can be associated with musculoskeletal pain and dysfunction. Current management is delivered by a multidisciplinary team, but evidence of effectiveness is limited. This clinical trial aimed to determine whether a structured multidisciplinary, multisite intervention resulted in improved clinical outcomes compared with standard care. METHOD A prospective randomised, single centre parallel group trial comparing an 8-week individualised multidisciplinary intervention programme (bespoke physiotherapy and occupational therapy in the clinical, home and school environment) with current standard management (advice, information and therapy referral if deemed necessary). The primary endpoint of the study was between group difference in child reported pain from baseline to 12 months as assessed using the Wong Baker faces pain scale. Secondary endpoints were parent reported pain (100 mm visual analogue scale), parent reported function (child health assessment questionnaire), child reported quality of life (child health utility 9-dimensional assessment), coordination (movement assessment battery for children version 2) and grip strength (handheld dynamometer). RESULTS 119 children aged 5 to 16 years, with symptomatic hypermobility were randomised to receive an individualised multidisciplinary intervention (I) (n = 59) or standard management (S) (n = 60). Of these, 105 completed follow up at 12 months. No additional significant benefit could be shown from the intervention compared to standard management. However, there was a statistically significant improvement in child and parent reported pain, coordination and grip strength in both groups. The response was independent of the degree of hypermobility. CONCLUSION This is the first randomised controlled trial to compare a structured multidisciplinary, multisite intervention with standard care in symptomatic childhood hypermobility. For the majority, the provision of education and positive interventions aimed at promoting healthy exercise and self-management was associated with significant benefit without the need for more complex interventions. TRIAL REGISTRATION The trial was registered prospectively with the national database at the Clinical Research Network (UKCRN Portfolio 9366). The trial was registered retrospectively with ISRCTN ( ISRCTN86573140 ).
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Affiliation(s)
- Peter Bale
- Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, UK.
| | - Vicky Easton
- grid.240367.4Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, UK
| | - Holly Bacon
- grid.240367.4Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, UK
| | - Emma Jerman
- grid.439334.aNorfolk Community Health and Care NHS Trust, Norwich, UK
| | - Laura Watts
- grid.240367.4Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, UK ,0000 0001 1092 7967grid.8273.eNorwich Medical School, University of East Anglia, Norwich, UK
| | - Garry Barton
- 0000 0001 1092 7967grid.8273.eNorwich Medical School, University of East Anglia, Norwich, UK
| | - Allan Clark
- 0000 0001 1092 7967grid.8273.eNorwich Medical School, University of East Anglia, Norwich, UK
| | - Kate Armon
- grid.240367.4Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, UK
| | - Alex J. MacGregor
- grid.240367.4Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, UK ,0000 0001 1092 7967grid.8273.eNorwich Medical School, University of East Anglia, Norwich, UK
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Affiliation(s)
- Rosie Close
- Paediatric Rhematology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - George Millington
- Dermatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Peter Bale
- Paediatric Rhematology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rhematology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
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Richards C, Armon K, Bale P. P11 Assessing and managing the flexible child using the 2017 hypermobile Ehlers-Danlos syndromes diagnostic criteria: managing symptoms is more important than labels. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key273.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chantelle Richards
- Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UNITED KINGDOM
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27
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Li T, Gallagher K, Bale P, Armon K. P44 Streptococcal serology in a two-year cohort of patients with juvenile idiopathic arthritis: practical guidance. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key273.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tanya Li
- School of Clinical Medicince, University of Cambridge, Cambridge, UNITED KINGDOM
| | - Kathy Gallagher
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UNITED KINGDOM
| | - Kate Armon
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UNITED KINGDOM
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Eachempati SB, Shastri A, Armon K. P28 Arrhythmias and acute coronary syndrome after infliximab therapy in a child with juvenile idiopathic arthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key273.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sripriya B Eachempati
- Paediatrics, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
- Paediatric Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Aravind Shastri
- Paediatric Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rheumatology, Addenbrooke's Hospital, Cambridge, UNITED KINGDOM
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29
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Gallagher K, Armon K, Bale P. P32 Bone inflammation and fever: an atypical presentation of chronic recurrent multifocal osteomyelitis (CRMO)? Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key273.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kathy Gallagher
- Paediatric Rheumatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rheumatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Paediatric Rheumatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
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Suo C, Bale P, Armon K. R12 East of England experience: can the Bristol diagnostic criteria be applied to an unrelated cohort of childhood chronic recurrent multifocal osteomyelitis (CRMO)? Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key273.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chenqu Suo
- Department of Paediatrics, Cambridge University Hospitals, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Department of Paediatrics, Cambridge University Hospitals, Cambridge, UNITED KINGDOM
- Department of Paediatrics, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Kate Armon
- Department of Paediatrics, Cambridge University Hospitals, Cambridge, UNITED KINGDOM
- Department of Paediatrics, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
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31
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Affiliation(s)
- Kathy Gallagher
- Paediatric Rheumatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Paul Brogan
- Paediatric Rheumatology, Great Ormond Steet NHS Foundation Trust, London, UNITED KINGDOM
| | - Nigel Burrows
- Paediatric Dermatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Julia Gass
- Paediatric Dermatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Paediatric Rheumatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rheumatology, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
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32
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Achilleos KM, Bale P, Shastri A, Puvanachandra N, Armon K. 3. Transient acute coronary syndrome: delayed reaction to infliximab in an adolescent with juvenile idiopathic arthritis. Rheumatol Adv Pract 2018. [PMCID: PMC6652470 DOI: 10.1093/rap/rky031.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - Peter Bale
- Paediatric Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Aravind Shastri
- Paediatric, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Narman Puvanachandra
- Paediatric Ophthalmology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
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33
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Affiliation(s)
- Cee Yi Yong
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Chetan Mukhtyar
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
| | - Kate Armon
- Paediatric Rheumatology, Norfolk and Norwich University Hospital, Norwich, UNITED KINGDOM
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de Graaf H, Sukhtankar P, Arch B, Ahmad N, Lees A, Bennett A, Spowart C, Hickey H, Jeanes A, Armon K, Riordan A, Herberg J, Hackett S, Gamble C, Shingadia D, Pallett A, Clarke SC, Henman P, Emonts M, Sharland M, Finn A, Pollard AJ, Powell C, Marsh P, Ballinger C, Williamson PR, Clarke NM, Faust SN. Duration of intravenous antibiotic therapy for children with acute osteomyelitis or septic arthritis: a feasibility study. Health Technol Assess 2018; 21:1-164. [PMID: 28862129 DOI: 10.3310/hta21480] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is little current consensus regarding the route or duration of antibiotic treatment for acute osteomyelitis (OM) and septic arthritis (SA) in children. OBJECTIVE To assess the overall feasibility and inform the design of a future randomised controlled trial (RCT) to reduce the duration of intravenous (i.v.) antibiotic use in paediatric OM and SA. DESIGN (1) A prospective service evaluation (cohort study) to determine the current disease spectrum and UK clinical practice in paediatric OM/SA; (2) a prospective cohort substudy to assess the use of targeted polymerase chain reaction (PCR) in diagnosing paediatric OM/SA; (3) a qualitative study to explore families' views and experiences of OM/SA; and (4) the development of a core outcome set via a systematic review of literature, Delphi clinician survey and stakeholder consensus meeting. SETTING Forty-four UK secondary and tertiary UK centres (service evaluation). PARTICIPANTS Children with OM/SA. INTERVENTIONS PCR diagnostics were compared with culture as standard of care. Semistructured interviews were used in the qualitative study. RESULTS Data were obtained on 313 cases of OM/SA, of which 218 (61.2%) were defined as simple disease and 95 (26.7%) were defined as complex disease. The epidemiology of paediatric OM/SA in this study was consistent with existing European data. Children who met oral switch criteria less than 7 days from starting i.v. antibiotics were less likely to experience treatment failure (9.6%) than children who met oral switch criteria after 7 days of i.v. therapy (16.1% when switch was between 1 and 2 weeks; 18.2% when switch was > 2 weeks). In 24 out of 32 simple cases (75%) and 8 out of 12 complex cases (67%) in which the targeted PCR was used, a pathogen was detected. The qualitative study demonstrated the importance to parents and children of consideration of short- and long-term outcomes meaningful to families themselves. The consensus meeting agreed on the following outcomes: rehospitalisation or recurrence of symptoms while on oral antibiotics, recurrence of infection, disability at follow-up, symptom free at 1 year, limb shortening or deformity, chronic OM or arthritis, amputation or fasciotomy, death, need for paediatric intensive care, and line infection. Oral switch criteria were identified, including resolution of fever for ≥ 48 hours, tolerating oral food and medicines, and pain improvement. LIMITATIONS Data were collected in a 6-month period, which might not have been representative, and follow-up data for long-term complications are limited. CONCLUSIONS A future RCT would need to recruit from all tertiary and most secondary UK hospitals. Clinicians have implemented early oral switch for selected patients with simple disease without formal clinical trial evidence of safety. However, the current criteria by which decisions to make the oral switch are made are not clearly established or evidence based. FUTURE WORK A RCT in simple OM and SA comparing shorter- or longer-course i.v. therapy is feasible in children randomised after oral switch criteria are met after 7 days of i.v. therapy, excluding children meeting oral switch criteria in the first week of i.v. therapy. This study design meets clinician preferences and addresses parental concerns not to randomise prior to oral switch criteria being met. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hans de Graaf
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Priya Sukhtankar
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Barbara Arch
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Nusreen Ahmad
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Public Health England, Southampton, UK
| | - Amanda Lees
- Health and Wellbeing Research and Development Group, University of Winchester, Winchester, UK
| | - Abigail Bennett
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Catherine Spowart
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Helen Hickey
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Annmarie Jeanes
- Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Armon
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Andrew Riordan
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jethro Herberg
- Section of Paediatrics, Imperial College London, St Mary's Campus, London, UK
| | - Scott Hackett
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carrol Gamble
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Delane Shingadia
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, UK
| | - Ann Pallett
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stuart C Clarke
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Philip Henman
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Marieke Emonts
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Mike Sharland
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Adam Finn
- Bristol Children's Vaccine Centre, School of Clinical Sciences, University of Bristol, Bristol, UK.,Paediatric Infectious Diseases and Immunology, Bristol Royal Hospital for Children, Bristol, UK
| | - Andrew J Pollard
- Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Colin Powell
- School of Medicine, University of Cardiff, Cardiff, UK.,Department of Paediatrics, University Hospital of Wales, Cardiff, UK
| | - Peter Marsh
- Public Health England, South East Public Health England Regional Laboratory, Southampton, UK
| | - Claire Ballinger
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Paula R Williamson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Nicholas Mp Clarke
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Paediatric Orthopaedics, University of Southampton, Southampton, UK
| | - Saul N Faust
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Gurung P, Lee ASW, Armon K, Millington GWM. Chilblains accompanying interleukin-1 receptor-associated kinase (IRAK)-4 deficiency. Clin Exp Dermatol 2018; 43:596-597. [DOI: 10.1111/ced.13621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 01/13/2023]
Affiliation(s)
- P. Gurung
- Dermatology Department; Norfolk and Norwich University Hospital; Norwich UK
| | - A. S. W. Lee
- Dermatology Department; Norfolk and Norwich University Hospital; Norwich UK
| | - K. Armon
- Paediatric Rheumatology Department; Cambridge University Hospitals; Cambridge UK
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Gallagher K, Bale P, Armon K. 291 Juvenile dermatomyositis associated with interstitial lung disease: would anti-MDA5 antibody detection improve early diagnosis and management? Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kathy Gallagher
- Paediatrics, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Peter Bale
- Paediatrics, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
| | - Kate Armon
- Paediatrics, Addenbrookes Hospital, Cambridge, UNITED KINGDOM
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Callan C, Armon K. 34. Service Provision for children with JIA in the East of England remains inadequate: A five-year audit cycle update. Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex390.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lythgoe H, Morgan T, Heaf E, Lloyd O, Al-Abadi E, Armon K, Bailey K, Davidson J, Friswell M, Gardner-Medwin J, Haslam K, Ioannou Y, Leahy A, Leone V, Pilkington C, Rangaraj S, Riley P, Tizard EJ, Wilkinson N, Beresford MW. Evaluation of the ACR and SLICC classification criteria in juvenile-onset systemic lupus erythematosus: a longitudinal analysis. Lupus 2017; 26:1285-1290. [PMID: 28361566 DOI: 10.1177/0961203317700484] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives The Systemic Lupus International Collaborating Clinics (SLICC) group proposed revised classification criteria for systemic lupus erythematosus (SLICC-2012 criteria). This study aimed to compare these criteria with the well-established American College of Rheumatology classification criteria (ACR-1997 criteria) in a national cohort of juvenile-onset systemic lupus erythematosus (JSLE) patients and evaluate how patients' classification criteria evolved over time. Methods Data from patients in the UK JSLE Cohort Study with a senior clinician diagnosis of probable evolving, or definite JSLE, were analyzed. Patients were assessed using both classification criteria within 1 year of diagnosis and at latest follow up (following a minimum 12-month follow-up period). Results A total of 226 patients were included. The SLICC-2012 was more sensitive than ACR-1997 at diagnosis (92.9% versus 84.1% p < 0.001) and after follow up (100% versus 92.0% p < 0.001). Most patients meeting the SLICC-2012 criteria and not the ACR-1997 met more than one additional criterion on the SLICC-2012. Conclusions The SLICC-2012 was better able to classify patients with JSLE than the ACR-1997 and did so at an earlier stage in their disease course. SLICC-2012 should be considered for classification of JSLE patients in observational studies and clinical trial eligibility.
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Affiliation(s)
- H Lythgoe
- 1 Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK
- 2 NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - T Morgan
- 1 Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK
| | - E Heaf
- 3 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - O Lloyd
- 3 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - E Al-Abadi
- 4 Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - K Armon
- 5 Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Bailey
- 6 Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, UK
| | - J Davidson
- 7 Royal Hospital for Sick Children, Edinburgh, UK
| | - M Friswell
- 8 The Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - K Haslam
- 10 Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Y Ioannou
- 11 Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK
| | - A Leahy
- 12 Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - V Leone
- 13 Leeds Children's Hospital NHS Trust, Leeds, UK
| | - C Pilkington
- 14 Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - S Rangaraj
- 15 Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, UK
| | - P Riley
- 16 Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - E J Tizard
- 17 Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, UK
| | - N Wilkinson
- 18 Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, UK
| | - M W Beresford
- 1 Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK
- 2 NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- 3 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Bale P, Easton V, Bacon H, Jerman E, Armon K, MacGregor A. OP2. The efficacy of a multidisciplinary intervention strategy for the treatment of benign joint hypermobility syndrome in childhood: a randomized, single centre parallel group trial (The BENDY Study). Rheumatology (Oxford) 2015. [DOI: 10.1093/rheumatology/keu491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bale PJ, Easton V, Bacon H, Jerman E, Armon K. The efficacy and cost effectiveness of a multidisciplinary intervention strategy for the treatment of benign joint hypermobility syndrome (BJHS) in childhood. a randomised, single centre parallel group trial. (The bendy study). Pediatr Rheumatol Online J 2014. [PMCID: PMC4184277 DOI: 10.1186/1546-0096-12-s1-p58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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Easton V, Bale P, Bacon H, Jerman E, Armon K, Macgregor AJ. A89: The Relationship Between Benign Joint Hypermobility Syndrome and Developmental Coordination Disorders in Children. Arthritis Rheumatol 2014. [DOI: 10.1002/art.38505] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Victoria Easton
- Norfolk and Norwich University Hospital; Norwich United Kingdom
| | - Peter Bale
- University of East Anglia; Norwich United Kingdom
| | - Holly Bacon
- Norfolk and Norwich University Hospital; Norwich United Kingdom
| | - Emma Jerman
- Norfolk and Norwich University Hospital; Norwich United Kingdom
| | - Kate Armon
- Norfolk and Norwich University Hospital; Norwich United Kingdom
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Bale PJ, MacGregor AJ, Armon K, Easton V, Bacon H, Emma J. 288. The Brighton Criteria Fail to Capture the Clinical Characteristics of Benign Joint Hypermobility Syndrome in Children: Data from the Bendy Study. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu125.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bale PJ, Armon K, Yale C, Lane S. 27. Side Effect of Tocilizumab or Just Sojia-Associated Inflammation: A Case Report of a 10-Year-Old Boy with Multiple Antibiotic Responsive Inflammatory Collections. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu096.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bale PJ, MacGregor AJ, Armon K, Easton V, Bacon H, Jerman E. 286. Level of Joint Hypermobility in Children not Associated with Degree of Pain or Restriction in Function. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu125.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Easton VL, Bacon H, Jerman E, Armon K, Bale PJ, Macregor AJ. 296. The Relationship Between Benign Joint Hypermobility Syndrome and Motor Difficulties in Children. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu125.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chiewchengchol D, Murphy R, Morgan T, Edwards SW, Leone V, Friswell M, Pilkington C, Tullus K, Rangaraj S, McDonagh JE, Gardner-Medwin J, Wilkinson N, Riley P, Tizard J, Armon K, Sinha MD, Ioannou Y, Mann R, Bailey K, Davidson J, Baildam EM, Pain CE, Cleary G, McCann LJ, Beresford MW. Mucocutaneous manifestations in a UK national cohort of juvenile-onset systemic lupus erythematosus patients. Rheumatology (Oxford) 2014; 53:1504-12. [PMID: 24692572 DOI: 10.1093/rheumatology/keu137] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To determine whether mucocutaneous manifestations are associated with major organ involvement in a UK national cohort of juvenile-onset SLE (JSLE) patients. METHODS JSLE patients (n = 241) from 15 different centres whose diagnosis fulfilled four or more of the ACR criteria were divided into two groups: those with at least one ACR mucocutaneous criterion (ACR skin feature positive) and those without (ACR skin feature negative) at diagnosis. The relative frequency of skin involvement was described by the paediatric adaptation of the 2004 British Isles Lupus Assessment Group (pBILAG-2004) index. RESULTS One hundred and seventy-nine patients (74%) had ACR-defined skin involvement with no significant demographic differences compared with those without. ACR skin feature negative patients showed greater haematological (84% vs 67%), renal (43% vs 26%) (P < 0.05) and neurological (16% vs 4%) involvement (P = 0.001). Forty-two per cent of ACR skin feature negative patients had skin involvement using pBILAG-2004, which included maculopapular rash (17%), non-scaring alopecia (15%), cutaneous vasculitis (12%) and RP (12%). ACR skin feature negative patients with moderate to severe skin involvement by pBILAG-2004 showed greater renal and haematological involvement at diagnosis and over the follow-up period (P < 0.05). Higher immunosuppressive drug use in the skin feature negative group was demonstrated. CONCLUSION Patients who fulfil the ACR criteria but without any of the mucocutaneous criteria at diagnosis have an increased risk of major organ involvement. The pBILAG-2004 index has shown that other skin lesions may go undetected using the ACR criteria alone, and these lesions show a strong correlation with disease severity and major organ involvement.
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Affiliation(s)
- Direkrit Chiewchengchol
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Ruth Murphy
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Thomas Morgan
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Steven W Edwards
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Valentina Leone
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Mark Friswell
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Clarissa Pilkington
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kjell Tullus
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Satyapal Rangaraj
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Janet E McDonagh
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Janet Gardner-Medwin
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Nick Wilkinson
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Phil Riley
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Jane Tizard
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kate Armon
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Manish D Sinha
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Yiannis Ioannou
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Rebecca Mann
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kathryn Bailey
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK. Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, Universi
| | - Joyce Davidson
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Eileen M Baildam
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Clare E Pain
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Gavin Cleary
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Liza J McCann
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Michael W Beresford
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
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Birt L, Pfeil M, MacGregor A, Armon K, Poland F. Adherence to home physiotherapy treatment in children and young people with joint hypermobility: a qualitative report of family perspectives on acceptability and efficacy. Musculoskeletal Care 2014; 12:56-61. [PMID: 23818237 DOI: 10.1002/msc.1055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Joint hypermobility can lead to pain and motor developmental problems in children and young people (CYP). Exercise programmes may help CYP with joint hypermobility strengthen core muscle groups. Non- adherence to home physiotherapy is common. The present study aimed to understand how families experienced an intensive multidisciplinary intervention. METHOD This was a qualitative study nested within a randomized controlled trial of a multidisciplinary treatment intervention, including physiotherapy, for children aged five to 17 years. Twenty-eight families were recruited following the intervention. Semi-structured interviews were used to examine the views and expectations of parents and CYP, and examine adherence to the exercise programme. Thematic analysis of data was used to develop findings. RESULTS Parents and CYP reported that exercise reduced the symptoms of hypermobility. Parental motivation, adapting family routines, making exercise a family activity and seeing benefit increased adherence to exercise. Non-adherence to exercise was linked to lower levels of parental supervision, not understanding the treatment, not seeing benefit and not having specific time to dedicate to doing the exercises. CONCLUSION Even when exercise is seen to benefit a child's well-being, families experience challenges in adhering to a physiotherapy programme for hypermobility. Therapists can utilize findings on what enhances adherence to help CYP effectively exercise in the home setting.
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Affiliation(s)
- Linda Birt
- School of Allied Health Professions, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
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Smith TO, Easton V, Bacon H, Jerman E, Armon K, Poland F, Macgregor AJ. The relationship between benign joint hypermobility syndrome and psychological distress: a systematic review and meta-analysis. Rheumatology (Oxford) 2013; 53:114-22. [DOI: 10.1093/rheumatology/ket317] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Smith TO, Bacon H, Jerman E, Easton V, Armon K, Poland F, Macgregor AJ. Physiotherapy and occupational therapy interventions for people with benign joint hypermobility syndrome: a systematic review of clinical trials. Disabil Rehabil 2013; 36:797-803. [DOI: 10.3109/09638288.2013.819388] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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