1
|
Lim L, McMillan T, Chédeville G, Lahiry P, Lee JJY, Heale LD, Human AL, McGrath TR, MacQueen SE, Stringer E, Jariwala MP, Neufeld KM, Soon GS, Spiegel LR, Luca NJC. Choosing Wisely: The Canadian Rheumatology Association Pediatric Committee's List of Items Physicians and Patients Should Question. J Rheumatol 2023:jrheum.2023-0043. [PMID: 37527858 DOI: 10.3899/jrheum.2023-0043] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
OBJECTIVE To develop a list of tests or treatments frequently used in pediatric rheumatology practice that may be unnecessary based on existing evidence. METHODS A Choosing Wisely (CW) working group composed of 16 pediatric rheumatologists, 1 allied health professional, 1 parent, and 1 patient used the Delphi method to generate, rank, and refine a list of tests and treatments that may be unnecessary or harmful. The items with the highest content agreement and perceived impact were presented in a survey to all Canadian Rheumatology Association (CRA) physicians who practice pediatric rheumatology. Respondents were asked to rate their agreement and impact, and to rank the items. Five items with the highest composite scores and 2 additional items selected by the CW working group were put forward for literature review. RESULTS The initial Delphi procedure generated 80 items. After 3 rounds, the list was narrowed to 13 items. The survey was completed by 41/81 (51%) CRA pediatric members across Canada. Respondent characteristics were similar to those of the CRA pediatric membership for self-reported gender, geographical location, and career stage. The highest composite score items were antinuclear antibody testing, drug toxicity monitoring, HLA-B27 testing, rheumatoid factor/anticyclic citrullinated peptide testing, and Lyme serology testing. Two additional items (numerous or repeated intraarticular corticosteroid injections, and autoinflammatory diseases genetic testing) were also selected. Literature review was performed for these 7 highest priority items. CONCLUSION We have identified areas for quality improvement in the evaluation and treatment of rheumatic diseases in Canadian children.
Collapse
Affiliation(s)
- Lillian Lim
- L. Lim, MD, MPH, Division of Rheumatology, Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta
| | - Tara McMillan
- T. McMillan, MD, MSc, Division of Rheumatology, Department of Pediatrics, University of Manitoba, Children's Hospital of Winnipeg, Winnipeg, Manitoba
| | - Gaëlle Chédeville
- G. Chédeville, MD, Division of Rheumatology, Department of Pediatrics, McGill University Health Center, Montreal, Quebec
| | - Piya Lahiry
- P. Lahiry, MD, PhD, Division of Rheumatology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Jennifer J Y Lee
- J.J.Y. Lee, MD, MSc, Division of Rheumatology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Liane D Heale
- L.D. Heale, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario
| | - Andrea L Human
- A.L. Human, MD, MScHQ, Division of Rheumatology, Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia
| | - Tara R McGrath
- T.R. McGrath, MD, Division of Rheumatology, Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta
| | - Sue E MacQueen
- S.E. MacQueen, PT, BScPT, ACPAC, Arthritis Society Canada, and Western University, Waterloo, Ontario
| | - Elizabeth Stringer
- E. Stringer, MD, MSc, IWK Health, Dalhousie University, Halifax, Nova Scotia
| | - Mehul P Jariwala
- M.P. Jariwala, MBBS, DNB (Pediatrics), Division of Rheumatology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Kate M Neufeld
- K.M. Neufeld, MD, Division of Rheumatology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Gordon S Soon
- G.S. Soon, MD, Division of Rheumatology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Lynn R Spiegel
- L.R. Spiegel, MD, Division of Rheumatology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Nadia J C Luca
- N.J.C. Luca, MD, MSc, Section of Rheumatology, Department of Pediatrics, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
2
|
Abstract
Childhood onset anti-neutrophilic cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a rare group of primary systemic vasculitides affecting medium and small blood vessels. AAV includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), and renal limited ANCA vasculitis. These disorders are associated with severe clinical manifestations, frequent relapses and a high cumulative morbidity, and often present with multisystem involvement. Renal involvement is common in the pediatric age group, characterized by pauci-immune necrotizing and crescentic glomerulonephritis which frequently progresses to chronic kidney disease in adulthood. ANCAs against proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO) (MPO-ANCA) remain the hallmark of AAV and are integral to the disease pathogenesis. Newer understanding of neutrophil extracellular traps and complement activation have provided better insights into disease pathogenesis. A pediatric vasculitis working group has developed and validated childhood vasculitis classification criteria and disease activity and damage scores. No specific pediatric treatment recommendations exist due to rare nature of the illness in pediatric population. Smaller case series have been published on the efficacy of adult treatment regimens in pediatric patients. The prognosis often remains guarded with frequent relapses and a high cumulative morbidity. The aim of this article is to provide a comprehensive review on pediatric AAV with a focus on recent observations regarding epidemiology, disease pathogenesis, treatment, and prognosis.
Collapse
Affiliation(s)
- Mehul P Jariwala
- Saskatoon Health Region, Saskatoon, SK, Canada.,Department of Pediatrics, Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | - Ronald M Laxer
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| |
Collapse
|