Clinical Characteristics and Factors Associated With Disability and Impaired Quality of Life in Children With Juvenile Systemic Sclerosis: Results From the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry

OBJECTIVE

To investigate clinical manifestations of juvenile systemic sclerosis (SSc; scleroderma), including disease characteristics and patient quality of life, using the multinational Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry.

METHODS

Patients with juvenile SSc were prospectively enrolled between 2010 and 2013. The diagnosis of juvenile SSc was determined by the enrolling pediatric rheumatologist, with the requirement for disease onset prior to age 18 years. Collected data included demographics, disease characteristics, medication exposure, and quality of life metrics.

RESULTS

In total, 64 patients with juvenile SSc were enrolled a median of 3.6 years after disease onset, which occurred at a median age of 10.3 years. The most common organ manifestations were dermatologic and vascular, followed by musculoskeletal, gastrointestinal, and pulmonary; in 38% of patients, ≥4 organ systems were affected. Patients with juvenile SSc had significantly more disability at enrollment compared with CARRA Legacy Registry patients with juvenile idiopathic arthritis, dermatomyositis, or systemic lupus erythematosus. Although physician-reported measures correlated most closely with arthritis, dermatologic manifestations, and pulmonary manifestations, poor patient-reported measures were associated with gastrointestinal involvement. During >50 person-years of follow-up, most organ manifestations remained stable, and no mortality or development of new solid organ involvement after enrollment was reported.

CONCLUSION

In the first multicenter prospective cohort of patients with juvenile SSc in North America, the disease burden was high: multiorgan manifestations were common, and functional disability was greater than that observed in patients with other childhood-onset rheumatic diseases. Gastrointestinal involvement had the greatest impact on quality of life.

Development of a conceptual model of cancer caregiver health literacy

Caregivers play a vital role in caring for people diagnosed with cancer. However, little is understood about caregivers' capacity to find, understand, appraise and use information to improve health outcomes. The study aimed to develop a conceptual model that describes the elements of cancer caregiver health literacy. Six concept mapping workshops were conducted with 13 caregivers, 13 people with cancer and 11 healthcare providers/policymakers. An iterative, mixed methods approach was used to analyse and synthesise workshop data and to generate the conceptual model. Six major themes and 17 subthemes were identified from 279 statements generated by participants during concept mapping workshops. Major themes included: access to information, understanding of information, relationship with healthcare providers, relationship with the care recipient, managing challenges of caregiving and support systems. The study extends conceptualisations of health literacy by identifying factors specific to caregiving within the cancer context. The findings demonstrate that caregiver health literacy is multidimensional, includes a broad range of individual and interpersonal elements, and is influenced by broader healthcare system and community factors. These results provide guidance for the development of: caregiver health literacy measurement tools; strategies for improving health service delivery, and; interventions to improve caregiver health literacy.

Estimated noise distributions across stages of consciousness utilizing the Fsp quantification technique

We used the Fsp technique to quantify the influence of changing stages of consciousness on the signal-to-noise ratio of the middle latency response (MLR). The MLR and polysomnographic activity were obtained from 10 subjects during a continuous 6-hour period. The Fsp statistic was applied to the MLR data in order to determine the number of scores above a specified criterion in each stage of consciousness and time window of analysis. Results demonstrated that the number of Fsp scores exceeding the criterion of acceptance decreased with increasing depth of sleep. The awake stage yielded the greatest proportion of scores above the criterion. The background noise data were analyzed separately. The distributions of noise differed as a function of stage of consciousness.

A comparison of endovascular assisted and conventional in situ bypass grafts

Thirty-three in situ saphenous vein bypass grafts were performed using a conventional open technique (CI) while 31 in situ bypass grafts were performed using endovascular occlusion of side branches (EAI). Bypass grafts were performed from the femoral to the popliteal (n = 37) or a trifurcation (n = 27) artery for claudication (n = 7), rest pain (n = 14), or tissue loss (n = 43). Wound complications developed in 11 Cl and four EAI limbs. Postoperative hospitalization in CI and EAI patients was, respectively, 8.4 +/- 2.0 days and 4 +/- 1.6 days. Missed arteriovenous fistulas were noted in one CI and 17 EAI limbs postoperatively. At follow-up four (12%) CI and six (19%) EAI grafts were occluded or had undergone revision surgery. Based on life-table analysis CI and EAI cumulative patency rates at 18 months were 79% and 83%, respectively. Although this new technique (EAI bypass grafting) did not reduce operative time, it did decrease the length of surgical incisions and the duration of postoperative hospitalization (p < 0.001, Student's t test). Wound complications occurred less frequently in EAI limbs but the incidence of missed arteriovenous fistulas was significantly higher. These data suggest that EAI and CI patency is comparable. Ultimately long-term patency will be the crucial test for determining the utility of this new technique.

Esophageal obstruction in a tracheostomized infant

Partial esophageal obstruction was an unusual complication of tracheostomy in an infant. Emesis and failure to thrive prompted a modified barium-swallow study, which revealed that the tracheostomy tube was causing an obstruction in the proximal esophagus. Use of a shorter, customized tube eliminated the esophageal obstruction, allowing normal feeding and weight gain.

Evidence that the onset of the breeding season in the ewe may be independent of decreasing plasma prolactin concentrations

Ten ewes of each of two breeds, Dorset Horn (long breeding season) and Welsh Mountain (short breeding season), were given subcutaneous oestradiol-17 beta implants and then ovariectomized. Another 10 ewes of each breed were left intact. On 3 May 1982, all the ewes were housed in an artificial photoperiod of 16L:8D. After 4 weeks, half of the ewes of each breed and physiological state were abruptly exposed to a short-day (8L:16D) photoperiod while the others remained in long days (16L:8D). The time of onset of the breeding season was significantly (P less than 0.05) advanced in ewes switched to short days (12 August +/- 10 days) compared to those maintained in long days (4 September +/- 14 days). Dorset Horn ewes began to cycle (20 July +/- 7 days) significantly (P less than 0.001) earlier than Welsh Mountain ewes (19 September +/- 6 days). Disparities in the time of onset of cyclic activity in ewes of different breeds and daylength groups were echoed in disparities in the time at which plasma LH and FSH concentrations rose in oestrogen-implanted, ovariectomized ewes of the same light treatment group. Prolactin concentrations showed an immediate decrease in ewes switched to short days, but remained elevated in long-day ewes. Since the breeding season started in the presence of high prolactin concentrations in long-day ewes, it seems unlikely that prolactin is an important factor determining the timing of the onset of cyclic activity.