Cardiovascular risk in juvenile idiopathic arthritis.

JIA is the most common chronic inflammatory arthritis in children and young people. More than one-third of individuals have persistent active disease into adulthood. In RA, there has been considerable interest in long-term cardiovascular outcomes. Increased cardiovascular mortality and morbidity have been observed and consensus guidelines recommend annual cardiovascular risk assessment for adults with RA. The increased risk is attributed to a higher prevalence of traditional cardiovascular risk factors and the role of systemic inflammation in the acceleration of atherosclerosis. The long-term risk of cardiovascular disease for individuals with JIA remains uncertain and guidance on risk assessment is not currently available. Given the potential for longer disease duration, it is possible that cardiovascular risk in this group surpasses that observed in adult-onset inflammatory arthritides. In this article, we consider the evidence for cardiovascular risk in JIA.

Real-world single-centre experience of rheumatoid arthritis patients requiring four or more higher cost drugs: response and duration of treatment.

The cost-effectiveness of higher cost drugs (HCDs) after several failures is disputed by some purchasers of services for people with rheumatoid arthritis (RA). We were interested to explore our service experience of using HCDs beyond the third choice to document response rates and duration of treatments. METHOD: Records from our multi-disciplinary team meeting (MDT) that is used to decide on the use of HCDs were used to identify all RA patients who had been exposed to four or more HCDs. Notes were scrutinised for sequence of treatments, duration and response to treatments and reasons for stopping at each choice point. RESULTS: From a total of 2648 RA patients in our service, 49 (< 2%) had been exposed to four or more HCDs. Response rates based on descriptive assessments for fourth to sixth choices were between 50 and 55% as well as some partial responders. There were responders and failures to all drugs at every choice point. Patients who had responded to one drug were more likely to respond to the next. Patients often responded to drugs for approximately 2 years. Only four patients had stopped looking for the next HCD. CONCLUSION: Patients often respond to late choice HCDs. There are responders and failures at each time point and they are difficult to predict. There is no justification for restricting the number of HCDs that can be tried for RA. Key Points • Less than 2% of our RA patients required 4 or more higher cost drugs. • Fourth to sixth choice drugs still worked in 50 to 55% of patients. • There is no justification for CCGs restricting the number of drugs that can be tried.

Reliability and validity of ultrasound imaging of features of knee osteoarthritis in the community.

BACKGROUND: Radiographs are the main outcome measure in epidemiological studies of osteoarthritis (OA). Ultrasound imaging has unique advantages in that it involves no ionising radiation, is easy to use and visualises soft tissue structures. Our objective was to measure the inter-rater reliability and validity of ultrasound imaging in the detection of features of knee OA. METHODS: Eighteen participants from a community cohort, had both knees scanned by two trained musculoskeletal sonographers, up to six weeks apart. Inter-rater reliability for osteophytes, effusion size and cartilage thickness was calculated by estimating Kappa (κ) and Intraclass correlation coefficients (ICC), as appropriate. A measure of construct validity was determined by estimating κ between the two imaging modalities in the detection of osteophytes. RESULTS: Reliability: κ for osteophyte presence was 0.77(right femur), 0.65(left femur) and 0.88 for both tibia. ICCs for effusion size were 0.70(right) and 0.85(left). Moderate to substantial agreement was found in cartilage thickness measurements. VALIDITY: For osteophytes, κ was moderate to excellent at 0.52(right) and 0.75(left). CONCLUSION: Substantial to excellent agreement was found between ultrasound observers for the presence of osteophytes and measurement of effusion size; it was moderate to substantial for femoral cartilage thickness. Moderate to substantial agreement was observed between ultrasound and radiographs for osteophyte presence.

Acceptability and practicality of musculoskeletal examination in acute general pediatric assessment.

OBJECTIVE: To evaluate the practicality and the acceptability of pGALS (pediatric Gait, Arms, Legs and Spine) screening, a simple pediatric musculoskeletal screening examination, when performed as part of an acute pediatric assessment. STUDY DESIGN: Consecutive school-aged children attending an acute pediatric assessment unit were assessed with the addition of pGALS to the routine clinical examination. Practicality (ie, time taken, degree of completion) and patients/parent-assessed acceptability (ie, time taken, discomfort caused) were recorded. RESULTS: Fifty consecutive school-aged children (median age 8 years) were evaluated by pGALS. Median time taken was 3 minutes (range 1.2-5.3), and examination was completed in 47/50 (96%) children. Acceptability of pGALS was deemed high: time taken was "about right" (98% children, 94% parents) and caused no or little discomfort (72% of children, 92% of parents). Abnormalities on pGALS examination were common, with most (17/50, 34%) explained by confirmed musculoskeletal disease, and 6 of 50 (12%) had non- musculoskeletal disease. CONCLUSIONS: PGALS is practical and acceptable to perform in acute pediatric assessment performed by a non expert in musculoskeletal medicine. Abnormal musculoskeletal findings are common as part of the pGALS examination but need to be interpreted in the global clinical context and assessment.

Mixed methods study of a new model of care for chronic disease: co-design and sustainable implementation of group consultations into clinical practice.

OBJECTIVES: Group consultations are used for chronic conditions, such as inflammatory arthritis, but evidence of efficacy for treatment to target or achieving tight control is lacking. Our aim was to establish whether group consultation is a sustainable, co-designed routine care option and to explore factors supporting spread. METHODS: The study used mixed methods, observational process/outcome data, plus qualitative exploration of enabling themes. It was set in two community hospitals, in 2008-19, with a third hospital from 2016, and was triangulated with primary care qualitative data. There was a total of 3363 arthritis patient attendances at 183 clinics during 2008-19. The early arthritis cohort comprised 46 patients, followed monthly until the treatment target was achieved, during 2016-19. Focus groups included 15 arthritis and 11 osteoporosis group attendees. Intervention was a 2 h group consultation, attended monthly for early/active disease and annually for stable disease. Measurements included attendance, DAS, satisfaction and enabling themes. RESULTS: There was a mean number of 18.4 patients per clinic (n = 16, 2010-15; n = 18, 2016; n = 20, 2017; n = 23, 2018-19). Forty per cent (1161/2874) of patients with DAS data reached low disease activity (DAS < 3.2) or remission (DAS < 2.6). Forty-six early arthritis patients followed monthly until they achieved remission responded even better: 50% remission; and 89% low disease activity/remission by 6 months. Qualitative analysis derived five main enabling themes (efficiency, empathy, education, engagement and empowerment) and five promotors to translate these themes into practice (prioritization, personalization, participation, personality and pedagogy). Limitations included the prospectively collected observational data and pragmatic design susceptible to bias. CONCLUSION: Co-designed group consultations can be sustainable, clinically effective and efficient for monthly review of early active disease and annual review of stable disease. Promoting factors may support effective training for chronic disease group consultations.

MediLex: the medical jargon-busting game.

BACKGROUND: During their training, medical students are expected to acquire the ability to use thousands of new terms that make up the medical lexicon. Clear communication requires knowledge of this lexicon. We developed a simple word game, MediLex, to facilitate the development of these skills. This paper describes the intervention and evaluates students' experiences. METHODS: MediLex is a card-based description game played in small groups. One hundred cards contain 500 medical terms grouped into five categories. The cardholder is asked to describe the terms on the card while group members have a limited time to deduce the term being described. Students were asked to evaluate MediLex using an electronic survey with free-text responses. Content analysis was undertaken by two independent researchers, and after discussion a consensus on themes was reached. Medical students are expected to acquire the ability to use thousands of new terms that make up the medical lexicon RESULTS: MediLex was used on six different occasions. Sixty-eight students played the game and 61 completed the survey. Fifty-six out of 61 students deemed MediLex to be a valuable learning experience. The analysis of responses revealed five themes: 'highlighted knowledge gaps'; 'revision/reactivation of knowledge'; 'explanation skills'; 'fun/engaging'; and 'fast pace'. DISCUSSION: Learning new vocabulary is a complex process, yet is a principle contributor to comprehension, fluency and achievement. Research suggests that playing games with content vocabulary allows learners to explore pronunciation and meanings simultaneously. MediLex allows learners to do this, whilst giving the opportunity to hear their peers' comprehension of meaning. Mastering the medical lexicon is a huge challenge because of the breadth and complexity of medical terminology, and focused teaching on this appears to be well received by students.

Musculoskeletal training: are GP trainees exposed to the right case mix for independent practice?

Musculoskeletal conditions are common in general practice, but clinicians express poor self confidence in dealing with them. Training in general practice relies on clinical exposure to a range of presentations in order to gain competence. It has been suggested that trainees are exposed to a different case mix from qualified general practices (GPs), due to seeing more minor illness and less chronic disease and that this may be responsible in part for their subsequent lack of confidence. The aims of this study were to analyse the case mix of musculoskeletal conditions encountered by general practice trainees and to compare this to the overall population consulting behaviour. This is a prospective observational study. Thirteen general practices in North East England were recruited. Musculoskeletal disorders encountered by 13 GP trainees (7 junior and 6 senior) were prospectively recorded using a handheld diary. Disorders were classified according to working diagnosis or body region if diagnosis was unclear. Musculoskeletal (MSK) disorders comprised 17 % of consultations, and the distribution of diagnoses of these was in proportion to epidemiological studies of MSK disorders in the UK as they present in primary care. Back pain was the most frequent label with 141 (29 %) consultations with a further 43 (9 %) for neck pain. Inflammatory arthritis accounted for the same number 43 (9 %). Individual joint problems were 115 (24 %) with knee being most common. A specific diagnosis was more likely to be applied when symptoms were more distal and less likely when axial. Trainees are exposed to the same spectrum of MSK disorders as are present in the population as a whole. Case mix does not appear to be a significant factor in low confidence levels in dealing with MSK disorders.

Paediatric musculoskeletal learning needs for general practice trainees: achieving an expert consensus.

BACKGROUND: Paediatric musculoskeletal (pMSK) disorders are common in clinical practice, but training in their recognition and management is suboptimal at both undergraduate and postgraduate level. Exposure to pMSK conditions is variable in GP training, and there is no standardised curriculum for what GPs should know about pMSK medicine. AIM: To attain expert agreement on the gold standard of pMSK skills and knowledge required at completion of GP training. DESIGN AND SETTING: Modified Delphi process followed by consensus group meeting and focus groups. METHODS: Two iterative rounds of Delphi process conducted by email, followed by a face-to-face meeting of stakeholders. Items with >80% agreement included in final curriculum statement. Member checking by GPs conducted through focus group meetings. RESULTS: A curriculum covered by 12 overarching statements was developed, with positive feedback from GP educators on the feasibility of delivering the curriculum and usefulness of the items. CONCLUSION: The introduction of expert-derived learning needs to the GP curriculum on pMSK medicine should help with improving the recognition and management of children with MSK disorders.

Poor sensitivity of musculoskeletal history in children.

OBJECTIVES: To demonstrate the sensitivity of musculoskeletal (MSK) history taking. DESIGN: Prospective study: consecutive children attending outpatient clinics. SETTING AND PATIENTS: Paediatric rheumatology clinic (n=45; girls n=28; median age 12 years, range 3-18), acute general paediatric assessment unit (n=50; girls n=21; median age 8 years, range 3-16). INTERVENTION: Pro forma recording abnormal joint involvement from history taking and then following MSK examination completed by clinicians. MAIN OUTCOME MEASURES: Sensitivity of MSK history taking compared with clinical examination. RESULTS: Paediatric rheumatology clinic: 135 abnormal joints identified in 34 children; 53/135 (39%) by history alone, 82/135 (61%) detected on examination resulting in MSK history sensitivity 53%, specificity 98%. Acute paediatric unit: 29 abnormal joints identified in 17 children; 18/29 identified on history (sensitivity 62%). CONCLUSIONS: MSK history taking failed to identify a large number of abnormal joints which were detected on physical examination, emphasising the need for all joints to be examined as part of a screening examination as a minimum.