Pediatric joint hypermobility: a diagnostic framework and narrative review.

BACKGROUND: Hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are debilitating conditions. Diagnosis is currently clinical in the absence of biomarkers, and criteria developed for adults are difficult to use in children and biologically immature adolescents. Generalized joint hypermobility (GJH) is a prerequisite for hEDS and generalized HSD. Current literature identifies a large proportion of children as hypermobile using a Beighton score ≥ 4 or 5/9, the cut off for GJH in adults. Other phenotypic features from the 2017 hEDS criteria can arise over time. Finally, many comorbidities described in hEDS/HSD are also seen in the general pediatric and adolescent population. Therefore, pediatric specific criteria are needed. The Paediatric Working Group of the International Consortium on EDS and HSD has developed a pediatric diagnostic framework presented here. The work was informed by a review of the published evidence. OBSERVATIONS: The framework has 4 components, GJH, skin and tissue abnormalities, musculoskeletal complications, and core comorbidities. A Beighton score of ≥ 6/9 best identifies children with GJH at 2 standard deviations above average, based on published general population data. Skin and soft tissue changes include soft skin, stretchy skin, atrophic scars, stretch marks, piezogenic papules, and recurrent hernias. Two symptomatic groups were agreed: musculoskeletal and systemic. Emerging comorbid relationships are discussed. The framework generates 8 subgroups, 4 pediatric GJH, and 4 pediatric generalized hypermobility spectrum disorders. hEDS is reserved for biologically mature adolescents who meet the 2017 criteria, which also covers even rarer types of Ehlers-Danlos syndrome at any age. CONCLUSIONS: This framework allows hypermobile children to be categorized into a group describing their phenotypic and symptomatic presentation. It clarifies the recommendation that comorbidities should be defined using their current internationally accepted frameworks. This provides a foundation for improving clinical care and research quality in this population.

Diagnostic outcomes for molecular genetic testing in children with suspected Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders characterized by hyperextensible skin, hypermobile joints, easy bruisability, and fragility of the connective tissues. The diagnosis is based on clinical assessment and phenotype-guided genetic testing. Most EDS subtypes can be confirmed by genetic testing except for hypermobile EDS. This study explored the utility of applying the 2017 EDS classification criteria and molecular genetic testing in establishing an EDS diagnosis in children. In this retrospective study, we reviewed 72 patients referred to a tertiary care center for evaluation of EDS who underwent one or more forms of genetic testing. Eighteen patients (18/72, 25%) met the clinical criteria for one of the EDS subtypes and of these, 15 (15/18, 83%) were confirmed molecularly. Fifty-four patients (54/72, 75%) had features that overlapped EDS and other syndromes associated with joint hypermobility but did not fully meet clinical criteria. Twelve of them (12/54, 22%) were later shown to have a positive molecular genetic diagnosis of EDS. Different molecular genetic tests were performed on the cohort of 72 patients (EDS panel, n = 44; microarray, n = 25; whole exome sequencing [WES], n = 9; single gene sequencing, n = 3; familial variant testing, n = 10; other genetic panels n = 3). EDS panel was completed in 44 patients (61%), and a molecular diagnosis was confirmed in nine of the patients who satisfied criteria for one of the EDS subtypes (9/12, 75%) and in nine of the patients who did not fully meet criteria (9/32, 28%). We observed a correlation between generalized joint hypermobility, poor healing, easy bruising, atrophic scars, skin hyperextensibility, and developmental dysplasia of the hip with a positive molecular result. This study provides guidance for the use of molecular genetic testing in combination with the 2017 clinical diagnostic criteria in children presenting with EDS characteristics.

A qualitative exploration: questioning multisource feedback in residency education.

BACKGROUND: Multisource feedback (MSF), involves the collection of feedback from multiple groups of assessors, including those without a traditional hierarchal responsibility to evaluate doctors. Allied healthcare professionals (AHCPs), administrative staff, peers, patients and their families may all contribute to the formative assessment of physicians. Theoretically, this feedback provides a thorough view of physician performance; however, the ability of MSF programs to consistently impact physician behavior remains in question. Therefore, the objective of this study was to explore perceptions and prerequisites to an effective MSF program in postgraduate medical education from the perspectives of both pediatric residents and AHCPs. METHODS: This exploratory study was conducted in a pediatric inpatient unit prior to implementation of a MSF program. Focus groups were conducted with purposefully recruited participants from three distinct groups: junior pediatric residents, senior pediatric residents, and AHCPs. Discussions were audio recorded, transcribed verbatim and analyzed using thematic analysis. RESULTS: Both residents and AHCPs expressed a strong interest in the concept of MSF. However, more in depth discussions identified barriers to residents' acceptance of, and AHCPs' provision of feedback. Roles and responsibilities, perceptions of expertise, hospital culture/interprofessionalism and power dynamics were identified as barriers to the acceptance and provision of feedback. All groups expressed interest in opportunities to engage in bi-directional feedback. CONCLUSIONS: The identified barriers and prerequisites to providing and accepting MSF suggest limits to the efficacy of the MSF process. Our findings suggest that these factors should be considered in the design and implementation of MSF programs.