Attribution of neuropsychiatric symptoms and prioritisation of evidence in the diagnosis of neuropsychiatric lupus: mixed methods analysis of patient and clinician perspectives from the international INSPIRE study.

OBJECTIVE: Neuropsychiatric lupus (NPSLE) is challenging to diagnose. Many neuropsychiatric symptoms, such as headache and hallucinations, cannot be verified by tests or clinician assessment. We investigated prioritisations of methods for diagnosing NPSLE and attributional views. METHODS: Thematic and comparative analyses were used to investigate how clinicians prioritise sources of evidence from a 13-item list, and explore discordances in clinician and patient perspectives on attribution. RESULTS: We identified high levels of variability and uncertainty in clinicians' assessments of neuropsychiatric symptoms in SLE patients. In attributional decisions, clinicians (surveys n = 400, interviews n = 50) ranked clinicians' assessments above diagnostic tests (many of which they reported were often unenlightening in NPSLE). Clinicians ranked patient opinion of disease activity last, and 46% of patients reported never/rarely having been asked if their SLE was flaring, despite experienced patients often having "attributional insight". SLE Patients (surveys n = 676, interviews n = 27) estimated higher attributability of neuropsychiatric symptoms to the direct effects of SLE on the nervous system than clinicians (p < 0.001 for all symptoms excluding mania), and 24% reported that their self-assessment of disease activity was never/rarely concordant with their clinicians. Reports of misattributions were common, particularly of non-verifiable diffuse symptoms. Terminology differed between clinicians and influenced attribution estimates. CONCLUSION: NPSLE diagnostic tests and clinician assessments have numerous limitations, particularly in detecting diffuse neuropsychiatric symptoms that can be directly attributable and benefit from immunosuppression. Our findings suggest that incorporating patient attributional insights-although also subject to limitations-may improve attribution decision-making. Consensus regarding terminology and interpretations of "direct attributability" is required.

Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial.

Aims: Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS). Methods: UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion: The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.

Percutaneous Arthroscopic-assisted Glenoid Fixation: A Novel Surgical Technique.

INTRODUCTION: Scapular fractures are rare injuries and are often an indicator of high-energy trauma. These injuries are rare, and many are managed without surgery. The caveat to this is intra-articular extension into the glenoid when AO Foundation principles of fracture fixation for intra-articular injuries must be adhered to. We report a percutaneous arthroscopically assisted technique for fixation of a scapular fracture with extension into the glenoid fossa in a young male patient. CASE REPORT: A 22-year-old Caucasian male presented to the emergency department after a road traffic collision. Primary assessment and secondary surgery demonstrated an isolated shoulder injury involving the glenoid. Three-dimensional imaging was performed and revealed an intra-articular glenoid fracture with the involvement of the superior suspensory apparatus of the shoulder, not fitting into known classification systems. He underwent an arthroscopically assisted percutaneous screw fixation, which resulted in reduction of the suspensory apparatus and the glenoid fossa. CONCLUSION: Intra-articular glenoid involvement in scapular fractures mandates anatomical reduction through internal fixation. We highlight that this technique is of benefit in these injuries and is easy and quick to perform. Validated outcomes, in this case, have been excellent, with no adverse events.

Septic Arthritis of the Hip Complicated by Secondary Fungal Superinfection.

INTRODUCTION: Fungal joint infection can lead to serious consequences for those affected. It can often be a delayed diagnosis due to initial negative organism growth or lack of clinician awareness. Treatment should be early and aggressive to prevent patient morbidity and mortality. CASE REPORT: We present a case of staphylococcal septic arthritis of the native hip joint with secondary superinfection by Candida albicans in a young patient with no appreciable risk factors. We explain the complexity of a delayed diagnosis and subsequent treatment. CONCLUSION: This case highlights important learning points in terms of considering secondary fungal infection in any septic arthritis patient that does not respond to conventional antimicrobial treatment.