Examination of the musculoskeletal system: junior doctors' perceptions of the usefulness of the Gait, Arms, Legs and Spine (GALS) technique.

BACKGROUND: Musculoskeletal (MSK) conditions affect millions of people around the world. Gait, Arms, Legs and Spine (GALS) is a simple and useful screening tool for routine MSK examination in hospitals and general practice and has been integrated into the undergraduate medical curriculum. Despite this, there is evidence that doctors lack competency in MSK examination and that GALS are underperformed routinely. OBJECTIVES: The study explored the views of junior doctors (JDs) on how they were taught MSK examination as undergraduates; the usefulness of GALS as a technique for excluding significant MSK problems; why MSK examination was often poorly carried out and how this could be improved. METHODS: A qualitative study was performed with data gathered through focus group interviews from 32 JDs working in two acute NHS hospitals. Six interviews were conducted over a 6-week period from mid-June to the end of July in consecutive years 2013 and 2014. RESULTS: Ninety JDs were invited to participate in the focus group interviews; 32 (36%) agreed to participate, 28 (88%) of whom had graduated in the UK. The perception of JDs was that undergraduate training for GALS and regional MSK examination was adequate, but reasons for lack of MSK competency in the workplace are multifactorial and complex. CONCLUSIONS: Proposing more practical and interactive sessions to reinforce MSK skills during postgraduate training may not resolve issues of MSK competency among JDs. Recognition of the complexity of workplace learning and the influence of tacit learning is required if MSK competency is to be enhanced.

Serial analysis of clinical and imaging indices reveals prolonged efficacy of TNF-α and IL-6 receptor targeted therapies in refractory Takayasu arteritis.

OBJECTIVES: We analysed a large cohort of patients with Takayasu arteritis, seeking robust clinical evidence for prolonged responses to tumour necrosis factor-α (TNF-α) and interleukin-6 receptor (IL-6R) antagonists in severe refractory disease. METHODS: Case notes from ninety-eight patients with Takayasu arteritis were retrospectively reviewed. Drug treatment, laboratory and serial non-invasive imaging data were analysed, and the Indian Takayasu arteritis activity (ITAS) and damage scores (TADs) calculated. RESULTS: Nine patients were treated with biologic therapies. All had previously received high dose prednisolone and ≥1 conventional immunosuppressant. Five patients had failed cyclophosphamide. The patients prescribed biologics had more extensive arterial injury than the remainder of the cohort and persistent active disease (ITAS range 2-9, CRP 12-206 mg/L, TADs 3--1). Eight patients were prescribed anti-TNF-α therapy, three IL-6R blockade. The mean duration of anti-TNF-α treatment was 42 months (maximum 8 years). One patient developed new arterial stenoses while receiving anti-TNF-α and subsequently achieved disease remission with tocilizumab. Two patients have now demonstrated sustained responses to IL-6R inhibition at 19 and 20 months. Following introduction of biologic therapy, serial non-invasive imaging has revealed no significant progression in arterial injury. A significant fall in CRP (p<0.01), prednisolone dose (p<0.01) and ITAS (p<0.01) was observed, with no increase in TADs. CONCLUSIONS: We report for the first time sustained responses to both anti-TNF-α and IL6R antagonists in refractory Takayasu arteritis. As 5/9 patients were cyclophosphamide non-responders, we propose that biologics should now be considered ahead of cyclophosphamide in these young patients.

Development of a benchmarking toolkit for adolescent and young adult rheumatology services (BeTAR).

BACKGROUND: Young people (YP; 12-24 years old) with rheumatic diseases face many challenges associated with chronic illness in addition to the physiological and psychosocial changes of adolescence. Timely access to developmentally appropriate multidisciplinary care is key to successfully managing rheumatic diseases, but gaps in the care of this vulnerable age group still exist. This study aimed to develop a benchmarking toolkit to enable comparative evaluation of YP rheumatology services in order to promote best practice and reduce variations in service delivery. METHODS: A staged and consultative method was used across a broad group of stakeholders in the UK (YP, parents/other carers, and healthcare professionals, HCPs) to develop this toolkit, with reference to pre-existing standards of YP-friendly healthcare. Eighty-seven YP (median age 19 years, range 12-24 years) and 26 rheumatology HCPs with 1-34 years of experience caring for YP have participated. RESULTS: Thirty quality criteria were identified, which were grouped into four main domains: assessment and treatment, information and involvement, accessibility and environment, and continuity of care. Two toolkit versions, one to be completed by HCPs and one to be completed by patients, were developed. These were further refined by relevant groups and face validity was confirmed. CONCLUSIONS: A toolkit has been developed to systematically evaluate and benchmark YP rheumatology services, which is key in setting standards of care, identifying targets for improvement and facilitating research. Engagement from YP, clinical teams, and commissioners with this tool should facilitate investigation of variability in levels of care and drive quality improvement.