Foot orthoses in children with juvenile idiopathic arthritis: a randomised controlled trial.

INTRODUCTION: There is limited evidence supporting the podiatric treatment of children with juvenile idiopathic arthritis (JIA). This multicentre randomised controlled trial aimed to determine whether preformed foot orthoses (FOs) impacted on pain and quality of life (QoL) in children with JIA. METHODS: Eligible children were randomised to receive either 'fitted' FOs with customised chair-side corrections or 'control' FOs made without corrections. Changes in pain and QoL were measured using a visual analogue scale and Paediatric Quality of Life questionnaire, respectively. JIA children were assessed at baseline, 3 months and 6 months. RESULTS: 60 children were recruited. 179 out of a possible 180 assessments (99.4%) were completed. A statistically significant greater difference in pain reduction (baseline - 6 months) was seen between the two groups favouring fitted FOs (p=0.029). The reduction in pain in the fitted FOs group was clinically important (8 mm). Significant differences in QoL favouring fitted FOs were also identified as measured by the children and independently by their parents/carers. CONCLUSIONS: Fitted FOs may reduce pain and improve QoL in selected children with JIA. TRIAL REGISTRATION NUMBER: NCT02001844.

Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants.

BACKGROUND: Persistent patent ductus arteriosus (PDA) is associated with mortality and morbidity in preterm infants. Prostaglandin synthetase inhibitors such as indomethacin promote PDA closure but also have potential side effects. The effect of the prophylactic use of indomethacin, where infants who may not have gone on to develop a symptomatic PDA would be exposed to indomethacin, warrants particular scrutiny. OBJECTIVES: To determine the effect of prophylactic indomethacin on mortality and morbidity in preterm infants. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2010), MEDLINE, EMBASE and CINAHL (until April 2010), conference proceedings, and previous reviews. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that compared prophylactic indomethacin versus placebo or no drug in preterm infants. DATA COLLECTION AND ANALYSIS: The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS: Nineteen eligible trials in which 2872 infants participated were identified. Most participants were very low birth weight, but the largest single trial restricted participation to extremely low birth weight infants (N = 1202). The trials were generally of good quality.The incidence of symptomatic PDA [typical relative risk (RR) 0.44, 95% confidence interval (CI) 0.38 to 0.50] and PDA surgical ligation (typical RR 0.51, 95% CI 0.37,0.71) was significantly lower in treated infants. Prophylactic indomethacin also significantly reduced the incidence of severe intraventricular haemorrhage (typical RR 0.66, 95% CI 0.53 to 0.82). Meta-analyses found no evidence of an effect on mortality (typical RR 0.96, 95% CI 0.81 to 1.12) or on a composite of death or severe neurodevelopmental disability assessed at 18 to 36 months old (typical RR 1.02, 95% CI 0.90, 1.15). AUTHORS' CONCLUSIONS: Prophylactic indomethacin has short-term benefits for preterm infants including a reduction in the incidence of symptomatic PDA, PDA surgical ligation, and severe intraventricular haemorrhage. However, there is no evidence of effect on mortality or neurodevelopment.

Towards safer diagnosis in clinical practice - understanding and using diagnostic tests in the neonatal unit more appropriately.

The diagnostic process is a complex task that is more often than not done inherently by clinicians. However, it is in fact based around quantitative risk assessment and, as a result, when done intuitively is open to a significant risk of bias. By adopting a more structured and quantitative approach to diagnosis, clinicians might be in a position to make better diagnostic decisions. To achieve this, explicit recognition about the uncertainty surrounding diagnosis and knowledge about the basic properties of diagnostic tests, including disease incidence and predictive values, is necessary, as well as some consideration of newer concepts such as 'action thresholds'. Examples from everyday neonatal practice illustrate the potential clinical risks associated with the inappropriate use and interpretation of diagnostic tests and the potential benefits of approaching diagnosis in a more robust manner. A number of tools are now readily available to help clinicians move towards more 'evidence-based' diagnosis.