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The COVID-19 pandemic has led to a rapid increase in the use of telemedicine. This is likely to continue when the social distancing restrictions have been eased. There have been a number of technological advances that have contributed to the roll-out and improved quality of telemedicine consultations. Telemedicine has a number of benefits including facilitating home working for clinicians, reduce travel time for families and allows multidisciplinary team working across different sites. In addition to these clinical benefits there are also the environmental benefits of reduced travel to and from the hospital setting. There are limitations to this change in practice including the need for repeat appointments if a telemedicine facilitated contact is not adequate and the perpetuation of inequality for vulnerable families, the so called "digital divide". Due to the increase in the use of telemedicine it is important that clinicians develop effective consultation practices including appropriate selection of patients, technical setup and consultation tools. In order to ensure trainees are developing appropriate skills in telemedicine, educational opportunities should be developed including structured assessment tools to allow the demonstration of competence in this area.

Background A significant proportion of children and young people with juvenile idiopathic arthritis (JIA) do not achieve inactive disease during the first two years following diagnosis. Refinements to clinical care pathways have the potential to improve clinical outcomes but a lack of consistent and contemporaneous clinical data presently precludes standard setting and implementation of meaningful quality improvement programmes. This study was the first to pilot clinical data collection and analysis using the CAPTURE-JIA dataset, and to explore patient and clinician-reported feasibility and acceptability data. Methods A multiphase mixed-methods approach enabled prospective collection of quantitative data to examine the feasibility and efficacy of dataset collection and of qualitative data informing the context and processes of implementation. An initial paper pilot informed the design of a bespoke electronic data collection system (the Agileware system), with a subsequent electronic pilot informing the final CAPTURE-JIA data collection tool. Results Paper collection of patient data was feasible but time-consuming in the clinical setting. Phase 1 paper pilot data (121 patients) identified three themes: problematic data items (14/62 data items received >40% missing data), formatting of data collection forms and a clinician-highlighted need for digital data collection, informing Phase 2 electronic data collection tool development. Patients and families were universally supportive of the collection and analysis of anonymised patient data to inform clinical care. No apparent preference for paper / electronic data collection was reported by families. Phase 3 electronic pilot data (38 patients) appeared complete and the system reported to be easy to use. Analysis of the study dataset and a dummy longitudinal dataset confirmed that all eleven JIA national audit questions can be answered using the electronic system. Conclusions Multicentre CAPTURE-JIA data collection is feasible and acceptable, with a bespoke data collection system highlighted as the most satisfactory solution. The study is informing ongoing work towards a streamlined and flexible national paediatric data collection system to drive quality improvement in clinical care.

To review the impact of COVID-19 on postgraduate paediatric training, a 10-question online survey was designed to evaluate trainees’ training opportunities. 56 trainees working at a single centre, Alder Hey Children’s Hospital, completed the survey. The majority of trainees felt that COVID-19 had affected their training. Trainees wanted to become involved in Quality Improvement Programs. Face-to-face teaching was still favourable but web-based teaching methods were preferred. Novel online, Worked Based Assessment clinics were well received. COVID-19 has affected traditional learning opportunities but offered a new positive range of digital solutions to give and store educational material.

The COVID-19 emergency has been a challenging but innovative time for the National Health Service (NHS) and paediatrics. Enhancing patient care through use of digital technology was already recognised in the NHS long-term plan.1 Remote consultations, working and learning have rapidly accelerated and become established ways of working during the COVID-19 emergency. This rapid deployment must be used to help inform new models of care and training in paediatrics as outlined in a recent the Royal College of Paediatrics and Child Health (RCPCH) project 2040 report.2 Here we consider some of the new remote working and learning opportunities available to trainees, how they can be used and we propose formal integration into future …

Background Measuring the outcomes that matter to children and young people (CYP) with juvenile idiopathic arthritis (JIA), is a necessary precursor to patient-centred improvements in quality of clinical care. We present a two-centre validation of novel JIA patient-reported outcome and experience measures (PROM and PREM) developed as part of the CAPTURE-JIA project. Methods CYP with JIA were recruited from paediatric rheumatology clinics, completing the CAPTURE-JIA PROM and PREM, CHAQ and CHU 9D. A subset participated in face-to-face interviews and completed the PROM/PREM 1 week later. The OMERACT filter was applied and the three domains of validation assessed. Truth assessments included cognitive interviewing, sensitivity analysis and Spearman’s correlations. Discrimination assessments included specificity and reliability testing. Feasibility was assessed using time to form completion and proportion of missing data. Results Eighty-two CYP and their families were recruited; ten cognitive interviews and fifteen PROM/PREM test/retests were conducted. Truth: CYP and parents understood the PROM/PREM and felt important areas were covered. PROM criteria had high sensitivities (> 70%) against similar items on the CHU 9D, with the exception of fatigue (58%). Correlations between similar PROM and CHU 9D criteria were moderate to very strong (coefficients 0.40–0.82.) Discrimination: high specificities (> 70%) on corresponding PROM and CHU 9D domains. Feasibility: median completion times for PROM 60 s (IQR 38–75) and PREM 49 s (IQR 30–60) respectively. Conclusion The CAPTURE-JIA PROM and PREM are valid and feasible in UK paediatric rheumatology clinics. Embedding routine collection into clinical care would be a major step towards improving quality of care.

Many patients presenting to paediatric rheumatology services require physical therapy. The physiotherapist may take on multiple roles and responsibilities within the team, including diagnostic, therapeutic, disease education, coordinator, patient advocate and facilitator of access to research programmes. As such the physiotherapist will need a background understanding of each disease involving the multi-disciplinary management. In this review, we aim to highlight the importance of the physiotherapist and the roles taken in our multi-disciplinary approach to assessment and treatment of children with rheumatological disorders. Early accurate diagnosis and appropriate management will lead to improved prognosis.

Limping in children is common and may arise from a spectrum of disorders ranging from normal variations in gait development, through to potentially life threatening systemic disease. In this review we take the reader through the normal development of gait, then discuss normal variants of gait in order to identify pathological gait patterns. We aim to provide a framework for the holistic clinical assessment of the limping child and review in more detail some of the commoner diseases associated with limping. Finally some of the commoner pitfalls to establishing a correct diagnosis are presented along with suggestions that may help to improve the diagnostic yield.

Katy was a 6-year-old girl who first presented to the local paediatric minor injuries centre with a history of a swollen, painful right knee. This was of “a couple of days” duration, and the family could not recall any traumatic events in the preceding days. She had a mild upper respiratory tract infection. There was no family history of arthritis, psoriasis or inflammatory bowel disease. The examining practitioner observed Katy walking into the consultation room slowly and with an antalgic gait. She was noted to be rather quiet but did not look toxic. She denied any joint pain when asked specifically. She was rather flushed, but had no rash, and her temperature was 37.5°C. She had a swollen right knee with an effusion. There was no bruising, but the joint was warm to touch and had a reduced range of movement. Remaining detailed systemic examination, including urinalysis, blood pressure and assessment of height and weight that were plotted on appropriate centile charts, was normal. Katy was referred that day to the orthopaedic team at the nearby district general hospital, with possible septic arthritis as the working diagnosis. The examining practitioner was aware that acute septic arthritis is a medical emergency with the potential to cause rapid and irreversible joint damage, so must always be considered in any child with a new presentation of arthritis. Bacterial seeding to the joint via haematogenous transmission is the most frequent pathophysiological process, so he looked specifically for signs of systemic toxicity suggestive of bacterial sepsis. The commonest cause of acute arthritis is reactive arthritis, and there was evidence of an upper respiratory tract infection. Inflammatory joint disease can be associated with other systemic illnesses such as connective tissue disorders and inflammatory bowel disease, signs of which were looked for on detailed multisystem examination, which …

Background Frequent complaints of pain (FCP) are common in high-income countries, affecting about 25% of children, and may have significant adverse consequences including prolonged school absence and disability. Most FCP are unexplained, and the aetiology is poorly understood. This study aimed to identify risk factors for FCP and explore how risk factors explain variation in pain reporting by childhood socioeconomic conditions (SECs). Methods Analysis of the UK Millennium Cohort Study, including 8463 singleton children whose parents provided data throughout the study. At 11 years, mothers were asked whether their child frequently complains of pain. Risk ratios (RR) and 95% CIs for FCP were estimated using Poisson regression, according to maternal education. Other risk factors were explored to assess if they attenuated any association between FCP and SECs. Results 32.3% of children frequently complained of pain. Children of mothers with no educational qualifications were more likely to have FCP than children of mothers with higher degrees (RR 2.06, 95% CI 1.64 to 2.59) and there was a clear gradient across the socioeconomic spectrum. Female sex, fruit consumption, childhood mental health and maternal health measures were associated with childhood FCP in univariable and multivariable analyses. Inclusion of these factors within the model attenuated the RR by 17% to 1.70 (95% CI 1.36 to 2.13). Conclusion In this representative UK cohort, there was a significant excess of FCP reported in less advantaged children that was partially attenuated when accounting for indicators of parental and childhood mental health. Addressing these factors may partially reduce inequalities in childhood FCP.

Background Biologic agents may cause auto-antibody formation and drug induced lupus but no paediatric guidelines exist regarding monitoring of auto-antibodies. The UK Royal College of Nursing Guidance advises checking ANA and anti-dsDNA before starting biologic treatment and repeating anti-dsDNA if concerned. The Alder Hey protocol tested an autoantibody profile (Table 1, 2) 3-6 monthly for data entry for the British Paediatric and Adolescent Rheumatology (BSPAR) Biologics and New Drugs Registry (BDNR) and children with day ward IV biologic administration often had automatic antibodies testing 4-6 weekly.

Results Case 1 A 15 year old girl with worsening asthma and rhinitis presented with a persistent 10x6 cm breast lump 6 months after starting Montelukast. Chest X-rays and CT scan were normal, maxillary sinuses congested, with absolute eosinophilia of 2.4 x 10/l, ESR normal, no proteinuria). On needle biopsy, dilated ducts contained necrotic eosinophilic debris, intense infiltrate of eosinophils and plasma cells without granulomatous infiltration or vasculitis. Despite withdrawing Montelukast the mass persisted but treatment with steroids was successful.

Aim Patients with Complex Regional Pain syndromes require multidisciplinary care to be managed effectively. Relief from the symptoms of neuropathic pain often requires the use of centrally acting medications, as well as physiotherapy and psychological support. There is currently no evidence of the relative clinical efficacy or side effect profiles of the medications used for neuropathic pain management. Methods A retrospective audit of paediatric patients with a diagnosis of complex regional pain syndrome attending a tertiary referral clinic (November 2008 – March 2013) was carried out to determine the pattern of medication use for neuropathic pain relief. Results Thirty-two patients were identified, average age at diagnosis 11y 9 m, male gender 25.0% (n = 8). No patient had a validated pain score/tool used at diagnosis. A prescription for a neuropathic pain medication was present in 93.8% (n=30). Physiotherapy was undertaken in 93.8% (n = 30) and psychology input was present in 56.3% (n = 18). The first medication used was Amitriptyline 86.7% (n = 26), combination Amitriptyline and Gabapentin 6.7% (n = 2), Gabapentin 3.3% (n = 1) and Pregabalin 3.3% (n = 1). Over the course of their treatment, the median number of neuropathic pain medications used was 2 (range 1–4), with 46.7% (n = 14) children only requiring a single medication, 33.3% (n = 10) requiring two, and 20% (n = 6) requiring 3+. The number of children receiving each medication is shown in Table 1. At the end of the audit process, 56.7% (n = 17) were still using these medications. Conclusion Amitriptyline is the most commonly used drug for initiating pain therapy in chronic pain, but during treatment there are a number of other medications used. Pharmacologically, the medications used have different modes of action, and hence there is reason to believe that there may be different rates of efficacy in these conditions, and different side effect profiles. Prospective studies are needed in this area to determine the optimal place of each medication in the treatment of neuropathic pain in complex regional pain disorders.

CML (Chronic myeloid leukemia) is a myeloproliferative disorder, with dysregulated proliferation and differentiation of granulocytes. CML is rare during childhood, incidence of 1 in 1,000,000 and accounts for less than 5% of childhood leukemia. There are 3 different stages: chronic phase, accelerated phase and blast phase.

Cranio-Osteoarthropathy (COA) is a very rare form of primary hypertrophic osteoarthropathy (HOA). HOA is characterised by digital clubbing, arthropathy, pachyderma and sub-periosteal new bone formation along shafts of long bones. In COA, decreased neurocranium ossification is seen without the pachyderma feature.

Protoplasmic astrocytoma is an extremely rare form of grade II low grade glioma which usually presents as a discrete mass lesion. We describe a 3-year-old female with diffuse protoplasmic astrocytoma with parenchymal involvement and leptomeningeal spread. This tumour proved extremely difficult to diagnose and followed a progressive course. Three superficial biopsies did not give the diagnosis and this was only confirmed 8 months from presentation from a larger fourth biopsy taken deeper from the cerebellum. To our knowledge this case represents the distinct presentation of protoplasmic astrocytoma presenting as extensive diffuse meningeal disease. Pediatr Blood Cancer 2010;54:768–769. © 2009 Wiley-Liss, Inc.

Aims We describe successful arthrodiastasis by the means of an Ilizarov frame in two children with juvenile idiopathic arthritis (JIA) with localised destructive disease despite medical therapy. Methods Case 1 - A 2 year old girl was diagnosed with polyarticular JIA (rheumatoid factor (RF) negative, intermittent antinuclear antibody (ANA) positive). Active symptomatic disease progressed despite combinations of intra-articular steroids, methotrexate (MTX), and biologic agents. Magnetic resonance imaging (MRI) showed erosive change of the left ankle with complete loss of joint space and subtalar joints, and by the age of 13 her mobility was increasingly limited. In order to control pain and prevent permanent arthrodesis, Ilizarov distraction of the left ankle was performed. Case 2 - A 13 year old girl with 10 year history of polyarticular JIA (ANA positive RF negative) developed destructive arthropathy in her right ankle with bone on bone crepitus despite treatment with MTX and etanercept. Serial MR scans showed progressive destructive disease. The patient was treated with cross ankle distracting Ilizarov frame with a perioperative course of intravenous methyprednisolone (IVMP) to control synovitis. She had minor skin sepsis at pin sites. Results In both cases, an improvement has been shown post-operatively in terms of reduced pain and improved function. There is radiological evidence of improvement in both patients. Conclusion JIA is a potentially destructive inflammatory disease. Treatment by a skilled multidisciplinary team with access to disease modifying drugs including biologic therapies usually prevents articular damage and disabling symptoms. Joint destruction is rare, but can significantly impact on the quality of life through pain, deformity, and loss of function. Arthrodiastasis, or joint distraction using an orthopaedic frame, can be used as rescue procedure to avoid arthrodesis in severely painful damaged joints unresponsive to medical therapies.

Background & aims The Medicines and Healthcare Regulatory Authority (MHRA) in the UK runs a national spontaneous reporting system (Yellow Card Scheme) to collect ‘suspected’ Adverse Drug Reactions (ADRs) for all medicines. To increase the data for paediatric medicines, current MHRA advice is to report all suspected ADRs in paediatric patients. Yellow Cards submitted between 2000 and 2009 were analysed for medications commonly used in paediatric rheumatology. Methods Data on all UK spontaneous ‘suspected’ ADRs reported to the MHRA in patients