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There is increasing concern into the decline of insect populations, with corresponding calls for conservation action aimed towards threatened species in particular. However, there is a distinct paucity of knowledge surrounding habitat requirements, microhabitat selection and conservation actions that may be undertaken for the vast majority of invertebrate species.Carabus intricatus (Coleoptera: Carabidae) Linnaeus, 1761 is a threatened ancient woodland specialist in the United Kingdom with a highly restricted distribution and is listed as a section 41 species of principal importance in England. Despite this, no empirical systematic evidence exists for even basic habitat requirements.Here, we used a patch‐occupancy modelling framework to determine occupancy and detection parameters for C. intricatus and a sympatric generalist species, C. problematicus, which is a potential competitor.Our models showed that decayed deadwood availability and leaf litter covering (an indicator of the availability of mature broadleaved trees) leads to higher occupancy of C. intricatus, whereas decayed dead wood availability and slug abundance are primary determinants of overall abundance. Additionally, detection models showed that higher humidity substantially increased activity of C. intricatus.For C. problematicus, ground moss coverage and overall deadwood volume most strongly influenced occupancy and abundance, whereas there were no humidity related influences on activity.The results support our general predictions about the specialist–generalist nature of the two species in the United Kingdom and indicate that key characteristics of old‐growth temperate rain forests, particularly the availability of deadwood and high humidity, are central to the conservation of these charismatic carabids. [ABSTRACT FROM AUTHOR]

Background: Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery. Methods: An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression. Results: Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications. Conclusion: There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed. [ABSTRACT FROM AUTHOR]

Objectives To define the incidence and prevalence of Behçet's syndrome (BS) in children and young people (CYP) up to the age of 16 years in the United Kingdom (UK) and Republic of Ireland (ROI). Methods A prospective epidemiological study was undertaken with the support of the British Paediatric Surveillance Unit (BPSU) and the British Society of Paediatric Dermatologists (BSPD). Consultants reported anonymised cases of BS seen. A follow-up study at one year examined progression of disease and treatment. Results Over a two-year period, 56 cases met the International Criteria for Behçet's Disease. For children under 16 years of age, the two-year period prevalence estimate was 4.2 per million (95% CI: 3.2, 5.4) and the incidence was 0.96 per million person years (95% CI: 0.66, 1.41). Mucocutaneous disease was the most common phenotype (56/100%), with ocular (10/56; 17.9%), neurological (2/56; 3.6%) and vascular involvement (3/56; 5.4%) being less common. Median age at onset was 6.34 years and at diagnosis was 11.72 years. There were slightly more female than male children reported (32/56; 55.6%). The majority of cases (85.7%) were white Caucasian. Apart from genital ulcers, which were more common in females, there were no significant differences in frequency of manifestations between male or females, nor between ethnicities. Over 83% of cases had three or more non-primary care healthcare professionals involved in their care. Conclusion BS is extremely rare in CYP in the UK and ROI and most have mucocutaneous disease. Healthcare needs are complex, and coordinated care is key. [ABSTRACT FROM AUTHOR]

Objective: Vasculopathy is considered central to the pathogenesis of juvenile dermatomyositis (DM) and is associated with severe extramuscular manifestations. We undertook this study to investigate the hypothesis that the vasculopathy of juvenile DM can be noninvasively tracked by examining biomarkers of endothelial injury, subclinical inflammation, hypercoagulability, and vascular arterial stiffness. Methods: The study population was a UK cohort of children with juvenile DM. Circulating endothelial cells (CECs) and microparticles (MPs) were identified using immunomagnetic bead extraction and flow cytometry, respectively. Plasma thrombin generation was determined using a fluorogenic assay. Cytokine and chemokine levels were measured by electrochemiluminescence. Arterial stiffness was assessed using pulse wave velocity (PWV). Results were expressed as the median and interquartile range (IQR), and statistical significance was assessed using nonparametric analyses. Results: Ninety patients with juvenile DM and 79 healthy control subjects were included. The median age of the patients was 10.21 years (IQR 6.68–13.40), and the median disease duration was 1.63 years (IQR 0.28–4.66). CEC counts were higher in all patients with juvenile DM compared to controls (median 96 cells/ml [IQR (40–192] and 12 cells/ml [IQR 8–24], respectively; P < 0.0001). Circulating MP numbers were also significantly higher in patients with active juvenile DM compared to controls (median 204.7 × 103/ml [IQR 87.9–412.6] and 44.3 × 103/ml [IQR 15.0–249.1], respectively; P < 0.0001). MPs were predominantly of platelet and endothelial origin. Enhanced plasma thrombin generation was demonstrated in patients with active juvenile DM compared to those with inactive disease (P = 0.0003) and controls (P < 0.0001). Carotid‐radial PWV adjusted for age was increased in patients with juvenile DM compared to controls (P = 0.003). Conclusion: We observed increased endothelial injury and increased levels of proinflammatory cytokines in patients with active juvenile DM. MP profiles reflected distinct disease activity status in juvenile DM and are markers of vascular pathology, platelet activation, and thrombotic propensity. Ongoing long‐term vascular injury may result in increased arterial stiffness in patients with juvenile DM. [ABSTRACT FROM AUTHOR]

Kawasaki disease (KD) is an inflammatory disorder of young children, associated with vasculitis of the coronary arteries with subsequent aneurysm formation in up to one-third of untreated patients. Those who develop aneurysms are at life-long risk of coronary thrombosis or the development of stenotic lesions, which may lead to myocardial ischaemia, infarction or death. The incidence of KD is increasing worldwide, and in more economically developed countries, KD is now the most common cause of acquired heart disease in children. However, many clinicians in the UK are unaware of the disorder and its long-term cardiac complications, potentially leading to late diagnosis, delayed treatment and poorer outcomes. Increasing numbers of patients who suffered KD in childhood are transitioning to the care of adult services where there is significantly less awareness and experience of the condition than in paediatric services. The aim of this document is to provide guidance on the long-term management of patients who have vascular complications of KD and guidance on the emergency management of acute coronary complications. Guidance on the management of acute KD is published elsewhere. [ABSTRACT FROM AUTHOR]

Objectives Hereditary systemic autoinflammatory diseases are rare genetic disorders, which if untreated, can be complicated by AA amyloidosis leading to renal failure and premature death. Our objective was to find a genetic cause in a British family with a dominantly inherited autoinflammatory disease complicated by AA amyloidosis. Methods The index patient and his sister underwent comprehensive clinical and laboratory assessment including the next-generation sequencing panel targeting autoinflammatory genes. Subsequently, other relatives underwent clinical evaluation and genetic testing. Screening of the SAA1 gene was performed in all symptomatic cases. Results The index case and his sister presented with proteinuria due to AA amyloidosis. They have been suffering from episodes of fever accompanied by severe abdominal and chest pain, arthritis and erythema since childhood. Their father died aged 52 years from complications following a cadaveric renal transplantation. The post-mortem examination demonstrated AA amyloidosis. The index case's grandmother, two paternal cousins and two of their children described similar symptoms. All symptomatic individuals had excellent responses to colchicine. Next-generation sequencing analysis identified a single MEFV p.P373L variant in the index case, his sister and subsequently, in symptomatic family members. Sequencing of the SAA1 gene revealed all cases were heterozygous for the SAA1.1 allele. Conclusion Typically FMF is an autosomal recessive disorder; nonetheless rare cases of dominantly inherited disease have previously been described. Here we report a novel MEFV variant p.P373L, causing dominant FMF complicated by AA amyloidosis in four generations of a British family. [ABSTRACT FROM AUTHOR]

Objectives: Early treatment of HIV‐1 infection at all CD4 levels has demonstrated clinical and public health benefits. This analysis examined the costs, health outcomes, and cost‐effectiveness of increased HIV‐1 screening and early treatment initiation in the UK. Methods: A Markov model followed theoretical cohorts of men who have sex with men (MSM), heterosexuals, and people who inject drugs (PWID) with initially undiagnosed HIV‐1 infection over their remaining lifetimes. The analysis examined increased HIV‐1 screening (resulting in 10–50% improvements in diagnosis rates) versus current screening in sexual health services (SHS) and other settings, with all individuals initiating treatment within 3 months of diagnosis. Health status was modelled by viral load and CD4 cell count as individuals progressed to diagnosis and treatment. Individuals accrued quality‐adjusted life‐years (QALYs), incurred costs for screening and HIV‐related clinical management, and were at risk of transmitting HIV‐1 infection to their partners. Input parameter data were taken primarily from UK‐specific published sources. All outcomes were discounted at 3.5% annually. Results: The model estimated that increased screening and early treatment resulted in fewer onward HIV transmissions, more QALYs, and higher total costs. For SHS, incremental cost‐effectiveness ratios (ICERs) for heterosexuals (~£22 000/QALY gained) were within typical UK willingness‐to‐pay thresholds and were well below these thresholds for MSM (~£9500/QALY gained) and PWID (~£6500/QALY gained). Sensitivity analysis showed that model results were robust. Conclusions: Increased HIV‐1 screening and early treatment initiation may be a cost‐effective strategy to reduce HIV transmission and improve health for MSM, heterosexuals, and PWID in the UK. [ABSTRACT FROM AUTHOR]

Aims: Rituximab is a chimeric IgG‐1 monoclonal antibody that depletes B cells, aiding in the treatment of several conditions including autoimmune diseases. It is not licensed for use in children. This study aimed to quantify the B cell‐related pharmacodynamics of rituximab in children with autoimmune disease. Methods: Routine electronic health record data were collected at a large paediatric tertiary hospital in London, UK. Dosing protocols were either 2 × 750 mg/m2 intravenous infusions of rituximab on days 1 and 15, or 4 × 375 mg/m2 infusions on days 1, 8, 15 and 22. Rituximab pharmacokinetics (PK) were not measured but CD19+ lymphocyte counts were taken before and after rituximab treatment. A dose–response model was constructed describing the life cycle of CD19+ lymphocytes, with rituximab assumed to increase the death rate. Rituximab effect was assumed to decay by first‐order kinetics. Results: In total, 258 measurements of CD19+ lymphocyte counts were collected from 39 children with 8 autoimmune diseases. The elimination rate constant (% relative standard error) of rituximab effect decay was 0.036 (22.7%) days−1 and CD19+ turnover was 0.02 (41%) days−1 corresponding to half‐lives of 19 and 35 days respectively. Rituximab increased CD19+ death rate 35‐fold, with methotrexate and cyclophosphamide associated with further increases. Simulations suggested that a single infusion of 750 mg/m2 provides similar 6‐month suppression of CD19+ lymphocytes to current dosing. Conclusions: Rituximab pharmacodynamics (PD) in paediatric autoimmune diseases has been described. Compared with rituximab alone, the additional effect of methotrexate or cyclophosphamide was statistically significant but small. [ABSTRACT FROM AUTHOR]

The article discusses research which investigated the clinical and laboratory characteristics of monogenic autoinflammatory disorders that mimic Behçet's disease (BD) in children. Topics explored include the challenges associated with the diagnosis of BD, the BD-related clinical manifestations observed in pediatric subjects, and the necessity of genetic screening of paediatric BD patients.

Background: Globally recommended in healthcare policy, Shared Decision-Making is also central to international policy promoting community palliative care. Yet realities of implementation by multi-disciplinary healthcare professionals who provide end-of-life care in the home are unclear. Aim: To explore multi-disciplinary healthcare professionals' perceptions and experiences of Shared Decision-Making at end of life in the home. Design: Qualitative design using focus groups, transcribed verbatim and analysed thematically. Setting/participants: A total of 43 participants, from multi-disciplinary community-based services in one region of the United Kingdom, were recruited. Results: While the rhetoric of Shared Decision-Making was recognised, its implementation was impacted by several interconnecting factors, including (1) conceptual confusion regarding Shared Decision-Making, (2) uncertainty in the process and (3) organisational factors which impeded Shared Decision-Making. Conclusion: Multiple interacting factors influence implementation of Shared Decision-Making by professionals working in complex community settings at the end of life. Moving from rhetoric to reality requires future work exploring the realities of Shared Decision-Making practice at individual, process and systems levels. [ABSTRACT FROM AUTHOR]

Objective: Kawasaki disease (KD) is an acute vasculitis that causes coronary artery aneurysms (CAA) in young children. Previous studies have emphasised poor long-term outcomes for those with severe CAA. Little is known about the fate of those without CAA or patients with regressed CAA. We aimed to study long-term cardiovascular status after KD by examining the relationship between coronary artery (CA) status, endothelial injury, systemic inflammatory markers, cardiovascular risk factors (CRF), pulse-wave velocity (PWV) and carotid intima media thickness (cIMT) after KD.Methods: Circulating endothelial cells (CECs), endothelial microparticles (EMPs), soluble cell-adhesion molecules cytokines, CRF, PWV and cIMT were compared between patients with KD and healthy controls (HC). CA status of the patients with KD was classified as CAA present (CAA+) or absent (CAA-) according to their worst-ever CA status. Data are median (range).Results: Ninety-two KD subjects were studied, aged 11.9 years (4.3-32.2), 8.3 years (1.0-30.7) from KD diagnosis. 54 (59%) were CAA-, and 38 (41%) were CAA+. There were 51 demographically similar HC. Patients with KD had higher CECs than HC (p=0.00003), most evident in the CAA+ group (p=0.00009), but also higher in the CAA- group than HC (p=0.0010). Patients with persistent CAA had the highest CECs, but even those with regressed CAA had higher CECs than HC (p=0.011). CD105 EMPs were also higher in the KD group versus HC (p=0.04), particularly in the CAA+ group (p=0.02), with similar findings for soluble vascular cell adhesion molecule 1 and soluble intercellular adhesion molecule 1. There was no difference in PWV, cIMT, CRF or in markers of systemic inflammation in the patients with KD (CAA+ or CAA-) compared with HC.Conclusions: Markers of endothelial injury persist for years after KD, including in a subset of patients without CAA. [ABSTRACT FROM AUTHOR]

Objectives and Methods: Head injury is the most common trauma presentation to UK emergency departments, with around 1.2 million patients each year. The key management principal for this time critical illness remains early surgical intervention. With the development of handheld near-infrared spectroscopy (NIRS) devices, there is now the possibility of triaging and diagnosing these patients immediately, where computed tomography (CT) scanner is unavailable. NIRS has two related but distinct potential uses within clinical medicine. Firstly, as a triage tool both in hospital and prehospital settings by doctors, nurses or paramedics as determined by its negative predictive value (NPV). Secondly, as a diagnostic aid as determined by its positive predictive value (PPV). The aim of this systematic review and meta-analysis is therefore to interrogate the current literature on NIRS in detecting intracranial haematomas.Results: NIRS technology has a cross-study sensitivity of 78%, specificity of 90%, PPV of 77%, and a NPV of 90%, which does not meet current standards as a diagnostic/triage tool in the populations studied. Additionally, its use is limited to those without extracranial injuries and may also be complicated by long scan times.Conclusion: Larger and more heterogeneous studies are required for specifically evaluating NIRS performance in detecting intracranial lesions requiring emergency evacuation. [ABSTRACT FROM AUTHOR]

This paper explores the possibility of the classroom as an exilic space of subversion in which we can pursue anarchist notions of personal transformation, relationships and society. Classroom environments in higher education institutions in Britain, particularly following the introduction of the Teaching Excellence Framework in September 2016, are premised upon relationships shaped by specific external standards: Employability, the instrumental pursuit of degrees, provider/consumer exchange, among others. Any notions of personal transformation are economic, and the broader goal is the pursuit of economic gain for individual, company and country. In an act of subversion of these external standards, I propose theorising the classroom as an exilic space: a temporally and spatially bracketed space in which participants and their relationships are not beholden to these various external referents. Instead, I put forward the exilic classroom as an anarchic space in which the interactions of the participants are not pre-defined but are formed in the process of the interactions themselves. In theorising the exilic classroom I draw on the work of Obika Gray, and push his notion of exilic space further by integrating the works of Michel de Certeau, Jamie Heckert and Gustav Landauer to help propose a classroom defined as a positive subversive everyday space that is not bound by its opposition to wider structures. The creation of such an exilic classroom assists the participants in stepping out of their expected roles as 'provider' and 'consumer', or 'teacher' and 'student', and allows the creation of a space of possibilities for our relationships [ABSTRACT FROM AUTHOR]

Objectives The aim of the study was to assess the cost-effectiveness of the four regimens studied in the AIDS Clinical Trials Group ( ACTG) 5202 clinical trial, tenofovir/emtricitabine ( TDF/ FTC) or abacavir/lamivudine ( ABC/3 TC) in combination with efavirenz ( EFV) or atazanavir/ritonavir ( ATV/r), for treatment-naïve adults with HIV-1 infection in the UK. Methods A Markov model with six health states based on CD4 cell count ranges was developed to predict long-term costs and health outcomes for individuals on first-line therapy. Head-to-head efficacy data comparing TDF/ FTC + EFV, TDF/ FTC + ATV/r, ABC/3 TC + EFV, and ABC/3 TC + ATV/r were obtained from ACTG 5202 for up to 192 weeks. Antiretroviral drug costs were based on current list prices. Other medical costs (2013 UK pounds sterling), utility values, and mortality rates were obtained from published sources. Base-case, sensitivity, and subgroup analyses (by baseline viral load) were conducted. Results Individuals using TDF/ FTC-based regimens were predicted to remain on first-line therapy longer and accrue more quality-adjusted life-years ( QALYs) than individuals using ABC/3 TC-based regimens. At a willingness-to-pay threshold of £30 000 per QALY gained, TDF/ FTC-based regimens were predicted to be cost-effective compared with ABC/3 TC-based regimens, with incremental cost-effectiveness ratios of £23 355 for TDF/ FTC + EFV vs. ABC/3 TC + EFV and £23 785 for TDF/ FTC + ATV/r vs. ABC/3 TC + ATV/r. Results were generally robust in subgroup, sensitivity, and scenario analyses. Conclusions In an analysis of the regimens studied in ACTG 5202 for treatment-naïve adults with HIV-1 infection in the UK, TDF/ FTC-based regimens yielded more favourable health outcomes and were generally predicted to be cost-effective compared with ABC/3 TC-based regimens. These results confirm that TDF/ FTC-based regimens are not only clinically effective but also cost-effective. [ABSTRACT FROM AUTHOR]

Objective. To describe the presenting clinical features, treatment and outcome in children with eosinophilic granulomatosis with polyangiitis (EGPA) and to define factors that predicted mortality. Methods. A retrospective case notes review of patients fulfilling the Chapel Hill Consensus Conference definition and/or ACR criteria for EGPA seen at Great Ormond Street Hospital, London. Demographics, clinical features, histopathology, treatment and outcomes were recorded. Descriptive statistics were expressed as median and range. Fisher's exact test was used for group comparisons. The Paediatric Vasculitis Activity Score and Paediatric Vasculitis Damage Index (PVDI) were calculated. Results. Thirteen children (38% female) aged at diagnosis 14.1 (4-15.6) years were identified. The median time to diagnosis was 2 (0-7.3) years. History of asthma was documented in 76%. The most common presenting features were pulmonary (69%), skin (61 %), gastrointestinal (46%), cardiac involvement (46%), paranasal sinus abnormality (38%), arthritis/arthralgia (38%) and neurological involvement (15%). Paediatric Vasculitis Activity Score at presentation was 8/63 (2-25/63); ANCA was negative in all 10/13 patients tested. Treatment included corticosteroids in all, combined with CYC in 38% or AZA in 23%. PVDI at 12 (3-48) months follow-up was 3/72 (0-13/72). Relapses were recorded in 46%. Mortality was 15%; cardiomyopathy and PVDI scores ≥5 significantly associated with mortality risk (P = 0.012). Conclusion. EGPA in the paediatric population is a rare and potentially life-threatening vasculitis. Increased awareness is essential to secure a timely diagnosis and to promptly initiate treatment since our data emphasize a high mortality, particularly in those with cardiac involvement and significant accrued damage. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to determine the short- and long-term efficacy and safety of 8-weekly canakinumab therapy in children with cryopyrin-associated periodic syndromes (CAPS) in routine clinical practice.Methods. A single-centre observational study was performed. Patients were assessed every 8 weeks at a dedicated clinic. Standardized assessments were the 10-domains DAS for CAPS, acute phase reactants (APRs), physician’s global assessment of disease activity, Child Health Assessment Questionnaire (CHAQ) and Child Health Questionnaire Parent Form 28 (CHQPF-28). The primary endpoint was clinical improvement, defined as a reduction of DAS score 8 weeks after commencing therapy. Secondary endpoints included sustained clinical improvement in APRs, relapses, CHAQ score and CHQPF-28 score.Results. Ten children with CAPS [eight Muckle-Wells syndrome (MWS), two chronic infantile cutaneous neurological articular (CINCA); median age 6.3 years] received 8-weekly canakinumab treatments at 2–8.7 mg/kg for a median of 21 months (range 12–31 months). Nine of 10 patients improved after the first dose: baseline median DAS of 7.5/20 decreased to 3.5/20 at 8 weeks (P = 0.04). This clinical improvement was sustained at a median follow-up of 21 months (range 12–31 months). Children with CINCA required higher doses of canakinumab than those with MWS. CHAQ and CHQ scores indicated improvement in functioning and health-related quality of life (HRQoL). Treatment was well tolerated, with no injection site reactions and no serious infections.Conclusion. Canakinumab, although costly, is a safe and effective treatment for CAPS in children, leading to sustained improvement in disease activity, serological markers, functional ability and HRQoL. [ABSTRACT FROM PUBLISHER]

Objective Polyarteritis nodosa (PAN) is a rare disease of childhood. The aims of this study were to describe the clinical features, treatment, and outcome of systemic childhood PAN and to identify predictors of relapse. Methods A single-center retrospective medical records review of children with PAN fulfilling the European League Against Rheumatism (EULAR)/Paediatric Rheumatology European Society (PRES)/Paediatric Rheumatology International Trials Organisation (PRINTO) classification criteria who were seen over a 32-year period was performed. Data on demographic and clinical features, treatments, relapses (recurrence of clinical signs/symptoms or occurrence of new symptoms after initial remission requiring escalation or resumption of immunosuppressive therapy), and deaths were recorded. A disease activity score was retrospectively assigned using the Paediatric Vasculitis Activity Score (PVAS) instrument. Cox regression analysis was used to identify significant predictors of relapse. Results Sixty-nine children with PAN were identified; 55% were male, and their median age was 8.5 years (range 0.9-15.8 years). Their clinical features at presentation were fever (87%), myalgia (83%), skin (88%), renal (19%), severe gastrointestinal (GI) (10%), and neurologic (10%) involvement. The PVAS at presentation was 9 of 63 (range 4-24). Histopathologic analysis of the skin showed necrotizing vasculitis in biopsy samples from 40 of 50 children. Results of selective visceral arteriography suggested the presence of PAN in 96% of patients. Treatment included cyclophosphamide and corticosteroids (83%), plasma exchange (9%), and biologic agents (after 2002; 13%). The relapse rate was 35%, and the mortality rate was 4%. Severe GI involvement was associated with increased risk of relapse ( P = 0.031), while longer time to induce remission ( P = 0.022) and increased cumulative dose of cyclophosphamide ( P = 0.005) were associated with lower relapse risk. Conclusion Childhood PAN is a severe inflammatory disease of insidious onset and variable clinical presentation. Relapses occurred more frequently in those with severe GI involvement. A higher cumulative dose of cyclophosphamide was associated with a lower risk of relapse. [ABSTRACT FROM AUTHOR]

Objectives. To describe the clinical, laboratory, histopathological presentations and final diagnoses for children presenting to a tertiary paediatric rheumatology service with an inflammatory lesion of the orbit.Methods. This was a retrospective descriptive case series of children with an inflammatory lesion of the orbit presenting to a single paediatric rheumatology service between January 1999 and July 2010.Results. Ten patients, median age 11.5 (range 3.1–16.2) years at referral to the paediatric rheumatology department were identified; median duration of symptoms at referral was 9 (0.75–17) months. Imaging was performed in 9/10 cases: orbital MRI (n = 4), orbital CT scan (n = 1), both MRI and CT scan (n = 4). All 10 patients had an orbital biopsy; 2 patients had repeat biopsies. The final diagnoses were granulomatosis with polyangiitis (Wegener's) (n = 5; ANCA positive n = 4, ANCA negative n = 1), idiopathic orbital inflammation (n = 3), atypical mycobacterial infection (n = 1) and sarcoidosis (n = 1).Conclusion. Inflammatory mass lesion of the orbit is an unusual presentation in children. The differential diagnosis is wide and may evolve over time. Orbital biopsy and screening for systemic features is essential before treatment with CSs or other immunosuppressants to exclude malignancy, infection, vascular lesions, autoimmune conditions or other causes of orbital inflammation that can be associated with serious systemic manifestations. [ABSTRACT FROM PUBLISHER]

Summary The problem of managing demand: Most healthcare systems have 'third-party payers' who face the problem of keeping within budgets despite pressures to increase resources due to the ageing population, new technologies and patient demands to lower thresholds for care. This paper uses the UK National Health Service as a case study to suggest techniques for system-based demand management, which aims to control demand and costs whilst maintaining the cost-effectiveness of the system. Technique for managing demand: The technique for managing demand in primary, elective and urgent care consists of managing treatment thresholds for appropriate care, using a whole-systems approach and costing the care elements in the system. It is important to analyse activity in relation to capacity and demand. Examples of using these techniques in practice are given. Conclusion: The practical effects of using such techniques need evaluation. If these techniques are not used, managing demand and limiting healthcare expenditure wilt be at the expense of clinical outcomes and unmet need, which wilt perpetuate financial crises. [ABSTRACT FROM AUTHOR]

This article proposes a clinical guideline for the diagnosis and treatment of Kawasaki disease in the UK based on the best available evidence to date, and highlights areas of practice where evidence is anecdotal or based on retrospective data. Future research as proposed by the London Kawasaki Disease Research Group is outlined, and clinicians are invited to prospectively enrol their suspected cases into this collaborative research project. [ABSTRACT FROM AUTHOR]

The article focuses on Streptococcus pyogenes pneumonia. 3% of all bacteremias in Great Britain is accounted to Streptococcus pyogenes. It is said that up to 80% of Streptococcus pyogenes pneumonias patients have experienced rapid accumulation of a pleural effusion. The response of the disease to antibiotic therapy is slow.