Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder of unknown origin that is often treated with a variety of disease-modifying agents. Tumor necrosis factor (TNF) inhibitors are a ...group of genetically engineered biologic agents that target the proinflammatory cytokine TNF. This review focuses on the use of TNF inhibitors in JIA. Etanercept was the first TNF inhibitor approved for use in children with moderate to severe polyarticular-course JIA following encouraging results from a randomized, double-blind, placebo-controlled, multicenter trial in children. Open-label extension studies of the original trial involving 8 years of follow-up demonstrated the long-term safety and efficacy of etanercept in children. Other studies from established registries also corroborate the safety of etanercept in JIA. The second TNF inhibitor to be approved for use in JIA is adalimumab following recent favorable results from another randomized, placebo-controlled, multicenter study in polyarticular-course JIA. While infliximab is not approved by the US FDA for use in JIA, it is frequently used in clinical practice for this indication. However, because the chimeric structure of infliximab incorporates murine components, it has the potential for allergic and infusion reactions. Patient responses to individual TNF inhibitors may vary depending on concomitant medications such as methotrexate, and also on the category of JIA.
Background
The incidence of adolescent suicide is rising in the United States, yet we have limited information regarding short‐term prediction of suicide attempts. Our aim was to identify predictors ...of suicide attempts within 3‐months of an emergency department (ED) visit.
Methods
Adolescents, ages 12–17, seeking health care at 13 pediatric EDs (Pediatric Emergency Care Applied Research Network) and one Indian Health Service Hospital in the United States were consecutively recruited. Among 10,664 approached patients, 6,448 (60%) were enrolled and completed a suicide risk survey. A subset of participants (n = 2,897) was assigned to a 3‐month telephone follow‐up, and 2,104 participants completed this follow‐up (73% retention). Our primary outcome was a suicide attempt between the ED visit and 3‐month follow‐up.
Results
One hundred four adolescents (4.9%) made a suicide attempt between enrollment and 3‐month follow‐up. A large number of baseline predictors of suicide attempt were identified in bivariate analyses. The final multivariable model for the full sample included the presence of suicidal ideation during the past week, lifetime severity of suicidal ideation, lifetime history of suicidal behavior, and school connectedness. For the subgroup of adolescents who did not report recent suicidal ideation at baseline, the final model included only lifetime severity of suicidal ideation and social connectedness. Among males, the final model included only lifetime severity of suicidal ideation and past week suicidal ideation. For females, the final model included past week suicidal ideation, lifetime severity of suicidal ideation, number of past‐year nonsuicidal self‐injury (NSSI) incidents, and social connectedness.
Conclusions
Results indicate that the key risk factors for adolescent suicide attempts differ for subgroups of adolescents defined by sex and whether or not they report recent suicidal thoughts. Results also point to the importance of school and social connectedness as protective factors against suicide attempts.
IMPORTANCE: The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services. OBJECTIVE: To develop and independently ...validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTS: Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts. EXPOSURES: Presentation at an ED. MAIN OUTCOME AND MEASURE: A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report. RESULTS: The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents 63.0%; mean SD age, 15.1 1.61 years) with 3-month follow-ups (72.9% retention 2075 adolescents). The study 2 validation sample included 2754 adolescents (1711 female adolescents 62.1%; mean SD age, 15.0 1.65 years), with 3-month follow-ups (69.5% retention 2754 adolescents). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 95% CI, 0.85-0.91) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 95% CI, 0.85-0.89). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1. CONCLUSIONS AND RELEVANCE: In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.
Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians ...in choosing a screening tool.
To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata.
The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023.
This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA.
Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls 62.2%; mean SD age at enrollment, 15.0 1.7 years; 469 Black participants 17.1%, 678 Hispanic participants 24.7%, and 1618 White participants 59.1%) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 95% CI, 0.918-0.984 vs 0.945 95% CI, 0.910-0.980), specificity (0.588 95% CI, 0.569-0.607 vs 0.643 95% CI, 0.625-0.662), positive predictive value (0.127 95% CI, 0.109-0.146 vs 0.144 95% CI, 0.123-0.165), and negative predictive value (both 0.995 95% CI, 0.991-0.998, respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 95% CI, 0.81-0.95 vs CASSY, 0.94 95% CI, 0.91-0.96). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 95% CI, 0.68-0.77 vs 0.57 95% CI, 0.55-0.59, respectively).
This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.
Joint hypermobility in Indian children HASIJA, R. P; KHUBCHANDANI, R. P; SHENOI, S
Clinical and experimental rheumatology,
2008, 2008 Jan-Feb, 20080101, Letnik:
26, Številka:
1
Journal Article
Recenzirano
To study the prevalence of joint hypermobility in children from Mumbai, India and to study its association with malnutrition.
In a cross-sectional field study from September '02 to February '03 in ...Mumbai, 829 children of the lower urban socio-economic strata, between 3 and 19 years of age were evaluated independently by two observers for hypermobility using the Beighton 9-point scoring system. A score of >or= 4/9 was considered positive. Their nutritional status was stratified using standard Indian growth charts and hypermobility was quantified in various nutritional groups. Musculoskeletal symptoms were assessed by a questionnaire given to parents. Standard tests of significance (Chi square test, p<0.05-significant) were applied.
58.7% of the population studied, had a Beighton score >or= 4/9. There was a declining prevalence of joint hypermobility noted with increasing age. Near equal sex incidence was noted. A higher incidence of finger signs was noted in comparison to elbow hyperextension, knee hyperextension and hands-to-floor. 26% of the hypermobile population had musculoskeletal symptoms as compared with 17.2% of the non-hypermobile population (p<0.05). A positive Beighton score was found in 452/734 (61.5%) children with Grade 3 and 4 malnutrition in comparison to 35/95 (36.8%) children with normal nutrition or mild grades (Grade 1 and 2) of malnutrition (p<0.05). In the group with Grade 3 and 4 malnutrition, 26.1% of those hypermobile had musculoskeletal symptoms in comparison to 17.7% of their non-hypermobile counterparts (p<0.05).
In our study population: 1. A high prevalence of hypermobility using Beighton's score was noted; 2. Finger signs of the Beighton score were more common than the other signs; 3. Moderate and severe malnutrition were associated with hypermobility; 4. Musculoskeletal symptoms were linked to joint hypermobility; 5. Moderate and severely malnourished hypermobile children were more likely to have musculoskeletal symptoms as compared to their non-hypermobile counterparts.
PDF
