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Article ; Online: Avoiding diagnostic pitfalls in children with musculoskeletal symptoms.

The Lancet. Rheumatology

2021 Volume 3, Issue 7, Page(s) e467–e468

Language	English
Publishing date	2021-05-11
Publishing country	England
Document type	Journal Article
ISSN	2665-9913
ISSN (online)	2665-9913
DOI	10.1016/S2665-9913(21)00120-X
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Article ; Online: Increasing the etanercept dose in a treat-to-target approach in juvenile idiopathic arthritis: does it help to reach the target? A post-hoc analysis of the BeSt for Kids randomised clinical trial.

van Dijk, Bastiaan T / Bergstra, Sytske Anne / van den Berg, J Merlijn / Schonenberg-Meinema, Dieneke / van Suijlekom-Smit, Lisette W A / van Rossum, Marion A J / Koopman-Keemink, Yvonne / Ten Cate, Rebecca / Allaart, Cornelia F / Brinkman, Daniëlle M C / Hissink Muller, Petra C E

Pediatric rheumatology online journal

2024 Volume 22, Issue 1, Page(s) 53

Abstract: Background: Etanercept has been studied in doses up to 0.8 mg/kg/week (max 50 mg/week) in juvenile idiopathic arthritis (JIA) patients. In clinical practice higher doses are used off-label, but evidence regarding the relation with outcomes is lacking. ... ...

Abstract	Background: Etanercept has been studied in doses up to 0.8 mg/kg/week (max 50 mg/week) in juvenile idiopathic arthritis (JIA) patients. In clinical practice higher doses are used off-label, but evidence regarding the relation with outcomes is lacking. We describe the clinical course of JIA-patients receiving high-dose etanercept (1.6 mg/kg/week; max 50 mg/week) in the BeSt for Kids trial. Methods: 92 patients with oligoarticular JIA, RF-negative polyarticular JIA or juvenile psoriatic arthritis were randomised across three treat-to-target arms: (1) sequential DMARD-monotherapy (sulfasalazine or methotrexate (MTX)), (2) combination-therapy MTX + 6 weeks prednisolone and (3) combination therapy MTX + etanercept. In any treatment-arm, patients could eventually escalate to high-dose etanercept alongside MTX 10mg/m Results: 32 patients received high-dose etanercept (69% female, median age 6 years (IQR 4-10), median 10 months (7-16) from baseline). Median follow-up was 24.6 months. Most clinical parameters improved within 3 months after dose-increase: median JADAS10 from 7.2 to 2.8 (p = 0.008), VAS-physician from 12 to 4 (p = 0.022), VAS-patient/parent from 38.5 to 13 (p = 0.003), number of active joints from 2 to 0.5 (p = 0.12) and VAS-pain from 35.5 to 15 (p = 0.030). Functional impairments (CHAQ-score) improved more gradually and ESR remained stable. A comparable pattern was observed in 11 patients (73% girls, median age 8 (IQR 6-9)) who did not receive high-dose etanercept despite eligibility (comparison group). In both groups, 56% reached inactive disease at 6 months. No severe adverse events (SAEs) occurred after etanercept dose-increase. In the comparison group, 2 SAEs consisting of hospital admission occurred. Rates of non-severe AEs per subsequent patient year follow-up were 2.27 in the high-dose and 1.43 in the comparison group. Conclusions: Escalation to high-dose etanercept in JIA-patients who were treated to target was generally followed by meaningful clinical improvement. However, similar improvements were observed in a smaller comparison group who did not escalate to high-dose etanercept. No SAEs were seen after escalation to high-dose etanercept. The division into the high-dose and comparison groups was not randomised, which is a potential source of bias. We advocate larger, randomised studies of high versus regular dose etanercept to provide high level evidence on efficacy and safety. Trial registration: Dutch Trial Register; NTR1574; 3 December 2008; https://onderzoekmetmensen.nl/en/trial/26585 .
MeSH term(s)	Humans ; Arthritis, Juvenile/drug therapy ; Etanercept/administration & dosage ; Etanercept/therapeutic use ; Etanercept/adverse effects ; Female ; Male ; Child ; Antirheumatic Agents/administration & dosage ; Antirheumatic Agents/therapeutic use ; Methotrexate/administration & dosage ; Methotrexate/therapeutic use ; Drug Therapy, Combination ; Child, Preschool ; Dose-Response Relationship, Drug ; Treatment Outcome ; Prednisolone/administration & dosage ; Sulfasalazine/administration & dosage ; Sulfasalazine/therapeutic use
Chemical Substances	Etanercept (OP401G7OJC) ; Antirheumatic Agents ; Methotrexate (YL5FZ2Y5U1) ; Prednisolone (9PHQ9Y1OLM) ; Sulfasalazine (3XC8GUZ6CB)
Language	English
Publishing date	2024-05-10
Publishing country	England
Document type	Journal Article ; Randomized Controlled Trial
ZDB-ID	2279468-2
ISSN	1546-0096 ; 1546-0096
ISSN (online)	1546-0096
ISSN	1546-0096
DOI	10.1186/s12969-024-00989-x
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Article ; Online: Patterns of clinical joint inflammation in juvenile idiopathic arthritis.

Heckert, Sascha L / Hissink-Muller, Petra C E / van den Berg, J Merlijn / Schonenberg-Meinema, Dieneke / van Suijlekom-Smit, Lisette W A / van Rossum, Marion A J / Koopman, Yvonne / Ten Cate, Rebecca / Brinkman, Danielle M C / Huizinga, Tom W J / Allaart, Cornelia F / Bergstra, Sytske Anne

RMD open

2023 Volume 9, Issue 1

Abstract: Objectives: We studied patterns of joint inflammation in juvenile idiopathic arthritis (JIA) to assess whether joint activity recurs locally in the same joints.: Methods: Joints of 91 patients of the BeSt for Kids study, a treat-to-target trial for ... ...

Abstract	Objectives: We studied patterns of joint inflammation in juvenile idiopathic arthritis (JIA) to assess whether joint activity recurs locally in the same joints. Methods: Joints of 91 patients of the BeSt for Kids study, a treat-to-target trial for children with recent-onset oligoarticular, rheumatoid factor-negative polyarticular and psoriatic JIA, were clinically assessed during 2 years (10 study visits). The association between joint inflammation at baseline and later inflammation in the same joint was assessed using a multilevel mixed-effects logistic regression model at joint level. With a Poisson model, the association between baseline joint inflammation and the number of study visits at which the same joint was recurrently inflamed was tested. Results: Of the 6097 joints studied, 15% (897) was clinically inflamed at baseline. In 42% (377/897) of those joints, inflammation recurred during follow-up. Joint inflammation at baseline was statistically significantly associated with joint inflammation during follow-up in the same joint (OR 3.9, 95% CI 3.5 to 4.4) and specifically with the number of episodes of recurrent joint inflammation (IRR 1.6, 95% CI 1.2 to 2.1). Conclusion: In JIA, joint inflammation has the tendency to recur multiple times in joints that are clinically inflamed at disease onset. This indicates that local factors might play a role in the processes contributing to the occurrence of JIA flares.
MeSH term(s)	Child ; Humans ; Arthritis, Juvenile/complications ; Arthritis, Juvenile/epidemiology ; Inflammation
Language	English
Publishing date	2023-03-16
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2812592-7
ISSN	2056-5933 ; 2056-5933
ISSN (online)	2056-5933
ISSN	2056-5933
DOI	10.1136/rmdopen-2022-002941
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Article ; Online: Significant pain decrease in children with non-systemic Juvenile Idiopathic Arthritis treated to target: results over 24 months of follow up.

Spekking, Katinka / Anink, Janneke / de Boer, Piroska / Bergstra, Sytske Anne / van den Berg, J Merlijn / Schonenberg-Meinema, Dieneke / van Suijlekom-Smit, Lisette W A / van Rossum, Marion A J / Koopman-Keemink, Yvonne / Cate, Rebecca Ten / Allaart, Cornelia F / Brinkman, Daniëlle M C / Muller, Petra C E Hissink

Pediatric rheumatology online journal

2023 Volume 21, Issue 1, Page(s) 90

Abstract: Background: The aim of this study was to compare pain-scores in three targeted treatment-strategies in JIA-patients and to identify characteristics predicting persistent pain.: Methods: In the BeSt-for-Kids-study 92 DMARD-naïve JIA-patients were ... ...

Abstract	Background: The aim of this study was to compare pain-scores in three targeted treatment-strategies in JIA-patients and to identify characteristics predicting persistent pain. Methods: In the BeSt-for-Kids-study 92 DMARD-naïve JIA-patients were randomized in 3 treatment-strategies: 1) initial sequential DMARD-monotherapy 2) initial methotrexate (MTX)/prednisolone-bridging or 3) initial MTX/etanercept. Potential differences in VAS pain scores (0-100 mm) over time between treatment-strategies were compared using linear mixed models with visits clustered within patients. A multivariable model was used to assess the ability of baseline characteristics to predict the chance of high pain-scores during follow-up. Results: Pain-scores over time reduced from mean 55.3 (SD 21.7) to 19.5 (SD 25.3) mm after 24 months. On average, pain-scores decreased significantly with β -1.37 mm (95% CI -1.726; -1.022) per month. No significant difference was found between treatment-strategies (interaction term treatment armtime (months) β (95% CI) arm 1: 0.13 (-0.36; 0.62) and arm 2: 0.37 (-0.12; 0.86) compared to arm 3). Correction for sex and symptom duration yielded similar results. Several baseline characteristics were predictive for pain over time. Higher VAS pain [β 0.44 (95% CI 0.25; 0.65)] and higher active joint count [0.77 (0.19; 1.34)] were predictive of higher pain over time, whereas, low VAS physician [ -0.34 (-0.55; -0.06)], CHQ Physical [ -0.42 (-0.72; -0.11)] and Psychosocial summary Score [ -0.42 (-0.77; -0.06)] were predictive of lower pain. Conclusions:* Treatment-to-target seems effective in pain-reduction in non-systemic JIA-patients irrespective of initial treatment-strategy. Several baseline-predictors for pain over time were found, which could help to identify patients with a high risk for development of chronic pain. Trial registration: Dutch Trial Registry number 1574.
MeSH term(s)	Humans ; Child ; Follow-Up Studies ; Arthritis, Juvenile/complications ; Arthritis, Juvenile/drug therapy ; Chronic Pain ; Antirheumatic Agents/therapeutic use ; Etanercept
Chemical Substances	Antirheumatic Agents ; Etanercept (OP401G7OJC)
Language	English
Publishing date	2023-08-26
Publishing country	England
Document type	Randomized Controlled Trial ; Journal Article
ZDB-ID	2279468-2
ISSN	1546-0096 ; 1546-0096
ISSN (online)	1546-0096
ISSN	1546-0096
DOI	10.1186/s12969-023-00874-z
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Article ; Online: Cost of biologics in the treatment of juvenile idiopathic arthritis: a factor not to be overlooked.

Prince, Femke H M / van Suijlekom-Smit, Lisette W A

Paediatric drugs

2013 Volume 15, Issue 4, Page(s) 271–280

Abstract: Biologics are a promising treatment option for juvenile idiopathic arthritis (JIA) but drug costs are very high compared to conventional treatment. From a socioeconomic view the additional costs of new interventions should be weighed against their ... ...

Abstract	Biologics are a promising treatment option for juvenile idiopathic arthritis (JIA) but drug costs are very high compared to conventional treatment. From a socioeconomic view the additional costs of new interventions should be weighed against their incremental health benefits compared to standard care. Therefore we evaluated data on cost-effectiveness of biologics in JIA. We searched Medline, Embase, and The York Centre for Reviews and Dissemination database for relevant literature. Current data show that biologics are reducing direct and indirect healthcare costs if one excludes the costs of the drug itself. The costs of biologics are more than ten times as high as conventional drug treatment. As a result of limited data, no comparison on cost-effectiveness between biologics could be performed. Although data on long-term cost-effectiveness of biologics are lacking, the expectation is that they will be cost-effective in the long-term. The idea behind this is that biologic treatment should be administered to patients that without these drugs would incur high direct and indirect costs due to continuous severe disease resulting in irreversible disabilities. In our opinion the best cost benefit could be gained if these patients receive biologic treatment introduced early in the disease. This is in order to minimize irreversible damage to the joints and minimize need for long-term biologic therapy by early suppression of the disease. To support these hypotheses future research is needed on long-term cost-effectiveness of all biologics used in JIA.
MeSH term(s)	Arthritis, Juvenile/drug therapy ; Arthritis, Juvenile/economics ; Biological Products/economics ; Biological Products/therapeutic use ; Cost-Benefit Analysis ; Drug Costs ; Humans
Chemical Substances	Biological Products
Language	English
Publishing date	2013-04-21
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	1492748-2
ISSN	1179-2019 ; 1174-5878
ISSN (online)	1179-2019
ISSN	1174-5878
DOI	10.1007/s40272-013-0023-7
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Article ; Online: Efficacy of biological agents in juvenile idiopathic arthritis: a systematic review using indirect comparisons.

Otten, Marieke H / Anink, Janneke / Spronk, Sandra / van Suijlekom-Smit, Lisette W A

Annals of the rheumatic diseases

2013 Volume 72, Issue 11, Page(s) 1806–1812

Abstract: Objective: Over the past decade, the availability of biological agents for the treatment of juvenile idiopathic arthritis (JIA) has increased substantially. Because direct head-to-head trials comparing these agents are lacking, we indirectly compared ... ...

Abstract	Objective: Over the past decade, the availability of biological agents for the treatment of juvenile idiopathic arthritis (JIA) has increased substantially. Because direct head-to-head trials comparing these agents are lacking, we indirectly compared their efficacy. Methods: In a systematic review, all available efficacy data from randomised controlled trials performed in JIA with inclusion of biological agents were retrieved. Indirect between-drug comparisons (based on Bucher's method) were conducted only if trials were comparable with regard to design and patients' characteristics related to treatment outcome. Results: We identified 11 randomised controlled trials. On the basis of the equality of the trials, six trials were grouped into two networks of evidence. Network 1 included withdrawal trials which evaluated etanercept, adalimumab and abatacept in polyarticular course JIA. Indirect comparisons identified no significant differences in short-term efficacy. Network 2 indirectly compared trials with a parallel study design investigating anakinra, tocilizumab and canakinumab in systemic JIA; no differences in comparative efficacy were identified. Although the two networks were constructed on the basis of comparability, small differences in trial design and case mix still existed. Conclusions: Because of the small number of trials and the observed differences between trials, no definite conclusions could be drawn about the comparative effectiveness of the indirectly compared biological agents. Therefore, for now, the paediatric rheumatologist has to rely on observational data and safety, practical and financial arguments. Comparability of future trials needs to be improved, and head-to-head trials are required to decide on the best biological treatment for JIA.
MeSH term(s)	Abatacept ; Adalimumab ; Antibodies, Monoclonal/therapeutic use ; Antibodies, Monoclonal, Humanized/therapeutic use ; Antirheumatic Agents/therapeutic use ; Arthritis, Juvenile/drug therapy ; Biological Products/therapeutic use ; Etanercept ; Humans ; Immunoconjugates/therapeutic use ; Immunoglobulin G/therapeutic use ; Interleukin 1 Receptor Antagonist Protein/therapeutic use ; Randomized Controlled Trials as Topic ; Receptors, Tumor Necrosis Factor/therapeutic use ; Treatment Outcome
Chemical Substances	Antibodies, Monoclonal ; Antibodies, Monoclonal, Humanized ; Antirheumatic Agents ; Biological Products ; Immunoconjugates ; Immunoglobulin G ; Interleukin 1 Receptor Antagonist Protein ; Receptors, Tumor Necrosis Factor ; canakinumab (37CQ2C7X93) ; Abatacept (7D0YB67S97) ; Adalimumab (FYS6T7F842) ; tocilizumab (I031V2H011) ; Etanercept (OP401G7OJC)
Language	English
Publishing date	2013-11
Publishing country	England
Document type	Journal Article ; Meta-Analysis ; Review
ZDB-ID	7090-7
ISSN	1468-2060 ; 0003-4967
ISSN (online)	1468-2060
ISSN	0003-4967
DOI	10.1136/annrheumdis-2012-201991
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Uh III Zs.114: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 2021: Bestellungen von Artikeln über das Online-Bestellformular ab Jg. 2022: Lesesaal (EG)
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Article ; Online: Participation in a single-blinded pediatric therapeutic strategy study for juvenile idiopathic arthritis: are parents and patient-participants in equipoise?

Hissink Muller, Petra C E / Yildiz, Bahar / Allaart, Cornelia F / Brinkman, Danielle M C / van Rossum, Marion / van Suijlekom-Smit, Lisette W A / van den Berg, J Merlijn / Ten Cate, Rebecca / de Vries, Martine C

BMC medical ethics

2018 Volume 19, Issue 1, Page(s) 96

Abstract: Background: Genuine uncertainty on superiority of one intervention over the other is called equipoise. Physician-investigators in randomized controlled trials (RCT) need equipoise at least in studies with more than minimal risks. Ideally, this equipoise ...

Abstract	Background: Genuine uncertainty on superiority of one intervention over the other is called equipoise. Physician-investigators in randomized controlled trials (RCT) need equipoise at least in studies with more than minimal risks. Ideally, this equipoise is also present in patient-participants. In pediatrics, data on equipoise are lacking. We hypothesize that 1) lack of equipoise at enrolment among parents may reduce recruitment; 2) lack of equipoise during participation may reduce retention in patients assigned to a less favoured treatment-strategy. Methods: We compared preferences of parents/patients at enrolment, documented by a questionnaire (phase 1), with preferences developed during follow-up by an interview-study (phase 2) to investigate equipoise of child-participants and parents in the BeSt-for-Kids-study (NTR 1574). This trial in new-onset Juvenile Idiopathic Arthritis-patients consists of three strategies. One strategy comprises initial treatment with a biological disease-modifying-antirheumatic-drug (DMARD), currently not standard-of-care. Semi-structured interviews were conducted with 23 parents and 7 patients, median 11 months after enrolment. Results: Initially most parents and children were not in equipoise. Parents/patients who refused participation, regularly declined due to specific preferences. Many participating families preferred the biological-first-strategy. They participated to have a chance for this initial treatment, and would even consider stopping trial-participation when not randomized for it. Their conviction of superiority of the biological-first strategy was based on knowledge from internet and close relations. According to four parents, the physician-investigator preferred the biological-first-strategy, but the majority (n = 19) stated that she had no preferred strategy. In phase 2, preferences tended to change to the treatment actually received. Conclusions: Lack of equipoise during enrolment did not reduce study recruitment, mainly due to the fact that preferred treatment was only available within the study. Still, when developing a trial it is important to evaluate whether the physicians' research question is in line with preferences of the patient-group. By exploring so-called 'informed patient-group'-equipoise, successful recruitment may be enhanced and bias avoided. In our study, lack of equipoise during trial-participation did not reduce retention in those assigned to a less favoured option. We observed a change for preference towards treatment actually received, possibly explained by comparable outcomes in all three arms.
MeSH term(s)	Adolescent ; Adult ; Arthritis, Juvenile/drug therapy ; Arthritis, Juvenile/therapy ; Child ; Female ; Humans ; Interviews as Topic ; Male ; Middle Aged ; Parents/psychology ; Patient Preference/psychology ; Randomized Controlled Trials as Topic/ethics ; Randomized Controlled Trials as Topic/methods ; Randomized Controlled Trials as Topic/psychology ; Single-Blind Method ; Surveys and Questionnaires ; Therapeutic Equipoise
Language	English
Publishing date	2018-12-20
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2041552-7
ISSN	1472-6939 ; 1472-6939
ISSN (online)	1472-6939
ISSN	1472-6939
DOI	10.1186/s12910-018-0336-8
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Article: Initiating etanercept in a once weekly dose in children with juvenile idiopathic arthritis.

Prince, Femke H M / van Suijlekom-Smit, Lisette W A

Rheumatology international

2007 Volume 28, Issue 4, Page(s) 397–8, author reply 399

MeSH term(s)	Adolescent ; Anti-Inflammatory Agents, Non-Steroidal/administration & dosage ; Arthritis, Juvenile/drug therapy ; Child ; Drug Administration Schedule ; Drug Therapy, Combination ; Etanercept ; Female ; Glucocorticoids/administration & dosage ; Humans ; Immunoglobulin G/administration & dosage ; Immunoglobulin G/adverse effects ; Immunosuppressive Agents/administration & dosage ; Immunosuppressive Agents/adverse effects ; Male ; Methotrexate/administration & dosage ; Prednisone/administration & dosage ; Receptors, Tumor Necrosis Factor/administration & dosage ; Treatment Outcome
Chemical Substances	Anti-Inflammatory Agents, Non-Steroidal ; Glucocorticoids ; Immunoglobulin G ; Immunosuppressive Agents ; Receptors, Tumor Necrosis Factor ; Etanercept (OP401G7OJC) ; Prednisone (VB0R961HZT) ; Methotrexate (YL5FZ2Y5U1)
Language	English
Publishing date	2007-10-17
Publishing country	Germany
Document type	Comment ; Letter
ZDB-ID	8286-7
ISSN	1437-160X ; 0172-8172
ISSN (online)	1437-160X
ISSN	0172-8172
DOI	10.1007/s00296-007-0468-5
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Article: Patient-reported joint count in juvenile idiopathic arthritis: the reliability of a manikin format.

Dijkstra, Maryanne E / Anink, Janneke / van Pelt, Philomine A / Hazes, Johanna M / van Suijlekom-Smit, Lisette W A

The Journal of rheumatology

2015 Volume 42, Issue 3, Page(s) 527–533

Abstract: Objective: To evaluate the reliability of a manikin format, patient-reported joint count in juvenile idiopathic arthritis (JIA), and to detect changes in agreement at a second visit.: Methods: Patients with JIA aged 12-21 were asked to mark joints ... ...

Abstract	Objective: To evaluate the reliability of a manikin format, patient-reported joint count in juvenile idiopathic arthritis (JIA), and to detect changes in agreement at a second visit. Methods: Patients with JIA aged 12-21 were asked to mark joints with active arthritis on a manikin before their regular clinic visit. The physician then performed a joint count without having seen the patient's assessment. Agreement between scores of physician-reported and patient-reported joint counts was assessed using ICC. Kappa statistics were used to assess reliability of scoring individual joints. Results: The study included 75 patients with JIA. In general, patients had a low number of active joints (median 1 joint, indicated by the physician). ICC was moderate (0.61) and κ ranged from 0.3-0.7. At the second visit, κ were similar; the ICC was 0.19. When a patient scored 0 joints, the physician confirmed this 93%-100% of the time. When the patient marked ≥ 1 joints, the physician confirmed arthritis 59%-76% of the time. Sensitivity to change was moderate. Conclusion: Agreement between physician and patient on the number of joints with active arthritis was reasonable. Untrained patients tended to overestimate the presence of arthritis when they marked active joints on a manikin-format joint count. When the patient indicated absence of arthritis, the physician usually confirmed this. As the agreement did not improve at followup, future research should focus on the possibility of achieving this through training. For now, the patient-reported joint count cannot replace the physicians' joint count in clinical practice; it may be used in epidemiological studies with caution.
MeSH term(s)	Adolescent ; Arthritis, Juvenile/pathology ; Child ; Female ; Humans ; Joints/pathology ; Male ; Manikins ; Severity of Illness Index ; Symptom Assessment ; Young Adult
Language	English
Publishing date	2015-03
Publishing country	Canada
Document type	Journal Article
ZDB-ID	194928-7
ISSN	1499-2752 ; 0315-162X
ISSN (online)	1499-2752
ISSN	0315-162X
DOI	10.3899/jrheum.140073
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Zs.A 1168: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (1.OG) ab Jg. 2022: Lesesaal (EG)
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Article ; Online: Manipulative interventions for reducing pulled elbow in young children.

Krul, Marjolein / van der Wouden, Johannes C / van Suijlekom-Smit, Lisette W A / Koes, Bart W

The Cochrane database of systematic reviews

2012 Volume 1, Page(s) CD007759

Abstract: Background: Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial ... ...

Abstract	Background: Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful. This is an update of a Cochrane review first published in 2009. Objectives: The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children. Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: July 2011. Selection criteria: Any randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment. Data collection and analysis: Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data. Main results: One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique. Authors' conclusions: There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence.
MeSH term(s)	Child, Preschool ; Elbow Joint/injuries ; Humans ; Infant ; Joint Dislocations/etiology ; Joint Dislocations/therapy ; Manipulation, Orthopedic/adverse effects ; Manipulation, Orthopedic/methods ; Pronation ; Radius/injuries ; Randomized Controlled Trials as Topic ; Sprains and Strains/etiology ; Sprains and Strains/therapy ; Supination
Language	English
Publishing date	2012-01-18
Publishing country	England
Document type	Journal Article ; Meta-Analysis ; Research Support, Non-U.S. Gov't ; Review ; Systematic Review
ISSN	1469-493X
ISSN (online)	1469-493X
DOI	10.1002/14651858.CD007759.pub3
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