Poster presentation Tuesday 8 October Background We present four cases of patients on etanercept treatment for juvenile idiopathic arthritis (JIA) subsequently diagnosed with inflammatory bowel disease (IBD). We hypothesise that there may be identifiable characteristics of these patients which makes them more identifiable to the physician. Etanercept is a recombinant dimer of human tumour necrosis factor (TNF) receptor proteins bound to human IgG1. It is an effective second line treatment option in JIA for those who have failed, or are intolerant to, methotrexate, and an effective first line treatment option in those who have axial disease at diagnosis. Anti-TNF treatments are effective in IBD, however etanercept in particular does not have therapeutic benefit, and in one trial there was a non-significant trend towards worsening of disease. Methods Please refer to the Results section. Results Four cases, in a 15 year old male, 11 year old female, 10 year old female and 11 year old female, have been identified at our site. The time from etanercept initiation and diagnosis of IBD was between 2 weeks and 2 years 1 month. None of the cases had gastrointestinal symptoms at JIA diagnosis. All four were ANA negative, and in the two with information, both were HLA-B27 negative. Three out of four had hip arthritis involvement. There was a family history of IBD (ulcerative colitis) in only one of the cases. Aside from non-steroidal anti-inflammatory medications, there were no other immunomodulatory medications concurrently being taken in any of the cases while on etanercept. All four were anaemic (Hb < 120g/L) at diagnosis of IBD. Only one had raised ESR (43mm/hr) while all had normal CRP. Albumin was low in two (17g/L and 29g/L). Following gastroenterology review and endoscopy, two cases were diagnosed with Crohn’s disease and two with ulcerative colitis. Conclusion It remains unclear whether etanercept plays a role in the development of IBD in these patients, whether it unmasks subclinical disease, or whether there is no association and it is simply a coincidence. However, there continue to be case reports and series suggesting an association between the two. We hope to identify further cases similar to these from sources such as the UK Biologics Registry and via surveys from teams at paediatric rheumatology centres throughout the UK. Further to the identification of cases, a retrospective review of patient characteristics will be carried out. This may allow for further determination of identifiable characteristics for these patients, and therefore suggest a subgroup of JIA patients with a higher risk of developing IBD, in which case caution when considering etanercept treatment would be advised. Conflicts of Interest The authors declare no conflicts of interest.
Background We present a case that was referred and seen in our chronic pain clinic, and highlight the importance of keeping an open mind about alternative diagnoses when reviewing these patients. Methods Please refer to the results section. Results A 12 year-old girl was referred with right sided neck and shoulder pain associated with occasional pins and needles. The patient was a competitive swimmer, training and competing five times a week at her peak. She did not have a history of mottling or colour change, and clinically she had full range of motion of her joints and no neurological deficit. On repeated assessments, she had reproducible pain on horizontal flexion and reduced muscle bulk of the right shoulder, although power was preserved. Functionally the patient had to reduce her participation in swimming due to pain, and found it difficult to carry or lift things, brush or wash her hair, or write for extended periods of time. Imaging with shoulder X-ray and shoulder and cervical spine MRI did not reveal a cause, and she did not have an anatomical variation such as a thoracic rib. Due to the reproducibility on swimming, an ultrasound looking at the insertion of the biceps insertion during dynamic movements was arranged and was also normal with no subluxation noted. As she failed to improve with chronic pain education, chronic pain approach to physiotherapy sessions and graded reintroduction of swimming, ultrasound angiology was arranged. This showed minor disease in the right subclavian, axillary, brachial, radial and ulnar arteries, with significant reduction in right brachial arterial flow with the patient supine, right arm in horizontal flexion and contralateral head turn. This suggested arterial thoracic outlet syndrome (TOS). All other positions resulted in no significant difference in arterial flow. TOS is traditionally broken into two categories – neurogenic and vascular, the latter can be broken down further into arterial or venous. While in adults, the vast majority (90-95%) present as neurogenic, in the paediatric population there is a higher proportion of vascular cases. This has implications, as vascular TOS can be complicated by vessel disease and thrombus formation. There are a number of case reports in which management is reported as decompression of the thoracic outlet with partial first rib resection, with or without scalene muscle resection. Consideration of hypercoagulable states is also warranted. We have referred our patient to the vascular team for an urgent review and await their assessment and feedback about management. Conclusion A proportion of patients managed with chronic pain syndrome will have an alternative explanation for their pain. In particular, if a patient has focal pain or pain that is reproducible on a particular movement or activity, consider alternate diagnoses. Conflicts of Interest The authors declare no conflicts of interest.
Background: Neonatal pain responses have been ignored for long, in spite of many pharmacological and non- pharmacological proven methods. Non pharmacological measures like breast feeding, non- nutritive sucking or glucose solutions are easily available, affordable and readily acceptable methods. Methods: 190 babies were compared for their responses to both intravenous pre discharge blood sampling and birth dose of hepatitis B vaccine. They were randomly divided into three groups - expressed breast milk (64 babies), 2ml 10% dextrose solution via syringe (63 babies), and non- nutritive sucking with 25% dextrose (63 babies). The response to each procedure was recorded in terms of cry duration and using NIPS scale. Kruskal Wallis test, Wilcoxon Signed Ranks test, Mann Whitney U test, ANOVA were used find the association between quantitative variables whereas McNemar test, McNemar-Bowker test and Chi-square test were used for qualitative variables. Results: The baseline demographic data of all the groups were comparable. The NIPS scores were reduced significantly in all the 3 groups in both the procedures. Babies on non-nutritive sucking with dextrose had the least scores, followed by babies on dextrose and finally those on expressed breast milk for both the procedures. All the 3 groups had significant variations in HR and SPO2 from baseline and at 3rd min, the variations were reducing with group 3 showing the maximum potential for quick stabilisation in both the procedures. The cry duration was significantly lower in group 3 in both the invasive procedures. Conclusion: Neonatal pain responses were least among the neonates provided with non- nutritive sucking with 25% dextrose during the intra-venous procedure and intra-muscular procedure. Non- nutritive sucking with 25% dextrose can be recommended as effective, reliable and useful method for decreasing the pain responses during the procedures.
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