Challenging able, interested and motivated (AIM) children within and beyond core subjects

This case study examines how able, interested and motivated (AIM) pupils are being challenged in Key Stage 2 within and beyond core subjects. The research project focuses on a primary school in England as its single case study. Alongside consideration of the range of practices that are currently in place to extend and challenge learning, a series of observations and interviews were used to gain insights into pupils’ and practitioners’ perspectives on how AIM children are being challenged in core and foundation subjects. Open observations, individual and group interviews were employed to gather data from groups of AIM and high attaining children from each year group in KS2, the school’s AIM coordinator and class teachers. The study suggests that the effective use of differentiation, acceleration and enrichment strategies by teachers not only challenge AIM children’s current understanding but can also motivate them to pursue challenging activities independently. However, schools need to ensure teachers’ subject knowledge, particularly in foundation subjects, is a secure enough foundation from which to extend children’s learning. The study also finds that the provision of learning experiences beyond the classroom can be effective approaches to challenge, providing children are given the opportunities to apply their new learning in the classroom. Additionally, the study proposes that the expectations set upon AIM children by themselves and teachers also play a role in enabling these children to be challenged

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study

Background: User-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension. No study has investigated whether this results in safer care. Objective: To compare the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing. Method: Single-blind, randomised parallel group in situ simulation. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing. Direct observation was used to time the simulation and identify errors. Participant confidence was measured using a validated instrument. The primary outcome was the percentage of simulations with at least one moderate-severe IMG-related error, with error severity classified by an expert panel. Results: In total, 133 participants were randomised to current guidelines and 140 to user-tested guidelines. Fewer moderate-severe IMG-related errors occurred with the user-tested guidelines (n=68, 49%) compared with current guidelines (n=79, 59%), but this difference was not statistically significant (risk ratio: 0.82; 95% CI 0.66 to 1.02). Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines (n=67, 48%) compared with current guidelines (n=26, 20%) (risk ratio: 2.46; 95% CI 1.68 to 3.60). Median simulation completion time was 1.6 min (95% CI 0.2 to 3.0) less with the user-tested guidelines. Participants who used user-tested guidelines reported greater confidence. Conclusion: User-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence. Trial registration number: researchregistry5275

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study

Background: User-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension. No study has investigated whether this results in safer care. Objective: To compare the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing. Method: Single-blind, randomised parallel group in situ simulation. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing. Direct observation was used to time the simulation and identify errors. Participant confidence was measured using a validated instrument. The primary outcome was the percentage of simulations with at least one moderatesevere IMG-related error, with error severity classified by an expert panel. Results: In total, 133 participants were randomised to current guidelines and 140 to user-tested guidelines. Fewer moderate-severe IMG-related errors occurred with the user-tested guidelines (n=68, 49%) compared with current guidelines (n=79, 59%), but this difference was not statistically significant (risk ratio: 0.82; 95% CI 0.66 to 1.02). Significantly more simulations were completed without any IMG-related errors with the usertested guidelines (n=67, 48%) compared with current guidelines (n=26, 20%) (risk ratio: 2.46; 95% CI 1.68 to 3.60). Median simulation completion time was 1.6min (95% CI 0.2 to 3.0) less with the user-tested guidelines. Participants who used user-tested guidelines reported greater confidence. Conclusion: User-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence. Trial registration: number researchregistry5275

Nutritional status, growth and disease management in children with single and dual diagnosis of type 1 diabetes mellitus and coeliac disease

Background: The consequences of subclinical coeliac disease (CD) in Type 1 diabetes mellitus (T1DM) remain unclear. We looked at growth, anthropometry and disease management in children with dual diagnosis (T1DM + CD) before and after CD diagnosis.<p></p> Methods: Anthropometry, glycated haemoglobin (HbA1c) and IgA tissue transglutaminase (tTg) were collected prior to, and following CD diagnosis in 23 children with T1DM + CD. This group was matched for demographics, T1DM duration, age at CD diagnosis and at T1DM onset with 23 CD and 44 T1DM controls.<p></p> Results: No differences in growth or anthropometry were found between children with T1DM + CD and controls at any time point. Children with T1DM + CD, had higher BMI z-score two years prior to, than at CD diagnosis (p <0.001). BMI z-score change one year prior to CD diagnosis was lower in the T1DM + CD than the T1DM group (p = 0.009). At two years, height velocity and change in BMI z-scores were similar in all groups. No differences were observed in HbA1c between the T1DM + CD and T1DM groups before or after CD diagnosis. More children with T1DM + CD had raised tTg levels one year after CD diagnosis than CD controls (CDx to CDx + 1 yr; T1DM + CD: 100% to 71%, p = 0.180 and CD: 100% to 45%, p < 0.001); by two years there was no difference.<p></p> Conclusions: No major nutrition or growth deficits were observed in children with T1DM + CD. CD diagnosis does not impact on T1DM glycaemic control. CD specific serology was comparable to children with single CD, but those with dual diagnosis may need more time to adjust to gluten free diet

The distinct features of microbial 'dysbiosis' of Crohn's disease do not occur to the same extent in their unaffected, genetically linked kindred

Background/Aims: Studying the gut microbiota in unaffected relatives of people with Crohn’s disease (CD) may advance our understanding of the role of bacteria in disease aetiology. Methods: Faecal microbiota composition (16S rRNA gene sequencing), genetic functional capacity (shotgun metagenomics) and faecal short chain fatty acids (SCFA) were compared in unaffected adult relatives of CD children (CDR, n = 17) and adult healthy controls, unrelated to CD patients (HUC, n = 14). The microbiota characteristics of 19 CD children were used as a benchmark of CD ‘dysbiosis’. Results: The CDR microbiota was less diverse (p = 0.044) than that of the HUC group. Local contribution of β-diversity analysis showed no difference in community structure between the CDR and HUC groups. Twenty one of 1,243 (1.8%) operational taxonomic units discriminated CDR from HUC. The metagenomic functional capacity (p = 0.207) and SCFA concentration or pattern were similar between CDR and HUC (p>0.05 for all SCFA). None of the KEGG metabolic pathways were different between these two groups. Both of these groups (HUC and CDR) had a higher microbiota α-diversity (CDR, p = 0.026 and HUC, p<0.001) with a community structure (β-diversity) distinct from that of children with CD. Conclusions: While some alterations were observed, a distinct microbial ‘dysbiosis’, characteristic of CD patients, was not observed in their unaffected, genetically linked kindred

Percutaneous endoscopic gastrostomy placement in paediatric Crohn's disease patients contributes to both improved nutrition and growth

Aim: This paper describes the outcomes of gastrostomy feeding in patients with Crohn's disease (CD). Methods: Patients with CD who attended the Royal Hospital for Children, Glasgow, and received gastrostomy feeding for at least two years between 2003-2010, were identified from the clinical database. The data recorded included the anthropometric data, CD phenotype, the surgical technique that was used, complications, medication, feed type, median feed, calories, volume and clinical outcomes. Results: The study identified 16 patients (14 male) who had a gastrostomy inserted using a pull technique at a median age of 12.6 years at. Of these two required laparoscopic placement. Short-term complications lasting less than one month were experienced by nine (56%) patients and one (6%) experienced long-term complications. Anthropometry significantly improved at follow up compared to baseline: at 12 months the body mass index z-score was 1.11 (p=0.005) and the weight z-score was 0.19 (p<0.05). At 24 months the height z-score was -1.03 (p=0.04). The daily median volume and calories from feeds increased significantly from baseline to post PEG insertion, from 400-738ml and 705 to 860kcal/day (p< =0.01). Conclusion: Gastrostomy feeding for paediatric patients with CD was associated with improved nutrition, weight gain and growth outcomes

76 Developing a protocol for a systematic review and meta-analysis of observational studies comparing direct oral anticoagulants with vitamin K antagonists for stroke prevention in people aged over 75 with atrial fibrillation

Introduction: Randomised controlled trials (RCTs) have demonstrated that anticoagulation by direct oral anticoagulants (DOACs) or vitamin-K-antagonists (VKAs) reduces the risk of stroke in people with atrial fibrillation. RCTs of DOACs demonstrated that they were non-inferior to VKAs and had a lower incidence of major bleeding. However, it is uncertain whether these results extrapolate to older people who were under-represented in these trials. This abstract describes the development of a protocol for a systematic review of observational studies to investigate whether the rates of ischaemic stroke and major bleeding differ between older patients treated with DOACs and vitamin-K-antagonists.Methods: The research question, search, inclusion and exclusion criteria were developed iteratively using the PICOS acronym as the base:Population– People aged over 75 with atrial fibrillationIntervention– DOACsComparator– Vitamin K antagonistsOutcomes– Stroke and major bleedingStudy design– Observational studiesResults: A systematic review protocol of observational studies was derived and registered with PROSPERO (CRD42018081696). The primary outcomes to be assessed were effectiveness (ischaemic stroke prevention) and safety (bleeding). In outline, Medline, EMBASE, Scopus and Web of Science will be searched from 2009 to present. Reference list searches will be used to identify further relevant studies. Manufacturers of DOACs will be contacted to request unpublished data. Data will be extracted independently by two reviewers using a pre-piloted form. Study data will be quantitatively synthesised and standard meta-analyses will be undertaken for each pair of treatment comparisons. Preliminary database searches have identified 13,623 citations. From abstract and title review it is expected that 400 will be eligible for full text review.Conclusions: This systematic review of observational data will complement the evidence from RCTs to provide an insight into the effectiveness and safety of these medications in older patients who have historically been be underrepresented in clinical trials. The findings of this review will provide important information for patients and practitioners alike

Disease Status and Pubertal Stage Predict Improved Growth in Anti-TNF Therapy for Pediatric Inflammatory Bowel Disease

Background: Growth failure is well-recognised in pediatric Inflammatory Bowel Disease (PIBD; <18 years). We aimed to examine whether anti-Tumor Necrosis Factor (TNF) therapy improves growth in a PIBD population-based cohort. Methods: A retrospective review of all Scottish children receiving anti-TNF (infliximab (IFX) and adalimumab (ADA)) from 2000-2012 was performed; height was collected at: 12 months before anti-TNF (T-12), start (T0) and 12 (T+12) months after anti-TNF. Results: 93/201 treated with IFX and 28/49 for ADA had satisfactory growth data; 66 had full pubertal data. Univariate analysis demonstrated early pubertal stages (Tanner 1-3 n = 44 vs. T4-5 n = 22), disease remission, disease duration >=2 years and duration of IFX >=12 months were associated with improved linear growth for IFX; for ADA only improvement was seen in Tanner 1-3. For IFX, Tanner 1-3 median [DELTA] ht SDS -0.3 (-0.7,0.2) at T0 changed to 0.04 (-0.5, 0.7) at T+12 (p < 0.001) vs -0.01 (-0.5, 0.9) at T0 in T4-5 changed to -0.01 (-0.4, 0.2) at T+12 (p > 0.05). For IFX disease duration >=2 year, median [DELTA] ht SDS was -0.13 (-0.6, 0.3) at T0 then 0.07 (-0.3, 0.6) at T+12 (p < 0.001). Remission improved [DELTA] ht SDS (median [DELTA] ht SDS -0.14 (-0.6, 0.3) at T0 to 0.17 (-0.2, 0.7) at T+12 (p > 0.001)). Multiple regression analysis demonstrated corticosteroid usage at T0 predicted improved [DELTA] ht SDS at T+12 for IFX and ADA. Conclusions: Anti-TNF therapy is more likely to be associated with growth improvement when used at earlier stages of puberty with remission a key growth-promoting strategy in Paediatric Crohn's disease

Comparison of clinical methods with the faecal gluten immunogenic peptide to assess gluten intake in coeliac disease

Objectives: Detection of faecal gluten immunogenic peptides (GIP) is a biomarker of recent gluten consumption. GIP levels can be used to monitor gluten intake and compliment clinical methods to evaluate compliance to gluten free diet (GFD). In this study, recent gluten intake was measured by GIP in CD children and compared to routine clinical measures to evaluate GFD compliance. Methods: GIP was measured in 90 samples from 63 CD children (44 previously and 19 newly diagnosed with follow-up samples at 6 and 12 months on GFD). Compliance to GFD was evaluated based on clinical assessment, tTG levels and Biagi score. Results: GIP was detectable in 16% of patients with previous CD diagnosis on GFD. BMI z-score (p=0.774), height z-score (p=0.723), haemoglobin concentration (p=0.233), age (p=0.448), gender (p=0.734) or disease duration (p=0.488) did not differ between those with detectable and non-detectable GIP. In newly diagnosed patients, on gluten containing diet, GIP was detectable in 95% of them. Following GFD initiation, GIP decreased (p<0.001); 17% and 27% had detectable levels at 6 and 12 months, respectively. Compared to GIP, the Biagi score, tTG and clinical assessment presented sensitivity of 17%, 42% and 17%. Likewise, GIP was detectable in 16%, 16%, 14% of patients evaluated as GFD compliant according to the Biagi score, tTG and clinical assessment. A combination of methods did not improve identification of patients who were non-compliant. Conclusions: Inclusion of faecal GIP measurements is likely to improve identification of GFD recent noncompliance in CD management and could be incorporated into current follow-up strategies