Juvenile idiopathic arthritis and physical activity: possible inflammatory and immune modulation and tracks for interventions in young populations

Conservative, Non-pharmacological Interventions for Pain Management in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effectiveness of conservative, non-pharmacological interventions for chronic pain management in children and adolescents with juvenile idiopathic arthritis (JIA). A comprehensive search strategy was implemented across PubMed, PEDro, and Web of Science databases, utilizing predefined terms and strict inclusion and exclusion criteria. The initial search yielded 1,308 studies, which were subsequently narrowed to 65 relevant articles. Following a rigorous evaluation, 14 studies met the inclusion criteria for final review, with an average PEDro scale score of 6.1/10, indicating fair to good methodological quality. The included RCTs focused on various interventions, including physical exercise (five studies), hydrotherapy (three studies), orthoses (two studies), online cognitive behavior therapy for pain management (two studies), low-level laser therapy (one study), and video games (one study). A random-effects model meta-analysis was performed for interventions and outcome measures that were comparable across at least three RCTs. Physical exercise interventions met this criterion and were thus subjected to meta-analytic evaluation. The pooled analysis demonstrated a statistically significant beneficial effect of exercise interventions on chronic pain (mean difference (MD) = -1.37, 95% CI = -2.19 to -0.55, p < 0.01). Subgroup analyses further supported the efficacy of exercise compared to both other active interventions (MD = -1.37, 95% CI = -2.25 to -0.5, p < 0.01) and control conditions (MD = -1.69, 95% CI = -3.09 to -0.29, p = 0.02). These findings suggest that conservative, non-pharmacological interventions, particularly physical exercise, show promise as a component of a multidisciplinary pain management strategy for patients with JIA. While further high-quality research is needed to bolster the evidence base, our findings highlight the potential efficacy of integrating physical exercise interventions into comprehensive pain management strategies for this pediatric population.

Adherence to exercise therapy among children and adolescents with Juvenile idiopathic arthritis: a scoping review

PURPOSE

To identify parameters and measurement methods of exercise therapy adherence, as well as barriers and facilitators affecting adherence among children and adolescents with juvenile idiopathic arthritis (JIA).

METHODS

Studies were eligible for inclusion if patients were 0-18 years of age, had JIA, and the focus of the research was on exercise therapy patterns, measurement/parameters of exercise adherence, and barriers/facilitators for exercise adherence. Two reviewers independently identified and categorized the barriers and facilitators to exercise therapy adherence using the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

Twenty articles were included in this review. Among patients with JIA, 29%-99% adhered to exercise therapy. The most commonly measured parameters of adherence were session completion and behavior component, with a self-report log serving as the most common means of assessment. Time pressure, symptoms related to JIA, lack of enjoyment, and insufficient motivation were the main barriers. Facilitators were commonly identified as adequate motivation, effective symptoms management, and social support.

CONCLUSIONS

Future interventions should consider the identified factors to promote exercise engagement in children and adolescents with JIA. Strategies for promoting exercise adherence in children and adolescents with JIA is needed.

Pathways of sleep disturbances in juvenile idiopathic arthritis and recommendations for clinical management approaches: A critical review

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease affecting young people. It has a profound impact on their physical, mental and social lives, leading to long-term disability. With the growing awareness of the importance of sleep in all areas of functioning in young people, an emerging literature has drawn attention to the role of sleep in the pathogenesis of JIA. Sleep disturbances in children and adolescents with JIA arise from a wide range of symptoms and pathways, leading to a vicious cycle that exacerbates subclinical inflammation, symptoms and disease progression. Putative factors contributing to sleep disturbances include chronic inflammation, JIA-associated sleep disorders, JIA symptoms (e.g. pain), psychological comorbidities and potential circadian disruption, which may be exacerbated by the transition to adolescence. Here, we review these pathways and advocate key strategies and alternatives for sleep management in young people with JIA in clinical settings. We identify gaps in knowledge and suggest future directions to improve our understanding of JIA sleep disorders, including clinical trials investigating potential strategies to improve sleep health in this young population.

Physical activity as a promising alternative for young people with juvenile idiopathic arthritis: Towards an evidence-based prescription

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in young people. Although biologics now enable most children and adolescents with JIA to enjoy clinical remission, patients present lower physical activity and spend more time in sedentary behavior than their healthy counterparts. This impairment probably results from a physical deconditioning spiral initiated by joint pain, sustained by apprehension on the part of both the child and the child's parents, and entrenched by lowered physical capacities. This in turn may exacerbate disease activity and lead to unfavorable health outcomes including increased risks of metabolic and mental comorbidities. Over the past few decades, there has been growing interest in the health benefits of increased overall physical activity as well as exercise interventions in young people with JIA. However, we are still far from evidence-based physical activity and / or exercise prescription for this population. In this review, we give an overview of the available data supporting physical activity and / or exercise as a behavioral, non-pharmacological alternative to attenuate inflammation while also improving metabolism, disease symptoms, poor sleep, synchronization of circadian rhythms, mental health, and quality of life in JIA. Finally, we discuss clinical implications, identify gaps in knowledge, and outline a future research agenda.

Construct validity of Patient-Reported Outcomes Measurement Information System Paediatric measures in juvenile idiopathic arthritis and systemic lupus erythematosus: cross-sectional evaluation

OBJECTIVES

Evaluate construct validity of Patient-Reported Outcomes Measurement Information System (PROMIS) Paediatric measures of symptoms and functioning against measures of disease activity among youth with juvenile idiopathic arthritis (JIA) or systemic lupus erythematosus (SLE).

DESIGN

Cross-sectional associations among PROMIS measures and clinical metrics of disease activity were estimated.

SETTING

Seven clinical sites of the Childhood Arthritis and Rheumatology Alliance (CARRA) in the USA.

PARTICIPANTS

Youth aged 8-17 years enrolled in the CARRA Registry.

INTERVENTION

PROMIS measures were collected and associations with clinical measures of disease activity estimated, by condition, in bivariate and multivariable analyses with adjustment for sociodemographics, insurance status, medications and disease duration.

MAIN OUTCOME MEASURES

PROMIS Paediatric measures of mobility, physical activity, fatigue, pain interference, family relationships, peer relationships, depressive symptoms, psychological stress, anxiety, and meaning and purpose, and clinical metrics of disease.

RESULTS

Among 451 youth (average age 13.8 years, 71% female), most (n=393, 87%) had a JIA diagnosis and the remainder (n=58, 13%) had SLE. Among participants with JIA, those with moderate/high compared with low/inactive disease had, on average, worse mobility (multivariable regression coefficient and 95% CIs) (-7.40; -9.30 to -5.50), fatigue (3.22; 1.02 to 5.42), pain interference (4.76; 3.04 to 6.48), peer relationships (-2.58; -4.52 to -1.64), depressive symptoms (3.00; 0.96 to 5.04), anxiety (2.48; 0.40 to 4.56) and psychological stress (2.52; 0.68 to 4.36). For SLE, youth with active versus inactive disease had on average worse mobility (-5.07; -10.15 to 0.01) but PROMIS Paediatric measures did not discriminate participants with active and inactive disease in adjusted analyses.

CONCLUSIONS

Seven PROMIS Paediatric measures discriminated between active and inactive disease in youth with JIA. Results advance the usefulness of PROMIS for understanding well-being and improving interventions for youth with JIA, but larger studies are needed to determine utility in SLE cohorts.

TRIAL REGISTRATION NUMBER

National Institute of Arthritis and Musculoskeletal and Skin Diseases (U19AR069522).

Physical Activity Influences Health-Related Quality of Life in Adults with Juvenile Idiopathic Arthritis

This cross-sectional study aimed to evaluate the impact of physical activity and physical fitness on the health-related quality of life (HQoL) of adult patients with Juvenile Idiopathic Arthritis (JIA). Fifty-nine JIA patients and sixty healthy individuals participated in this study. All individuals had the following evaluations performed: body composition (electrical bioimpedance), physical fitness (6 min walk test (6MWT)), physical activity level (International Physical Activity Questionnaire (IPAQ)), and HQoL (Quality of Life Questionnaire in relation to Health-Short Form (SF36)). Thirty-nine (66%) JIA patients were considered sedentary compared with 15 (25%) in the control group (p < 0.01). JIA patients had a lower HQoL compared with the control group in all variables studied (p < 0.05). JIA patients who were very physically active had better HQoL conditions in the categories of functional capacity (p = 0.001), limitations by physical aspects (p = 0.003), and emotional aspects (p = 0.002) compared with sedentary patients. JIA patients had more cardiovascular abnormalities and walked shorter distances compared with healthy controls in the 6MWT. In conclusion, we observed that HQoL was reduced in adults with JIA. A high percentage of JIA patients were sedentary with lower physical fitness, but physically active patients had a better HQoL than sedentary patients. The duration of physical activity, rather than intensity, influenced the mental aspects of HQoL.

Proteomics based markers of clinical pain severity in juvenile idiopathic arthritis

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is a cluster of autoimmune rheumatic diseases occurring in children 16 years of age or less. While it is well-known that pain may be experienced during inflammatory and non-inflammatory states, much remains ambiguous regarding the molecular mechanisms that may drive JIA pain. Thus, in this pilot study, we explored the variability of the serum proteomes in relation to pain severity in a cohort of JIA patients.

METHODS

Serum samples from 15 JIA patients (male and female, 12.7 ± 2.8 years of age) were assessed using liquid chromatography/mass spectrometry (LC/MS). Correlation analyses were performed to determine the relationships among protein levels and self-reported clinical pain severity. Additionally, how the expression of pain-associated proteins related to markers of inflammation (Erythrocyte Sedimentation Rate (ESR)) or morphological properties of the central nervous system (subcortical volume and cortical thickness) implicated in JIA were also evaluated.

RESULTS

306 proteins were identified in the JIA cohort of which 14 were significantly (p < 0.05) associated with clinical pain severity. Functional properties of the identified pain-associated proteins included but were not limited to humoral immunity (IGLV3.9), inflammatory response (PRG4) and angiogenesis (ANG). Associations among pain-associated proteins and ESR (IGHV3.9, PRG4, CST3, VWF, ALB), as well as caudate nucleus volume (BTD, AGT, IGHV3.74) and insular cortex thickness (BTD, LGALS3BP) were also observed.

CONCLUSIONS

The current proteomic findings suggest both inflammatory- and non-inflammatory mediated mechanisms as potential factors associated with JIA pain. Validation of these preliminary observations using larger patient cohorts and a longitudinal study design may further point to novel serologic markers of pain in JIA.

Reference Values for the Six Minute Walk Test in Children with Juvenile Idiopathic Arthritis

AIMS

To (1) describe six-minute walk test (6MWT) reference values for children with Juvenile Idiopathic Arthritis (JIA) and (2) explore predictors of 6MWT distance. A secondary objective was to determine how 6MWT distances of children with JIA compare to those of children without JIA reported in the literature.

METHODS

Demographic, clinical, height, weight and 6MWT data were extracted from clinical records of 120 children with JIA (70.8% female, mean age=12.4 ± 3.2 years) who attended a follow-up rheumatology clinic. A total of 272 6MWTs were included in the analyses. Linear mixed effects modeling was used to determine the relationship between predictive variables and 6MWT distance. 6MWT distances were compared to predicted values using published equations for estimating 6MWT distances in children without JIA.

RESULTS

Height, weight, and age were predictive of 6MWT distance (R² = 0.62). Mean 6MWT distances for children with JIA were lower than those reported for children without JIA (p < 0.001). Mean 6MWT distance was 84% and 78% of predicted values for children without JIA.

CONCLUSION

The reference values and associated predictive model have application for assessing exercise capacity in children with JIA.

Cardiovascular Health in Pediatric Rheumatologic Diseases

Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.

Suppression of lncRNA MALAT1 reduces pro-inflammatory cytokines production by regulating miR-150-5p/ZBTB4 axis through JAK/STAT signal pathway in systemic juvenile idiopathic arthritis

Systemic juvenile idiopathic arthritis (sJIA) is a common chronic disease occurring in children. Increasing studies have demonstrated that long noncoding RNAs (lncRNAs) play important roles in the pathogenesis of diverse human diseases. This study aimed to explore the role of lncRNA metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) and its mechanism in sJIA. We found that the expression of MALAT1, the plasma level of pro-inflammatory cytokines (IL-6, IL-17, IL-1β, and TNF-α) as well as MMP-8 and MMP-9 production were significantly elevated in sJIA patients. Moreover, we observed that the production of these cytokines in peripheral blood mononuclear cells (PBMCs) from sJIA patients were reduced after MALAT1 knockdown. Furthermore, bioinformatics analysis predicted that MALAT1 might bind to miR-150-5p and ZBTB4 was a downstream target gene of miR-150-5p. Besides, rescue assays revealed that MALAT1 knockdown-mediated suppressive effects on cytokine production could be reversed by ZBTB4 overexpression. In addition, MALAT1 activated the JAK/STAT signaling by upregulating ZBTB4 expression. In summary, our findings demonstrated that MALAT1 promoted pro-inflammatory cytokine and MMP production by targeting the miR-150-5p/ZBTB4 axis through JAK/STAT signaling pathway in sJIA, suggesting that MALAT1 may have a potential diagnostic biomarker for the pathogenesis and therapy of sJIA.

Infliximab therapy and outcomes in patients with polyarticular juvenile idiopathic arthritis: a single-center study in China

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease that includes seven heterogeneous subgroups with different prognoses. In particular, polyarticular JIA (pJIA) has a longer period of active disease and a poorer prognosis. Tumor necrosis factor (TNF)-alpha inhibitors are effective in patients with pJIA, but the therapeutic regimen remains controversial. Here, we performed a single-center study to determine the potential correlation between TNF-alpha inhibitor (infliximab) therapy and outcomes in these patients.

METHODS

Clinical data of 40 pJIA patients were collected at our center from January 1, 2010 to January 1, 2018, and patients were grouped according to the timing of infliximab therapy. The erythrocyte sedimentation rate (ESR), the number of joints with active disease, and the 27-point juvenile arthritis disease activity score (JADAS-27) were analyzed.

RESULTS

The ESR, the active joint count, and the JADAS-27 decreased significantly in all groups after 3 months (P = 0.041/0.415/0.008, 0.022/0.030/ < 0.001, and 0.05/0.012/ < 0.001, respectively) and 6 months (P = 0.036/0.045/0.041, 0.076/0.037/ < 0.001, and 0.096/0.006/ < 0.001, respectively) of infliximab treatment, although the rates of change of these parameters were similar. However, after 12 months, only patients treated with infliximab within 3 months of disease onset had a stable ESR, active joint count, and JADAS-27, while these parameters increased sharply when infliximab was administered 3 months and especially 1 year after disease onset.

CONCLUSIONS

TNF-alpha is a pleiotropic pro-inflammatory cytokine of crucial importance in the pathogenesis of JIA. Infliximab can improve the outcomes of patients with pJIA significantly, and should be introduced early during the clinical course.

Regulation of JAK/STAT signal pathway by miR-21 in the pathogenesis of juvenile idiopathic arthritis

BACKGROUND

Overexpression of the components of the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signalling pathway is the key factor of the pathogenic mechanisms underlying systemic juvenile idiopathic arthritis (sJIA). The study aims to investigate the association between miR-21 and the JAK/STAT signal pathway in JIA.

METHODS

Total RNA was extracted from peripheral blood mononuclear cells (PBMCs) in active JIA patients. The relative expressions of miR-21, STAT3 and suppressor of cytokine signalling 3 in PBMCs were measured by real-time polymerase chain reaction and their expressions were measured by western blotting and dual-luciferase reported assay. Rheumatoid arthritis fibroblast-like synovial cell (RASF) was stimulated to become to osteoclasts using macrophage colony-stimulating factor (M-CSF) and factors that can impact on their differentiation ability were identified through the transfection of LV3-miR-21. The expression of STAT3/p-STAT3 was measured by western blot, and the levels of interleukin (IL)-17A, p65, matrix metalloproteinases (MMP)-3, MMP-4 and receptor activator of nuclear factor-κB after the LV3-miR-21 transfection were tested by enzyme-linked immunosorbent assay. Finally, the miR-21 targeted STAT3 gene was detected by the dual-luciferase reported assay.

RESULTS

The expression of miR-21 was significantly lower in JIA patients than in healthy control (P < 0.05). The level of STAT3 was increased in PBMCs of JIA group compared with control group (P < 0.05). Furthermore, the expression levels of miR-21 in sJIA and polyarticular JIA groups were negatively correlated with STAT3 (r = - 0.5854/r = - 0.6134, P < 0.05). The expression of STAT3 changed little in PBMCS after the stimulation of IL-6 and not in RASFs with transfection of LV3-miR-21. The expression of p-STAT3 decreased after the stimulation of IL-6 in RASFs transfected by LV3-miR-21 (P < 0.05). RASFs were induced into osteoclasts using M-CSF. The number of osteoclasts as determined by tartrate-resistant acid phosphatase staining was significantly lower in group miR-21 mimics as compared with the negative control group (P < 0.05).

CONCLUSIONS

We showed that expression of miR-21 was significantly lower in JIA patients compared with healthy control. MiR-21 might affect the JAK/STAT signal pathway by suppressing the expression of STAT3 and phosphorylation of STAT3. MiR-21 could inhibit the production of osteoclasts induced from RASFs by M-CSF.

Physical activity and sedentary levels in children with juvenile idiopathic arthritis and inflammatory bowel disease. A systematic review and meta-analysis

BACKGROUND

Physical activity (PA) is essential for children throughout their growth and maturation. It improves physiological and psychological health and limits the risk of developing metabolic disorders. However, some chronic physiological and metabolic diseases may lead to decreased PA. The diversity of outcomes in the literature offers no consensus for physical activity and sedentary levels in children with juvenile idiopathic arthritis (JIA) or inflammatory bowel disease (IBD).

METHODS

A literature review and a meta-analysis were carried out with original studies from a Medline database search. Only high-quality studies (STROBE checklist) written in English comparing PA level or sedentary behavior (SB) between children with the disorders and their healthy peers were considered. The aim was to examine PA and SB in children with JIA or IBD compared to their healthy peers.

RESULTS

The literature review and meta-analysis identified decreased PA and increased time spent in SB in these populations, which may exacerbate both their lower physical fitness and the symptoms of their health disorders.

CONCLUSION

Results nevertheless show discrepancies due to the different materials and methods used and the variables measured. Further studies are needed to establish a gold standard method for assessing PA level in these populations.

Participation in school and physical education in juvenile idiopathic arthritis in a Nordic long-term cohort study

BACKGROUND

The aim of the study was to describe school attendance and participation in physical education in school among children with juvenile idiopathic arthritis (JIA).

METHODS

Consecutive cases of JIA from defined geographical areas of Finland, Sweden and Norway with disease onset in 1997 to 2000 were followed for 8 years in a multi-center cohort study, aimed to be as close to population-based as possible. Clinical characteristics and information on school attendance and participation in physical education (PE) were registered.

RESULTS

Participation in school and in PE was lowest initially and increased during the disease course. Eight years after disease onset 228/274 (83.2%) of the children reported no school absence due to JIA, while 16.8% reported absence during the last 2 months due to JIA. Full participation in PE was reported by 194/242 (80.2%), partly by 16.9%, and none by 2.9%. Lowest participation in PE was found among children with ERA and the undifferentiated categories. Absence in school and PE was associated with higher disease activity measures at the 8-year visit. School absence > 1 day at baseline predicted use of disease-modifying anti-rheumatic drugs, including biologics (DMARDs) (OR 1.2 (1.1-1.5)), and non-remission off medication (OR 1.4 (1.1-1.7) 8 years after disease onset.

CONCLUSION

School absence at baseline predicted adverse long-term outcome. In children and adolescents with JIA participation in school activities is mostly high after 8 years of disease. For the minority with low participation, special attention is warranted to promote their full potential of social interaction and improve long-term outcome.

Challenges in the treatment of Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammatory disease characterized by a heterogeneous clinical response to the different treatments. Some patients are difficult to treat and do not reach the treatment targets as clinical remission or low disease activity. Known negative prognostic factors, such as the presence of auto-antiantibodies and joint erosion, the presence of a genetic profile, comorbidities and extra-articular manifestations, pregnancy or a pregnancy wish may concur to the treatment failure. In this review we aimed at identify difficult to treat RA patients and define the optimal therapeutic and environmental targets. Genetic markers of severity such as HLA-DRB1, TRAF1, PSORS1C1 and microRNA 146a are differently associated with joint damage; other gene polymorphisms seem to be associated with response to biologic disease modifying anti-rheumatic drugs (bDMARDs). The presence of comorbidities and/or extra-articular manifestations may influence the therapeutic choice; overweight and obese patients are less responsive to TNF inhibitors. In this context the patient profiling can improve the clinical outcome. Targeting different pathways, molecules, and cells involved in the pathogenesis of RA may in part justify the lack response of some patients. An overview of the future therapeutic targets, including bDMARDs (inhibitors of IL-6, GM-CSF, matrix metalloproteinases, chemokines) and targeted synthetic DMARDs (filgotinib, ABT-494, pefacitinib, decernotinib), and environmental targets is addressed. Environmental factors, such as diet and cigarette smoke, may influence susceptibility to autoimmune diseases and interfere with inflammatory pathways. Mediterranean diet, low salt intake, cocoa, curcumin, and physical activity seem to show beneficial effects, however studies of dose finding, safety and efficacy in RA need to be performed.

Mechanisms of vascular comorbidity in autoimmune diseases

Purpose of review

Persuasive statistics support the clinical observation that because of cardiovascular comorbidities patients with inflammatory joint disease die significantly earlier despite anti-inflammatory therapy.

Recent findings

The reason for this earlier death is multifactorial and involves a combination of a complex genetic background, environmental influences, classical cardiovascular risk factors and the impact of anti-inflammatory therapy. We will describe the importance of several new mechanisms, especially the diverse intercellular communication routes including extracellular vesicles and microRNAs that support the development of cardiovascular comorbidities.

Summary

The aim of this review is to give an updated overview about the known risk factors in the development of cardiovascular comorbidities with the latest insights about their mechanism of action. Furthermore, the impact of newly identified risk factors and significance will be discussed.

Physical Exercise and Physical Activity for Children and Adolescents With Juvenile Idiopathic Arthritis: A Literature Review

PURPOSE

This is a review of studies that investigate the efficacy of exercise therapy and physical activity for children with juvenile idiopathic arthritis since the 2008 Cochrane Review.

METHOD

Studies were identified that investigated the use of physical activity and exercise therapy in the treatment of children and adolescents with juvenile idiopathic arthritis, excluding the Cochrane Review. Two reviewers individually analyzed the results of the search to determine the eligibility of studies. The randomized controlled trial study designs were evaluated using PEDro scales.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Recent literature supports the importance of the combination of strengthening, stretching, proprioceptive, and balance exercises and activities in water. Many of the reviewed studies proposed an intensive program of physical activity and exercise therapy, conducted 3 times a week for 12 weeks.

Design and implementation of a decision aid for juvenile idiopathic arthritis medication choices

BACKGROUND

Randomized trials have demonstrated the efficacy of patient decision aids to facilitate shared decision making in clinical situations with multiple medically reasonable options for treatment. However, little is known about how best to implement these tools into routine clinical practice. In addition, reliable implementation of decision aids has been elusive and spread within pediatrics has been slow. We sought to develop and reliably implement a decision aid for treatment of children with juvenile idiopathic arthritis.

METHODS

To design our decision aid, we partnered with patient, parent, and clinician stakeholders from the Pediatric Rheumatology Care and Outcomes Improvement Network. Six sites volunteered to use quality improvement methods to implement the decision aid. Four of these sites collected parent surveys following visits to assess outcomes. Parents reported on clinician use of the decision aid and the amount of shared decision making and uncertainty they experienced. We used chi-square tests to compare eligible visits with and without use of the decision aid on the experience of shared decision making and uncertainty.

RESULTS

After 18 rounds of testing and revision, stakeholders approved the decision aid design for regular use. Qualitative feedback from end-users was positive. During the implementation project, the decision aid was used in 35% of visits where starting or switching medication was discussed. Clinicians used the decision aid as intended in 68% of these visits. The vast majority of parents reported high levels of shared decision making following visits with (64/76 = 84%) and without (80/95 = 84%) use of the decision aid (p = 1). Similarly, the vast majority of parents reported no uncertainty following visits with (74/76 = 97%) and without (91/95 = 96%) use of the decision aid (p = 0.58).

CONCLUSIONS

Although user acceptability of the decision aid was high, reliable implementation in routine clinical care proved challenging. Our parsimonious approach to outcome assessment failed to detect a difference between visits with and without use of our aid. Innovative approaches are needed to facilitate use of decision aids and the assessment of outcomes.

Safety and effectiveness of etanercept for treatment of juvenile idiopathic arthritis: Results from a postmarketing surveillance

OBJECTIVES

The objectives of this surveillance were to determine safety and effectiveness of etanercept in patients with juvenile idiopathic arthritis (JIA).

METHODS

In this postmarketing surveillance, patients aged 5-16 years with active polyarthritis JIA were treated with etanercept at the doses approved in the Japanese package insert. The occurrence and seriousness of adverse events (AEs) were assessed using the Japanese Medical Dictionary for Regulatory Activities version 15.1. Effectiveness was determined as the improvement from baseline in disease activity score in 28 joints (DAS28)-erythrocyte sedimentation rate (ESR), remission, and physician's assessment of overall improvement. The number of responders was expressed as a percentage. The last observation carried forward method was used to impute missing data.

RESULTS

Safety analysis included 102 patients; 22 patients experienced 36 treatment-related AEs, three of which were unexpected. None of the AEs were deemed to need special safety warnings. Effectiveness analysis included 87 patients. At 24 weeks, 29/46 (63.0%) patients demonstrated either good or moderate response in DAS28-4/ESR and treatment was assessed to be markedly effective or effective by physicians in 79/83 (95.2%) patients.

CONCLUSIONS

These data are consistent with earlier reports showing that etanercept was effective and demonstrated no safety signals in patients with JIA.

Health-related quality of life among Swedish children with Juvenile Idiopathic Arthritis: parent-child discrepancies, gender differences and comparison with a European cohort

BACKGROUND

This study investigates gender differences in self-reports and between parent and child reports in Health-related Quality of Life (HRQOL), measured with disease-specific and generic instruments for chronic disease. Comparison of HRQOL results in this Juvenile Idiopathic Arthritis (JIA) sample to a European cohort of children with JIA and one of children with other health conditions are also made.

METHODS

Fifty-three children with juvenile idiopathic arthritis (JIA), aged 8-18 years, and their parents completed the condition-specific DISABKIDS for JIA, and the DISABKIDS generic instrument for chronic conditions (DCGM-37) in a cross-sectional study. European reference data were used for comparison of child and parental reports.

RESULTS

Child self-reports in DCGM-37 and DISABKIDS for JIA showed no gender differences. Parental and child reports of the child's HRQOL differed only in DCGM-37; this was among girls who scored their independence (p = 0.03), physical limitation (p = 0.01), social exclusion (p = 0.03), emotions (p <0.01), and general transformed score (p <0.01) higher than did their parents. Our sample of children with JIA reported more physical limitation compared to samples of European children with JIA (p = 0.01), European children with chronic conditions (p < 0.01), and their parents (p = 0.01 and p < 0.01). The Swedish children reported more problem with understanding compared to the European JIA sample (p = 0.03). Swedish parents perceived their children's independence significantly lower than did the European parents of JIA children (p < 0.01), as well as European parents of children with chronic conditions (p = 0.03). The Swedish parents also perceived their children to have significantly lower social inclusion (p < 0.05) and general transformed score (p = 0.04), in comparison to European parents of children with chronic conditions.

CONCLUSIONS

Parent-child differences in assessment of quality of life depend on the HRQOL instrument used, especially among girls. In comparison to European cohorts, our sample of children with JIA experienced more physical limitations and less understanding.

Ankylosis of the Temporomandibular Joint and Reconstruction With a Costochondral Graft in a Patient With Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA), the most common inflammatory autoimmune rheumatic disease in children, consists of a heterogeneous group of diseases with 7 distinct subtypes. Involvement of the temporomandibular joint (TMJ) in JIA varies from 17% to 87%, and can alter craniofacial growth due to damage to the condylar growth center. This study was a literature review and clinical report of bilateral ankylosis of the TMJ in a 13-year-old patient with polyarticular JIA. Temporomandibular joint reconstruction with a costochondral graft was carried out. The surgery was uneventful and the patient developed a mouth opening of 40 mm during the postoperative period of 24 months. The authors concluded that treatment of TMJ ankylosis should be surgical with removal of the ankylotic mass, and when necessary, joint reconstruction in patients undergoing a growth phase. Costochondral graft is still the gold standard due to its biological similarity and growth potential in patients with JIA. Research and early diagnosis of TMJ diseases should be carried out, because the earlier the identification of the disease, the better the chances of reducing its devastating effects, thus avoiding the worst possible outcome: TMJ ankylosis.

T cell subpopulations in juvenile idiopathic arthritis and their modifications after biotherapies

Inflammatory T cells are thought to be central to the pathogenesis of juvenile idiopathic arthritis. In particular, recent evidence has underlined the importance of a balance between Th17 and Treg cells. Several mechanisms have come to light that control this reciprocal relationship. Moreover, it has been shown that in certain conditions, Th17 cells can shift toward a nonclassic Th1 phenotype. Anti-rheumatic biologic therapies may interfere with these mechanisms and re-establish immune tolerance.

Epidemiology and risk of juvenile idiopathic arthritis among children with allergic diseases: a nationwide population-based study

BACKGROUND

Epidemiological research reveals that the incidence of allergic diseases and that of autoimmune diseases have been increasing in parallel, raising an interest in a potential link between the two disorders. However, the relationship between Th2-mediated allergic disease and Th1-mediated juvenile idiopathic arthritis (JIA) remains unclear. This population-based case-control study was aimed at investigating the development of childhood-onset allergic diseases and the subsequent risks of JIA.

METHODS

We included 329 children with JIA diagnosed between 2000 and 2008, and 1316 age- and sex-matched controls. The odds ratios of developing JIA were calculated to determine an association with preexisting allergic diseases.

RESULTS

The incidence rate of JIA in Taiwan between 2000 and 2008 was 1.33 cases per 100,000 children/year according to the International League of Associations for Rheumatology (ILAR) criteria. The children with a single allergic disease had an increased risk of JIA, with adjusted odds ratios of developing JIA of 1.44 for allergic conjunctivitis (95 % confidence interval [CI], 1.07-1.95), 1.50 for allergic rhinitis (1.15-1.96), and 1.44 for asthma (1.00-2.10). The adjusted odds ratios increased with the number of concurrent allergic diseases from 1.50 (95 % CI, 1.12-2.01) for those with only one allergic disease to 1.72 (1.24-2.38) for those with at least two allergic diseases. The adjusted odds ratios of those with at least two allergic diseases increased to 1.84 (95 % CI, 1.19-2.86) for boys and 2.54 (1.42-4.54) for those older than 12 years. The children who made two or more medical visits for associated allergic diseases per year had an increased risk of JIA.

CONCLUSION

Children with onset of allergic diseases were at increased risk of developing JIA. The increased risk was associated with the cumulative effect of concurrent allergic diseases and frequency of seeking medical care. Further study to investigate the role of Th2-mediated allergic diseases that contribute to the development of Th1-mediated JIA is warranted.