Juvenile Idiopathic Arthritis: Oligoarthritis and Polyarthritis

Maximal mouth opening is a simple method to evaluate the treatment outcome of temporomandibular joint arthritis in patients with juvenile idiopathic arthritis

OBJECTIVE

Temporomandibular joint (TMJ) arthritis is a common finding in juvenile idiopathic arthritis (JIA) patients. TMJ arthritis can cause significant disturbances in TMJ function and growth without treatment. Our aim was to evaluate the effectiveness of medical treatments used to manage TMJ arthritis and how to evaluate the outcome of the treatment. Furthermore, this study aimed to ascertain the prevalence of TMJ arthritis in JIA patients and investigate the potential impact of specific factors.

MATERIAL AND METHODS

Between 2015 and 2019, a total of 194 JIA patients who received treatment at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland were included in the study. We retrospectively screened the patient records and imaging studies to find out how many patients had TMJ arthritis and what medication was used to treat it.

RESULTS

Maximal incisal mouth opening (MIO) increased significantly with patients whose TMJ arthritis was successfully treated with intra-articular corticosteroid injection (IACI). Almost all patients with TMJ arthritis were treated with an IACI at some point during their treatment. Overall, 99 patients (51%) had been diagnosed with TMJ arthritis. No statistical difference was found between the prevalence of TMJ arthritis and different JIA subtypes, JIA onset time, gender, or immunological factors.

CONCLUSION

MIO is an easy way to evaluate the treatment outcome and possible disease activation of TMJ arthritis. The prevalence of TMJ arthritis is high among JIA patients. In our study, we could not find any parameters that predict TMJ arthritis, and despite systemic medication, TMJ arthritis might occur.

Serum CS/DS, IGF-1, and IGFBP-3 as Biomarkers of Cartilage Remodeling in Juvenile Idiopathic Arthritis: Diagnostic and Therapeutic Implications

Cartilage destruction in juvenile idiopathic arthritis (JIA) is diagnosed, often too late, on basis of clinical evaluation and radiographic imaging. This case-control study investigated serum chondroitin/dermatan sulfate (CS/DS) as a potential biochemical marker of cartilage metabolism, aiming to improve early diagnosis and precision treatment for JIA. We also measured the levels of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor-binding protein-3 (IGFBP-3) (using ELISA methods) in JIA patients (n = 55) both before and after treatment (prednisone, sulfasalazine, methotrexate, administered together), and analyzed their relationships with CS/DS levels. Untreated JIA patients [8.26 µg/mL (6.25-9.66)], especially untreated girls [8.57 µg/mL (8.13-9.78)] and patients with a polyarticular form of the disease [7.09 µg/mL (5.63-8.41)], had significantly reduced levels of serum CS/DS compared with the control [14.48 µg/mL (10.23-15.77)]. Therapy resulted in a significant increase in this parameter, but without normalization. We also found significantly lower levels of IGF-1 [66.04 ng/mL (49.45-96.80)] and IGFBP-3 [3.37 ng/mL (2.65-4.88)] in untreated patients compared with the control [96.92 ng/mL (76.04-128.59), 4.84 ng/mL (4.21-7.750), respectively]. Based on receiver operating characteristic (ROC) curve analysis, the blood concentration of CS/DS demonstrated the highest diagnostic power (AUC = 0.947) for JIA among all the tested markers. Untreated patients showed significant correlations between CS/DS and IGF-1 (r = -0.579, p = 0.0000), IGFBP-3 (r = -0.506, p = 0.0001), and C-reactive protein (r = 0.601, p = 0.0005). The observed changes in CS/DS during the course of JIA, influenced by both impairment of the IGF/IGFBP axis and inflammation, indicate the need for continued therapy to protect patients from potential disability. We suggest that CS/DS may be a useful biomarker of disease activity and could be employed to assess treatment efficacy and progress toward remission.

Heel pain in young athletes - not always Sever's Disease: A Narrative Review

Heel pain is a prevalent issue in young athletes, often arising from overuse and increased sporting demands. While Sever's Disease is the predominant cause, various other entities, including stress-related injuries and pathologies like tumors and bone lesions, contribute to this condition. The complex hind foot anatomy, encompassing ossicles, physis, and soft tissues, may lead to heel pain. This study aims to provide physicians with a clinically oriented narrative review of adolescent heel pain, supported by illustrative cases. CONCLUSION: This study aims to offer physicians a comprehensive understanding of the concepts surrounding heel pain in adolescents. By presenting clinically relevant information and illustrated cases, it seeks to enhance medical practitioners' ability to diagnose and manage heel pain effectively in this specific demographic.

Health Literacy Levels of Patients With Juvenile Idiopathic Arthritis and Their Parents

BACKGROUND

The aim of this study was to reveal the relationship between the health literacy (HL) levels of children with juvenile idiopathic arthritis (JIA) and their parents, and the general health status and physical performance of the children.

METHODS

This study included 79 children aged 9-18 years with a diagnosis of JIA and one of their parents. HL levels were evaluated with the Turkish version of the Health Literacy for School-Aged Children and Turkish Health Literacy-32 (THL-32) for children and Adult Health Literacy Scale (AHLS) for their parents. The Childhood Health Assessment Questionnaire (CHAQ), 6-minute walk test (6-MWT), 10-meter walking test (10-MWT) and 10-stair climbing test (10-SCT) was used to evaluate the children. Juvenile Arthritis Biopsychosocial Questionnaire (JAB-Q) was used to assess the children's and parents' psychosocial status and perception of health.

RESULTS

HL levels of patients with JIA were 16.5% low HL, %55.7 moderate HL and 27.8% high HL. According to THL-32 scale score, HL level of parents were as follows: inadequate, 3.8%; problematic, 22.8%; sufficient, 34.2%; and excellent, 39.2%. Children's HL levels increase positively as they get older, and no significant relationship was found with other parameters. The AHLS, CHAQ and JAB-Q scores were better in the group with higher education levels of the parents. No statistically significant association was found between the HL of the children and that of the parents.

CONCLUSION

In our study, it was found that the high education levels of the parents positively affected the quality of life and physical condition of their children and parental HL levels. In addition, it was shown that the HL levels of children with JIA were not statistically related to other parameters.

PATIENT OR PUBLIC CONTRIBUTION

Children diagnosed with JIA and one of their parents actively participated in the study. Feedback from children and families provided important information about obtaining and using HL information before and during the study. The importance of therapy programs and information focusing on the patient and their family, as well as the inter-multidisciplinary approach, in combating a chronic disease at an early age was reinforced by the feedback received from patients and their families.

MicroRNAs in Juvenile Idiopathic Arthritis: State of the Art and Future Perspectives

Juvenile Idiopathic Arthritis (JIA) represents the most common chronic pediatric arthritis in Western countries and a leading cause of disability in children. Despite recent clinical achievements, patient management is still hindered by a lack of diagnostic/prognostic biomarkers and targeted treatment protocols. MicroRNAs (miRNAs) are short non-coding RNAs playing a key role in gene regulation, and their involvement in many pathologies has been widely reported in the literature. In recent decades, miRNA's contribution to the regulation of the immune system and the pathogenesis of autoimmune diseases has been demonstrated. Furthermore, miRNAs isolated from patients' biological samples are currently under investigation for their potential as novel biomarkers. This review aims to provide an overview of the state of the art on miRNA investigation in JIA. The literature addressing the expression of miRNAs in different types of biological samples isolated from JIA patients was reviewed, focusing in particular on their potential application as diagnostic/prognostic biomarkers. The role of miRNAs in the regulation of immune responses in affected joints will also be discussed along with their potential utility as markers of patients' responses to therapeutic approaches. This information will be of value to investigators in the field of pediatric rheumatology, encouraging further research to increase our knowledge of miRNAs' potential for future clinical applications in JIA.

Knee acoustic emissions as a noninvasive biomarker of articular health in patients with juvenile idiopathic arthritis: a clinical validation in an extended study population

BACKGROUND

Joint acoustic emissions from knees have been evaluated as a convenient, non-invasive digital biomarker of inflammatory knee involvement in a small cohort of children with Juvenile Idiopathic Arthritis (JIA). The objective of the present study was to validate this in a larger cohort.

FINDINGS

A total of 116 subjects (86 JIA and 30 healthy controls) participated in this study. Of the 86 subjects with JIA, 43 subjects had active knee involvement at the time of study. Joint acoustic emissions were bilaterally recorded, and corresponding signal features were used to train a machine learning algorithm (XGBoost) to classify JIA and healthy knees. All active JIA knees and 80% of the controls were used as training data set, while the remaining knees were used as testing data set. Leave-one-leg-out cross-validation was used for validation on the training data set. Validation on the training and testing set of the classifier resulted in an accuracy of 81.1% and 87.7% respectively. Sensitivity / specificity for the training and testing validation was 88.6% / 72.3% and 88.1% / 83.3%, respectively. The area under the curve of the receiver operating characteristic curve was 0.81 for the developed classifier. The distributions of the joint scores of the active and inactive knees were significantly different.

CONCLUSION

Joint acoustic emissions can serve as an inexpensive and easy-to-use digital biomarker to distinguish JIA from healthy controls. Utilizing serial joint acoustic emission recordings can potentially help monitor disease activity in JIA affected joints to enable timely changes in therapy.

Craniofacial structures, occlusal features, and TMD symptoms in juvenile idiopathic arthritis patients: a retrospective study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease in which temporomandibular joint (TMJ) arthritis commonly occurs. It may be asymptomatic and could cause problems in the growing joints. Our aim was to evaluate the craniofacial structures, occlusal features and temporomandibular dysfunction (TMD) symptoms of patients with JIA.

METHODS

The study consisted of 195 JIA patients treated at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital (HUH), Finland between 2015 and 2019. We retrospectively screened their medical and dental records and classified them according to age at JIA diagnosis (<7 and ≥7 years).

RESULTS

Most of the patients had Angle Class I occlusion in both sides. Among all the patients, the mean overjet, and overbite were 3.3 mm and 2.4 mm, respectively. There were more open bite patients in the ≥7 years old group than in the <7 years old group (P = 0.010). Of all patients, 47% reported at least one TMD symptom. The TMD symptoms were more common in participants ≥7 years old than those <7 years old (P = 0.005).

CONCLUSION

Occlusal features and the incidence of malocclusions seem to have similar tendency among the JIA patients with systematic visits in rheumatologist and orthodontist as in the healthy population, except for open bite that is more common with JIA patients. While treating JIA patients, a well-functioning collaboration between paediatric rheumatologists and orthodontists is essential, as well as a clear screening protocol to detect potentially asymptomatic TMJ arthritis. Particular attention should be paid to children with JIA under school age.

Air pollution exposure and auto-inflammatory and autoimmune diseases of the musculoskeletal system: a review of epidemiologic and mechanistic evidence

Auto-inflammatory and autoimmune diseases of the musculoskeletal system can be perceived as a spectrum of rheumatic diseases, with the joints and connective tissues are eroded severely that progressively develop chronic inflammation and lesion. A wide range of risk factors represented by genetic and environmental factors have been uncovered by population-based surveys and experimental studies. Lately, the exposure to air pollution has been found to be potentially involved in the mechanisms of occurrence or development of such diseases, principally manifest in oxidative stress, local and systemic inflammation, and epigenetic modifications, as well as the mitochondrial dysfunction, which has been reported to participate in the intermediate links. The lungs might serve as a starting area of air pollutants, which would cause oxidative stress-induced bronchial-associated lymphoid tissue (iBALT) to further to influence T, B cells, and the secretion of pro-inflammatory cytokines. The binding of aromatic hydrocarbon receptor (AhR) to the corresponding contaminant ligands tends to regulate the reaction of Th17 and Tregs. Furthermore, air pollution components might spur on immune and inflammatory responses by damaging mitochondria that could interact with and exacerbate oxidative stress and pro-inflammatory cytokines. In this review, we focused on the association between air pollution and typical auto-inflammatory and autoimmune diseases of the musculoskeletal system, mainly including osteoarthritis (OA), rheumatoid arthritis (RA), spondyloarthritis (SpA) and juvenile idiopathic arthritis (JIA), and aim to collate the mechanisms involved and the potential channels. A complete summary and in-depth understanding of the autoimmune and inflammatory effects of air pollution exposure should hopefully contribute new perspectives on how to formulate better public health policies to alleviate the adverse health effects of air pollutants.

A Diagnostic Prediction Model for Separating Juvenile Idiopathic Arthritis and Chronic Musculoskeletal Pain Syndrome

OBJECTIVE

To develop and validate a diagnostic prediction model that can distinguish between juvenile idiopathic arthritis (JIA) and chronic musculoskeletal pain syndrome (CMPS) based on patient-reported outcomes.

STUDY DESIGN

This retrospective cohort study evaluated whether the Juvenile Arthritis Multidimensional Assessment Report (JAMAR) performs well in distinguishing JIA from CMPS. We analyzed JAMARs completed by 287 patients at their first visit to the pediatric rheumatology department of Wilhelmina Children's Hospital in Utrecht, The Netherlands. Relevant JAMAR items for predicting a diagnosis of JIA were selected in a penalized multivariable model suitable for clinical application. The model was subsequently validated with new data from the same center.

RESULTS

A total of 196 JAMARs (97 JIA, 99 CMPS) were collected in the model development data, and 91 JAMARs (48 JIA, 43 CMPS) were collected in the validation data. Variables in the prediction model that were strongest associated with a diagnosis of JIA instead of CMPS were asymmetric pain/swelling in the shoulder (OR, 2.34), difficulty with self-care (OR, 2.41), skin rash (OR, 2.07), and asymmetric/pain swelling in the knee (OR, 2.29). Calibration and discrimination (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.74-0.92) of the model in the validation data were good.

CONCLUSIONS

Several items from the JAMAR questionnaire can potentially distinguish JIA from CMPS in patients with corresponding symptoms. We present an easy-to-use, adjusted, and validated model to separate these 2 diagnoses early at presentation based on patient-reported outcomes to facilitate proper referral and treatment.

Increased Immunity against the Oral Germs Porphyromonas gingivalis and Prevotella intermedia in Different Categories of Juvenile Idiopathic Arthritis

(1) Background: The link between periodontal disease and rheumatoid arthritis (RA) is now widely reported. Several studies suggest the role of Porphyromonas gingivalis (P. gingivalis) in the pathophysiology of RA and some observations highlight the improvement of the disease activity induced by therapies against P. gingivalis. We have very little data on the prevalence of P. gingivalis carriage in patients with juvenile idiopathic arthritis (JIA) and its possible involvement in the pathophysiology of inflammatory joint diseases in children. (2) Methods: The specific IgG responses against P. gingivalis and Prevotella intermedia (P. intermedia) were determined in a cohort of 101 patients with JIA and 19 patients with other autoimmune diseases (inflammatory bowel disease and type 1 diabetes). (3) Results: Specific anti-P. gingivalis and anti-P. intermedia IgG titers were higher in JIA group than in control groups. These differences were mainly observed in the oligoarthritis group. The same pattern was observed in enthesitis-related arthritis (ERA). (4) Conclusions: Children with oligoarticular and ERA subsets had higher IgG titers to P. gingivalis and P. intermedia. These results suggest involvement of an oral dysbiosis in the occurrence of JIA in these subgroups.

Increased Relapse Rate During COVID-19 Lockdown in an Italian Cohort of Children With Juvenile Idiopathic Arthritis

OBJECTIVE

Changes of routine disease management associated with COVID-19 lockdown might have potentially affected the clinical course of juvenile idiopathic arthritis (JIA). The aim of our study was to assess the rate of disease flare before and during COVID-19 lockdown to investigate its impact on disease course in children with JIA.

METHODS

A single-center retrospective study was conducted, including patients presenting with inactive JIA between September 1, 2018 and March 9, 2019 (group A) and between September 1, 2019 and March 9, 2020 (group B). For each patient, demographic and clinical data were collected. The rate of JIA flare from March 10, 2019 to June 30, 2019 for group A and from March 10, 2020 to June 30, 2020 for group B was compared.

RESULTS

Group A included 126 patients, and group B 124 patients. Statistical analysis did not show significant differences among the 2 cohorts with respect to age, sex, age at JIA onset, JIA subtype, co-occurrence of uveitis, antinuclear antibody positivity, and past or ongoing medications. The rate of disease flare during lockdown at the time of the first COVID-19 pandemic wave was significantly higher in comparison to the previous year (16.9% versus 6.3%; P = 0.009).

CONCLUSION

Our study showed that COVID-19 lockdown was associated with a higher rate of joint inflammation in children with JIA. This finding has a considerable clinical implication, as restrictive measures may be necessary in order to contain pandemics. Our data highlight the need for rearrangement in the home and health care management of children with JIA during lockdowns.

Capturing critical data elements in Juvenile Idiopathic Arthritis: initiatives to improve data capture

BACKGROUND

Documentation of critical data elements is a focus of the Pediatric Rheumatology Care and Outcomes Improvement Network to aid in clinical care and research for patients with juvenile idiopathic arthritis. We aimed to increase data capture for critical data elements and hypothesized that quality improvement methodology would improve data capture. We also hypothesized that data capture for all critical data elements would be lower for virtual visits compared to in-person visits.

METHODS

All visits for patients with JIA between 9/14/2020 and 12/31/2021 at the University of Minnesota were included. We assessed completeness of critical data element capture. Sixteen interventions with providers were conducted, including email reminders, individual discussions, group meetings, and feedback reports. We used statistical process control charts to evaluate change over time.

RESULTS

Baseline included 355 patient-visits: 221 (62%) in-person and 134 (38%) virtual with critical data elements entry ranging between 50 and 60%. Post-intervention included 1,596 patient-visits: 1,350 (85%) in-person and 246 (15%) virtual, with critical data elements entry reaching 91%. All providers improved data entry during this study. In-person visits had significantly higher data capture rates than virtual visits for all 4 critical data elements.

CONCLUSION

We achieved our aim to increase critical data element documentation by focusing on provider buy-in, frequent reminders, and individualized feedback. We also found that collection of critical data elements occurred significantly less often with virtual visits than with in-person visits. Now that we improved capture of critical data elements, we can shift the focus to efforts aimed at improving outcomes for patients with juvenile arthritis.

Foot and Ankle Conventional Radiography in Juvenile Idiopathic Arthritis: Does It Still Matter?

Objectives:

The aim of this study was to evaluate the residual value of Conventional Radiography in children with arthralgia clinically suspected of Juvenile Idiopathic Arthritis (JIA).

Materials and Methods:

Three hundred seventy-two patients aged 1–18 years suspected of JIA were retrospectively reviewed. All patients had foot and ankle plain films performed in standard two projections: ankle in antero-posterior and lateral, and foot in antero-posterior and oblique. The cohort was divided into two groups: patients with confirmed JIA and non-JIA control group of children with foot and ankle arthralgia without diagnosis of inflammatory connective tissue disease. Radiographic findings in both groups were compared.

Results:

In 40% of JIA and 70% of non-JIA patients radiographs were normal. All radiographic findings were significantly more common in JIA than in non-JIA group (p = 0.000). Soft tissue swelling was the most frequent abnormality found in JIA patients (31, 51%) and only in 2.41% of non-JIA patients (p = 0.000). Osteoporosis and joint space narrowing were also significantly more common in JIA group (p = 0.000). The majority of imaging findings in non-JIA group were non-inflammatory abnormalities.

Conclusion:

Conventional radiography is an important tool in differential diagnosis of arthralgia of unknown etiology, as soft tissue swelling, osteoporosis and joint space narrowing are significantly more common in JIA patients as compared with patients without the diagnosis of inflammatory connective tissue disease. However, in case of high clinical suspicion of JIA and normal radiography, we recommend subsequent ultrasound (US) and/or MRI to allow early treatment.

Plasma Glycosaminoglycans in Children with Juvenile Idiopathic Arthritis Being Treated with Etanercept as Potential Biomarkers of Joint Dysfunction

We assessed the effect of two-year etanercept (ETA) therapy on the metabolism of the cartilage extracellular matrix (ECM) in patients with juvenile idiopathic arthritis (JIA). Methods: We performed a quantitative evaluation of glycosaminoglycans (GAGs) (performed by the multistage extraction and purification method) in blood obtained from patients before and during 24 months of ETA treatment, as potential biomarker of joint dysfunction and indicators of biological effectiveness of therapy. Since the metabolism of GAGs is related to the activity of proteolytic enzymes and prooxidant–antioxidant factors, we decided to evaluate the relationship between GAGs and the levels of metalloproteinases (MMP), i.e., MMP-1 and MMP-3 (using immunoenzymatic methods), as well as the total antioxidative status (TAS) (using the colorimetric method) in blood of the JIA patients. Results: When compared to the controls, GAGs and TAS concentrations were significantly lower in patients with an aggressive course of JIA qualified for ETA treatment. MMP-1 and MMP-3 levels were significantly higher versus control values. An anti-cytokine therapy leading to clinical improvement does not lead to the normalization of any of the assessed parameters. GAGs concentration is significantly related to MMP-1, MMP-3, TAS, TOS, and CRP levels. Conclusion: The results of the present study indicate the necessity of constant monitoring of the dynamics of destructive processes of articular cartilage in children with JIA. We suggest that GAGs may be a useful biomarker to assess the clinical status of the extracellular matrix of joints.

Efficacy and Safety of Curcumin and Curcuma longa Extract in the Treatment of Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

Background

Modern pharmacological research found that the chemical components of Curcuma longa L. are mainly curcumin and turmeric volatile oil. Several recent randomized controlled trials (RCT) have shown that curcumin improves symptoms and inflammation in patients with arthritis.

Methods

Pubmed, Cochran Library, CNKI, and other databases were searched to collect the randomized controlled trials (RCTs). Then, the risk of bias of RCTs were assessed and data of RCTs were extracted. Finally, RevMan 5.3 was utilized for meta-analysis.

Results

Twenty-nine (29) RCTs involving 2396 participants and 5 types of arthritis were included. The arthritis included Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Osteoarthritis (OA), Juvenile idiopathic arthritis (JIA) and gout/hyperuricemia. Curcumin and Curcuma longa Extract were administered in doses ranging from 120 mg to 1500 mg for a duration of 4-36 weeks. In general, Curcumin and Curcuma longa Extract showed safety in all studies and improved the severity of inflammation and pain levels in these arthritis patients. However, more RCTs are needed in the future to elucidate the effect of Curcumin and Curcuma longa Extract supplementation in patients with arthritis, including RA, OA, AS and JIA.

Conclusion

Curcumin and Curcuma longa Extract may improve symptoms and inflammation levels in people with arthritis. However, due to the low quality and small quantity of RCTs, the conclusions need to be interpreted carefully.

A Study Protocol for the Management of Children With Juvenile Idiopathic Arthritis Based on ePROs

Background

Juvenile idiopathic arthritis (JIA) is a common chronic rheumatic disease with no known cures, affecting children with the age of onset under 16 years. Patient-reported outcome (PRO) measures are an important basis for evaluating the impact of JIA and associated therapies, however, which is particular challenge in the pediatric setting. At present, no randomized controlled studies have investigated the effect and usability of ePROs symptom management for children with JIA.

Methods

This longitudinal, randomized, controlled trial will be carried out at outpatient and pediatric wards of the Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University School of Medicine. A total of one hundred children with JIA diagnosed according to the International League of Associations for Rheumatology (ILAR) patients are randomized to receive individualized symptom management based on ePROs or routine management. The primary outcome is the mean C-Ped-PROMIS T-scores of patients in the ePROs-based group and the control group. The secondary outcomes are the trajectories of C-Ped-PROMIS T-scores and HRQOL scores, and changing relationship between them. Data were collected at 5 time points: at enrollment ("baseline") and at the time of follow-up visits scheduled at 1, 3, 6, and 12 months.

Discussion

The findings are expected to conclude that the symptom management based on ePROs for children with JIA can improve the symptom of JIA, and it is a feasible and effective way to monitor and intervene children with JIA.

Clinical Trial

http://www.chictr.org.cn/showproj.aspx?proj=132769; (ChiCTR2100050503).

Electromyographic Activity of Masticatory Muscles in Subjects with Juvenile Idiopathic Arthritis: A Case—Control Study

The aim of this study was to evaluate the effect of juvenile idiopathic arthritis (JIA) on the activity of masticatory muscles using surface electromyography (sEMG). Forty-one JIA subjects (ten males, thirty-one females; average age 13 years ± 3) and thirty-two healthy control subjects (twenty-seven females, five males; average age 14 years ± 2) were recruited. sEMG of anterior temporalis (TA), masseter (MM), and sternocleidomastoid (SCM) muscles was performed by using the occlusal contact analyzer software called Teethan (BTS S.p.A., Garbagnate Milanese, Milan, Italy). Comparisons between groups were assessed with unpaired t-tests for non-normally distributed data and with Mann–Whitney U tests for normally distributed parameters. The JIA group showed a significant increased percentage overlapping coefficient of TA (POC TA) (p = 0.01) and impact index (IMP) (p = 0.003). No significant differences were observed for the POC MM, POC SCM, percentage overlapping coefficient between posterior and anterior teeth contact (BAR), the torsion index (TORS), and the asymmetry index (ASIM). Masticatory muscles seemed to be slightly affected by JIA. sEMG could be an effective aid in the early clinical detection of TMJ involvement in JIA. Further research is needed to confirm its validity.

A 3D CBCT Analysis of Airway and Cephalometric Values in Patients Diagnosed with Juvenile Idiopathic Arthritis Compared to a Control Group

Introduction: The temporomandibular joint (TMJ) is affected in 30–45% of juvenile idiopathic arthritis (JIA) patients, with all JIA subtypes at risk for TMJ involvement. JIA patients with TMJ involvement may present with altered craniofacial morphology, including micrognathia, mandibular retrognathia, a hyperdivergent mandibular plane angle, and skeletal anterior open bite. These features are also commonly present and associated with non-JIA pediatric patients with obstructive sleep apnea (OSA). Materials and Methods: The study was comprised of a group of 32 JIA patients and a group of 32 healthy control subjects. CBCT images were taken for all patients and were imported into Dolphin Imaging software. The Dolphin Imaging was used to measure the upper airway volumes and the most constricted cross-sectional areas of each patient. Cephalometric images were rendered from the CBCT data for each patient, and the following cephalometric values were identified: SNA angle, SNB angle, ANB angle, anterior facial height (AFH), posterior facial height (PFH), mandibular plane angle (SN-MP), FMA (FH-MP), overjet (OJ), and overbite (OB). Airway volumes, the most constricted cross-sectional area values, and cephalometric values were compared between the JIA and control groups. Results: For airway values, statistically significant differences were seen in the nasopharynx airway volume (p = 0.004), total upper airway volume (p = 0.013), and the most constricted cross-sectional area (p = 0.026). The oropharynx airway volume was not statistically significant (p = 0.051). For cephalometric values, only the posterior facial height showed a statistically significant difference (p = 0.024). Conclusions: There was a significant difference in airway dimensions in the JIA patients as compared to the control patients. In addition, the posterior facial dimensions seem to be affected in JIA patients. The ODDs ratio analysis further corroborated the findings that were significant.

Capillary microscopy is a potential screening method for connective tissue disease in children with Raynaud's phenomenon

BACKGROUND

Nailfold capillary microscopy (NCM) is a cornerstone in the diagnosis of Systemic Sclerosis (SSc) in adulthood. Although Raynaud's phenomenon (RP) is very common in childhood, studies on diagnostic methods to differentiate between primary RP (PRP) and secondary RP (SRP) at a young age are scarce. The aim of this study was to determine the value of NCM in differentiating between PRP and SRP in children and adolescents with RP.

METHODS

In this nested case-control study, 83 patients diagnosed with RP and having underwent NCM in childhood were retrospectively included. Based on whether they were diagnosed with a connective tissue disease (CTD) during follow-up, patients were classified as PRP or SRP. NCM was performed by a vascular technician. PRP and SRP patients were compared on demographics, NCM and serology. Variables associated with SRP were included in a multivariate logistic regression model. Predictive values were calculated for NCM, ANA positivity and the combination of NCM and ANA positivity.

RESULTS

At the time of the NCM, the mean age of the RP patients was 15.4 ± 2.3 years. Of these patients, 78.3% were classified as PRP and 21.7% as SRP at mean follow-up of 6.4 ± 3.20 years. CTDs were miscellaneous, with only one patient having developed SSc. Of the NCM parameters, only capillary loss was associated with SRP (p = 0.01). In a multivariate logistic regression model including ANA, capillary loss was not a predictor of SRP. In a model without ANAs, capillary loss was an independent predictor (OR = 3.98, CI 95% 1.22-12.99). Capillary loss had a sensitivity of 44.4% and a specificity of 84.4% for SRP. ANA combined with capillary loss had a sensitivity of 66.7% and a specificity of 85.7%.

CONCLUSION

Whereas RP in adulthood is most strongly associated with SSc, children with RP seem to be at risk for developing other CTDs with less apparent NCM abnormalities. Of all NCM findings, only capillary loss was predictive for SRP. NCM did not add to the predictive value of ANA screening. However, with a specificity of 84.4% and being non-invasive, NCM shows potential as a screening method for SRP. More research with a larger study population is required before drawing conclusions.

Shoulder arthroplasty in patients with juvenile idiopathic arthritis: long-term outcomes

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease that occurs in the pediatric population. Often, JIA continues throughout life, leading to progressive polyarticular arthritis and significant joint destruction and disability, oftentimes requiring replacement surgery. This study aimed to determine the outcomes of primary shoulder arthroplasty (SA) in patients with JIA.

METHODS

Over a 42-year time period (1977-2019), 67 primary SA (20 hemiarthroplasty [HA], 38 anatomic total shoulder arthroplasty [TSA], and 9 reverse shoulder arthroplasty [RSA]) with a prior diagnosis of JIA formally established in a multidisciplinary rheumatologic clinic met inclusion criteria. Further assessment was performed with inclusion of the visual analog scale pain score, active shoulder range of motion (ROM), imaging studies, complications, and implant survivorship free from reoperation and revision.

RESULTS

SA led to substantial improvements in pain and ROM across the entire cohort at an average follow-up period of 12.2 years (range, 2-34 years). TSA was associated with the lowest pain scores (0.8; P = .02) and the highest American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores (77.4; P = .04) at the most recent follow-up when compared to HA and RSA. There were 14 (21%) complications across the cohort with rotator cuff failure (n = 4; 5.9%) as the most common complication followed by infection (n = 3; 4.5%). Revision surgery was performed in 5 shoulders (7.5%), with 5-year implant survival rates of 95.1% at 5 years, 93% at 10 years, 89.4% at 20 years, and 79.5% at 30 years. At 30 years, TSA was associated with better survival (90.1%) than HA (71.8%).

CONCLUSIONS

Primary shoulder arthroplasty in the form of HA, TSA, and RSA offers a reliable surgical option for JIA patients with respect to pain reduction and ROM improvements. Unique challenges still exist in this cohort, in particular younger patients with an elevated propensity for glenoid bone erosion and a complication rate of 20.9%. As such, HA may not be ideal in this patient population. However, despite rotator cuff and glenoid concerns, TSA seems to be associated with better pain relief and patient-reported outcomes with the most durability in the long term when compared to HA.

Does Juvenile Idiopathic Arthritis Affect the Course of Legg-Calvé-Perthes Disease? A Case-Control Study with a Mean Follow-Up of 8 Years

BACKGROUND

This study aimed to determine the clinical and radiological course in children who had Legg-Calvé-Perthes disease (LCPD) associated with juvenile idiopathic arthritis (JIA).

METHODS

In a retrospective chart review between 2007 and 2019, eight consecutive JIA patients diagnosed with concomitant LCPD were identified and compared with a case-control group of 10 children with LCPD only.

RESULTS

LCPD was diagnosed at a mean age of 8.1 years (3.0-14.7) in children with JIA as compared to 6.1 years (2.9-10.0) in controls. According to the modified Harris Hip Score (mHHS), four children with JIA and all controls had an excellent result. Regarding the fragmentation severity and the duration of each stage, we found no differences using the lateral pillar and modified Elizabethtown classification. Five hips were classified as Stulberg I/II, two hips as Stulberg III, and one hip as Stulberg V with no evidence of hip dysplasia or severe overcoverage in either group.

CONCLUSIONS

The radiological outcome of LCPD did not differ between both groups, while the clinical outcome was slightly better in controls. Physicians should be aware that children with LCPD may have JIA too. In suspicious cases, further investigations are recommended, and patients should be referred to pediatric rheumatologists.

Clinical and Instrumental TMJ Evaluation in Children and Adolescents with Juvenile Idiopathic Arthritis: A Case—Control Study

To investigate temporomandibular joint (TMJ) involvement signs such as muscle pain, the ratio of masseter and temporal muscle activity, mouth opening width and jaw deviation during mouth opening in children and adolescents with juvenile idiopathic arthritis (JIA), a group of 32 subjects with JIA and a control group of 32 healthy subjects were evaluated. Data were collected clinically by muscle palpation (masseters, anterior temporalis and sternocleidomastoids) and instrumental analysis (electromyography and kinesiography). Higher pain was registered in the masseter and sternocleidomastoid muscles on both sides and in the right anterior temporalis in the JIA group compared to the control group (p < 0.05). Electromyography showed no statistically significant difference in the frequency of the pathological ratio of masseter and temporal muscle activity (MM/TA < 1) both in the JIA group and in the control group. Kinesiography showed a statistically significant difference in mouth opening width and jaw deviation during mouth opening between the groups (p < 0.05): JIA subjects showed lower mouth opening values and wider deviation on mouth opening; 29 out of 32 JIA subjects showed jaw deviation towards the right side. JIA affects the TMJ, causing myalgia in the head and neck muscles, a reduction in mouth opening width and an increase in jaw deviation during mouth opening.

Acute monoarthritis in young children: comparing the characteristics of patients with juvenile idiopathic arthritis versus septic and undifferentiated arthritis

Acute arthritis is a common cause of consultation in pediatric emergency wards. Arthritis can be caused by juvenile idiopathic arthritis (JIA), septic (SA) or remain undetermined (UA). In young children, SA is mainly caused by Kingella kingae (KK), a hard to grow bacteria leading generally to a mild clinical and biological form of SA. An early accurate diagnosis between KK-SA and early-onset JIA is essential to provide appropriate treatment and follow-up. The aim of this work was to compare clinical and biological characteristics, length of hospital stays, duration of intravenous (IV) antibiotics exposure and use of invasive surgical management of patients under 6 years of age hospitalized for acute monoarthritis with a final diagnosis of JIA, SA or UA. We retrospectively analyzed data from < 6-year-old children, hospitalized at a French tertiary center for acute mono-arthritis, who underwent a joint aspiration. Non-parametric tests were performed to compare children with JIA, SA or UA. Bonferroni correction for multiple comparisons was applied with threshold for significance at 0.025. Among the 196 included patients, 110 (56.1%) had SA, 20 (10.2%) had JIA and 66 (33.7%) had UA. Patients with JIA were older when compared to SA (2.7 years [1.8–3.6] versus 1.4 [1.1–2.1], p < 0.001). Presence of fever was not different between JIA and SA or UA. White blood cells in serum were lower in JIA (11.2 × 10⁹/L [10–13.6]) when compared to SA (13.2 × 10⁹/L [11–16.6]), p = 0.01. In synovial fluid leucocytes were higher in SA 105.5 × 10³ cells/mm³ [46–211] compared to JIA and UA (42 × 10³ cells/mm³ [6.4–59.2] and 7.29 × 10³ cells/mm³ [2.1–72] respectively), p < 0.001. Intravenous antibiotics were administered to 95% of children with JIA, 100% of patients with SA, and 95.4% of UA. Arthrotomy-lavage was performed in 66.7% of patients with JIA, 79.6% of patients with SA, and 71.1% of patients with UA. In children less than 6 years of age with acute mono-arthritis, the clinical and biological parameters currently used do not reliably differentiate between JIA, AS and UA. JIA subgroups that present a diagnostic problem at the onset of monoarthritis before the age of 6 years, are oligoarticular JIA and systemic JIA with hip arthritis. The development of new biomarkers will be required to distinguish JIA and AS caused by Kingellakingae in these patients.

Health-related quality of life in children with early-stage juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease resulting in physical and psychological disability. This study aimed to measure the health-related quality of life (HRQOL) and identify factors influencing the HRQOL.

METHODS

We conducted a cross-sectional study in Thai children with JIA and their parents between January and December 2015, using the Thai version of the Pediatrics Quality of Life (PedsQL) 4.0 generic core scale.

RESULTS

Sixty-five children (33 girls and 32 boys) were included. The median age of the children was 9.6 (interquartile range [IQR] 6.4-12.3) years and the median disease duration was 1.1 (IQR 0.2-2.2) years. The physical health subscale had the lowest score, with a median (range) of 78.1 (34.4-100). Twenty-five (45.4%) children were classified as having suboptimal HRQOL. The school functioning subscale had the lowest score, at 60 (25-100) reported by parents. High disease activity and a disease duration <1 year were significantly associated with suboptimal HRQOL reported by parents, with adjusted odds ratios (ORs) of 20.2 (95% confidence interval [CI] 1.4, 291.7) and 5.9 (95% CI 1.2, 33.3), respectively.

CONCLUSIONS

Almost half of Thai children with JIA had suboptimal HRQOL. The physical health score was the lowest subscale reported by the children. Early, effective management of disease activity could improve the HRQOL in children with JIA.

Pediatrician Beliefs about Juvenile Idiopathic Arthritis May Result in Referral Delays: A Spanish National Survey

We explored, through a national survey, pediatrician beliefs and misconceptions that could interfere with early referral of patients with juvenile idiopathic arthritis. A total of 831 pediatricians participated. Approximately one-half of the respondents underestimated the incidence of the disease and thought that pain was the leading symptom of oligoarticular forms.

Targeting Tregs in Juvenile Idiopathic Arthritis and Juvenile Dermatomyositis-Insights From Other Diseases

Regulatory T cells (Tregs) are believed to be dysfunctional in autoimmunity. Juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM) result from a loss of normal immune regulation in specific tissues such as joints or muscle and skin, respectively. Here, we discuss recent findings in regard to Treg biology in oligo-/polyarticular JIA and JDM, as well as what we can learn about Treg-related disease mechanism, treatment and biomarkers in JIA/JDM from studies of other diseases. We explore the potential use of Treg immunoregulatory markers and gene signatures as biomarkers for disease course and/or treatment success. Further, we discuss how Tregs are affected by several treatment strategies already employed in the therapy of JIA and JDM and by alternative immunotherapies such as anti-cytokine or co-receptor targeting. Finally, we review recent successes in using Tregs as a treatment target with low-dose IL-2 or cellular immunotherapy. Thus, this mini review will highlight our current understanding and identify open questions in regard to Treg biology, and how recent findings may advance biomarkers and new therapies for JIA and JDM.