Early juvenile idiopathic arthritis. Rheum Dis Clin North Am. 2012;38:355-372. [PMID: 22819089 DOI: 10.1016/j.rdc.2012.04.006]

Examining the Relationship between Systemic Immune-Inflammation Index and Disease Severity in Juvenile Idiopathic Arthritis

Juvenile Idiopathic Arthritis (JIA), the leading childhood rheumatic condition, has a chronic course in which persistent disease activity leads to long-term consequences. In the era of biologic therapy and tailored treatment, precise disease activity assessment and aggressive intervention for high disease activity are crucial for improved outcomes. As inflammation is a fundamental aspect of JIA, evaluating it reflects disease severity. Recently, there has been growing interest in investigating cellular immune inflammation indices such as the neutrophil-to-lymphocyte ratio (NLR) and systemic immune inflammation index (SII) as measures of disease severity. The aim of this retrospective study was to explore the potential of the SII in reflecting both inflammation and disease severity in children with JIA. The study comprised 74 JIA patients and 50 healthy controls. The results reveal a notable increase in median SII values corresponding to disease severity, exhibiting strong correlations with traditional inflammatory markers, including CRP and ESR (ρ = 0.714, ρ = 0.661), as well as the JADAS10 score (ρ = 0.690). Multiple regression analysis revealed the SII to be independently associated with JADAS10. Furthermore, the SII accurately distinguished patients with high disease activity from other severity groups (AUC = 0.827, sensitivity 81.5%, specificity 66%). These findings suggest that integrating the SII as an additional measure holds potential for assessing disease activity in JIA.

Arthritis Among Children and Adolescents Aged <18 Years - United States, 2017-2021

Arthritis affects persons of all ages, including younger adults, adolescents, and children; however, recent arthritis prevalence estimates among children and adolescents aged <18 years are not available. Previous prevalence estimates among U.S. children and adolescents aged <18 years ranged from 21 to 403 per 100,000 population depending upon the case definition used. CDC analyzed aggregated 2017-2021 National Survey of Children's Health data to estimate the national prevalence of parent-reported arthritis diagnosed among children and adolescents aged <18 years. An estimated 220,000 (95% CI = 187,000-260,000) U.S. children and adolescents aged <18 years (305 per 100,000) had diagnosed arthritis. Arthritis prevalence among non-Hispanic Black or African American children and adolescents was twice that of non-Hispanic White children and adolescents. Co-occurring conditions, including depression, anxiety, overweight, physical inactivity, and food insecurity were associated with higher prevalences of arthritis. These findings highlight that children and adolescents should be prioritized for arthritis prevention and treatments by identifying risk factors for arthritis, developing self-management interventions to improve arthritis, physical activity or weight control, and screening and linking to mental health services. Health systems and payors can take steps to ensure equitable access to therapies (e.g., physical therapies and medications).

The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register

BACKGROUND

The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma).

METHODS

Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed.

RESULTS

A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used.

CONCLUSIONS

We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

Features distinguishing juvenile idiopathic arthritis among children with musculoskeletal complaints

BACKGROUND

Musculoskeletal (MSK) complaints in children vary, ranging from benign, self-limited conditions to serious disorders. Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease, initially presenting with MSK complaints. Delayed diagnosis and appropriate treatment have an enormous impact on the long-term outcomes and the level of disability. This study aimed to identify the features distinguishing JIA among children presenting with MSK complaints and to describe the spectrum of diseases at a large, single, tertiary center.

METHODS

A retrospective chart review was performed of patients evaluated by pediatric rheumatology consultation at the Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, from July 2011 to June 2015.

RESULTS

Of 531 patients, 285 (53.6%) had at least one MSK complaint. The mean age of the patients was 9.1 ± 4.1 years. Joint pain was the most common MSK complaint (86.3%), followed by limping (33%) and refusal to walk (19.6%). Joint swelling and limited range of motion were found in 146 (51.2%) and 115 (40.4%) patients, respectively. Seventy-three (25.6%) patients were diagnosed as JIA. The other common diagnoses included Henoch-Schönlein purpura (16.1%), reactive arthritis (14.2%), and systemic lupus erythematosus (13.7%). Morning stiffness  ≥ 15 minutes [odds ratio (OR) 8.217 (3.404-19.833)]; joint swelling on MSK examination [OR 3.505 (1.754-7.004)]; a duration of MSK complaints of more than 6 weeks [OR 2.071 (1.120-3.829)]; and limping [OR 1.973 (1.048-3.712)] were significantly associated with the ultimate diagnosis of JIA.

CONCLUSIONS

Morning stiffness ≥ 15 minutes is a strong predictor of JIA. Comprehensive history taking and an MSK examination will provide clues for making the ultimate diagnosis for children with MSK complaints.

Defining new clinically derived criteria for high disease activity in non-systemic juvenile idiopathic arthritis: a Finnish multicentre study

Objectives

To redefine criteria for high disease activity (HDA) in JIA, to establish HDA cut-off values for the 10-joint Juvenile Arthritis Disease Activity Score (JADAS10) and clinical JADAS10 (cJADAS10) and to describe the distribution of patients’ disease activity levels based on the JADAS cut-off values in the literature.

Methods

Data on 305 treatment-naïve JIA patients were collected from nine paediatric units treating JIA. The median parameters of the JADAS were proposed to be the clinical criteria for HDA. The cut-off values were assessed by using two receiver operating characteristics curve–based methods. The patients were divided into disease activity levels based on currently used JADAS cut-off values.

Results

We proposed new criteria for HDA. At least three of the following criteria must be satisfied in both disease courses: in oligoarthritis, two or more active joints, ESR above normal, physician global assessment (PGA) of disease activity ≥2 and parent/patient global assessment (PtGA) of well-being ≥2; in polyarthritis, six or more active joints, ESR above normal, PGA of overall disease activity ≥4 and PtGA of well-being ≥2. The HDA cut-off values for JADAS10 (cJADAS) were ≥6.7 (6.7) for oligoarticular and ≥15.3 (14.1) for polyarticular disease. The distribution of the disease activity levels based on the JADAS cut-off values in the literature varied markedly based on which cut-offs were used.

Conclusion

New clinically derived criteria for HDA in JIA and both JADAS and cJADAS cut-off values for HDA were proposed.

Validating 10-joint juvenile arthritis disease activity score cut-offs for disease activity levels in non-systemic juvenile idiopathic arthritis

Objectives

To validate cut-offs of the Juvenile Arthritis Disease Activity Score 10 (JADAS10) and clinical JADAS10 (cJADAS10) and to compare them with other patient cohorts.

Methods

In a national multicentre study, cross-sectional data on recent visits of 337 non-systemic patients with juvenile idiopathic arthritis (JIA) were collected from nine paediatric outpatient units. The cut-offs were tested with receiver operating characteristic curve-based methods, and too high, too low and correct classification rates (CCRs) were calculated.

Results

Our earlier presented JADAS10 cut-offs seemed feasible based on the CCRs, but the cut-off values between low disease activity (LDA) and moderate disease activity (MDA) were adjusted. When JADAS10 cut-offs for clinically inactive disease (CID) were increased to 1.5 for patients with oligoarticular disease and 2.7 for patients with polyarticular disease, as recently suggested in a large multinational register study, altogether 11 patients classified as CID by the cut-off had one active joint. We suggest JADAS10 cut-off values for oligoarticular/polyarticular disease to be in CID: 0.0-0.5/0.0-0.7, LDA: 0.6-3.8/0.8-5.1 and MDA: >3.8/5.1. Suitable cJADAS10 cut-offs are the same as JADAS10 cut-offs in oligoarticular disease. In polyarticular disease, cJADAS10 cut-offs are 0-0.7 for CID, 0.8-5.0 for LDA and >5.0 for MDA.

Conclusion

International consensus on JADAS cut-off values is needed, and such a cut-off for CID should preferably exclude patients with active joints in the CID group.

Finding specific 10-joint Juvenile Arthritis Disease Activity Score (JADAS10) and clinical JADAS10 cut-off values for disease activity levels in non-systemic juvenile idiopathic arthritis: a Finnish multicentre study

OBJECTIVES

To establish the cut-off values for inactive disease, as well as low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA) in non-systemic JIA based on the Juvenile Arthritis Disease Activity Score (JADAS) and assessed with the 10-joint JADAS (JADAS10) and clinical JADAS10 (cJADAS10).

METHODS

In a multicentre cross-sectional study consisting of ∼20% of all patients with JIA in Finland (n = 509), we obtained data on their most recent registered visits between January 2013 and January 2014. We calculated the JADAS10 and cJADAS10 and established the cut-off values of both of these scores using two different receiver operating characteristics-based statistical methods.

RESULTS

Of the 509 patients studied, 65.8% were females and 53.8% had polyarticular disease. The most suitable method for determining cut-off values was the Youden index. In oligoarticular patients, a JADAS10 score of 0-0.5 represented inactive disease, 0.6-2.7 LDA and ≥2.8 MDA. In polyarticular disease, a JADAS10 score of 0-0.7 represented inactive disease, 0.8-3.9 LDA and ≥4.0 MDA. The cut-off values for HDA were not possible to establish because only two visits fulfilled HDA criteria.

CONCLUSION

We established cut-off values for LDA and MDA. A reliable definition for HDA will require more patients. In the clinical setting, both the cJADAS10 and JADAS10 serve equally well both for research and quality control purposes. In the future, uniform clinical disease activity levels should be established. We also suggest revising and validating the criteria for HDA. Valid and robust cut-off values for disease activity levels can guide both clinicians and researchers and equip them for quality control.

Septic Arthritis of the Hip in the Setting of Hemophagocytic Lymphohistiocytosis: A Case Report

CASE

A twenty-two-month-old boy with septic hip arthritis had persistent elevated inflammatory markers and daily fevers despite multiple antibiotic regimens and repeated surgical debridements yielding negative cultures. After exhaustive work-up for other infectious, rheumatologic, and immunologic etiologies, he met diagnostic criteria for hemophagocytic lymphohistiocytosis (HLH) and developed cultures positive for fungal hip arthritis. Following treatment for HLH and fungal hip arthritis, he improved and was discharged.

CONCLUSION

No previous report in the literature specifically associates HLH with septic hip arthritis, to our knowledge. Surgeons should suspect underlying immunologic deficiencies and atypical infectious causes of septic arthritis when usual treatment modalities have failed.

Juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease in childhood, which represents a nonhomogeneous group of disorders that share the clinical manifestation of arthritis lasting at least 6 wk under the age of 16. The exact diagnosis requires exclusion of other diseases that cause arthritis. The exact etiopathogenesis of JIA is still unknown. The interactions between genetic factors, environmental exposures and immune mechanisms are thought to contribute to pathogenesis of the disease. The “International League Against Rheumatism” classification divides JIA into 7 subtypes: oligoarticular JIA, rheumatoid factor (RF) positive polyarticular JIA, RF negative polyarticular JIA, systemic-onset JIA, enthesitis-related arthritis, juvenile psoriatic arthritis and undifferentiated JIA. Each subgroup of JIA is characterized by a different mode of presentation, disease course and outcome. The improvements in treatment of JIA in the last 2 decades, such as the early introduction of intraarticular corticosteroids, methotrexate and biologic agents, have dramatically upgraded the prognosis of the disease. If untreated, JIA may cause devastating results, such as disability from joint destruction, growth retardation, blindness from chronic iridocyclitis, and even multiple organ failure and death in systemic-onset JIA. The aim of treatment is the induction of remission and control the disease activity to minimize the pain and loss of function, and to maximize quality of life. JIA is a disease having a chronic course, which involves active and inactive cycles over the course of years. Recent studies showed that nearly half of the patients with JIA enter adulthood with their ongoing active disease. This review elucidates how recent advances have impacted diagnosis, pathogenesis and current treatment.