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Cintron D, Chang JC, Sadun RE. Transition to Adult Rheumatology Care: A Disease-Specific Guide. J Clin Rheumatol 2024; 30:159-167. [PMID: 38527973 DOI: 10.1097/rhu.0000000000002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
ABSTRACT Young adults with childhood-onset rheumatic diseases are more frequently establishing and continuing care with adult rheumatologists. The transfer of care can be challenging for both the young adult patients and their adult rheumatologists, in large part due to differences between pediatric-onset rheumatic diseases and their adult-onset counterparts, or due to the rarity of some pediatric-onset rheumatic conditions. Other challenges are due to cultural differences between pediatric and adult medical care and to the young adult needing to increasingly perform self-management skills that were previously managed by parents or other caregivers. In this review, we will provide a summary of strategies for working effectively with young adults as they transition to adult care. We will then discuss a subset of childhood-onset rheumatic diseases-including juvenile idiopathic arthritis, localized scleroderma, autoinflammatory diseases, pediatric-onset systemic lupus erythematosus, juvenile-onset dermatomyositis, and autoimmune encephalitis-for which clinical manifestations, management, and prognosis frequently differ between pediatric onset and adult onset. Our aim is to highlight differences that make caring for this population of transitioning young adults unique, providing tools and knowledge to empower the adult rheumatologist to care for these young adults in ways that are evidence-based, effective, efficient, and rewarding.
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Affiliation(s)
| | - Joyce C Chang
- Boston Children's Hospital and Harvard Medical School, Boston, MA
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Nicoară DM, Munteanu AI, Scutca AC, Brad GF, Jugănaru I, Bugi MA, Asproniu R, Mărginean O. Examining the Relationship between Systemic Immune-Inflammation Index and Disease Severity in Juvenile Idiopathic Arthritis. Cells 2024; 13:442. [PMID: 38474406 DOI: 10.3390/cells13050442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 03/02/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Delia-Maria Nicoară
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Andrei-Ioan Munteanu
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Alexandra-Cristina Scutca
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
| | - Giorgiana-Flavia Brad
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
| | - Iulius Jugănaru
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Meda-Ada Bugi
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Ph.D. School Department, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Raluca Asproniu
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
| | - Otilia Mărginean
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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Catarino S, Nunes J, Ganhão S, Aguiar F, Rodrigues M, Brito I. Application of the new PRINTO classification criteria for juvenile idiopathic arthritis in a sample of Portuguese patients. ARP RHEUMATOLOGY 2024; 3:11-17. [PMID: 38558063 DOI: 10.63032/jxnd6393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND The International League of Associations for Rheumatology (ILAR) classification system for juvenile idiopathic arthritis (JIA) does not depict homogenous subgroups of disease. As to unify our language with the adult rheumatic diseases, the Pediatric Rheumatology International Trials Organization (PRINTO) is attempting to revise these criteria. OBJECTIVE To reclassify a JIA sample according to the new provisional PRINTO subsets: systemic JIA (sJIA), RF-positive JIA (RF-JIA), early-onset ANA-positive JIA (eoANA-JIA), enthesitis/spondylitis-related JIA (ESR-JIA), "other JIA" and "unclassified JIA". METHODS Retrospective study including JIA patients followed in a Pediatric Rheumatology Unit at a university hospital. Medical records were reviewed, and patients were reclassified as per the provisional PRINTO criteria. RESULTS Of a total of 104 patients, 41 (39.4%) were reclassified as "other JIA", 36 (34.6%) as eoANA-JIA, 15 (14.4%) as ESR-JIA, 8 (7.7%) as sJIA and 4 (3.8%) as RF-JIA. More than 90% of the oligoarticular JIA were reclassified into either eoANA-JIA or "other JIA". Only one negative RF polyarticular JIA converted to RF-JIA due to the presence of a positive anti-citrulinated peptide antibody (ACPA). The psoriatic arthritis (PsA) subgroup disappeared into eoANA-JIA (25%), ESR-JIA (25%) or "other JIA" (50%). There were significant differences in age of onset, but not on the gender ratio or uveitis presence. Antinuclear antibody was more frequent in females (p=0.035) and younger patients (p<0.001). CONCLUSION The number of affected joints and PsA features elapsed in favour of laboratory RF, ACPA and ANA traits. PsA and oligoarticular JIA were abolished. The "other JIA" entity is heterogenous and prevalent, claiming reformulation.
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Affiliation(s)
- Sara Catarino
- Pediatrics Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Joana Nunes
- Pediatrics Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Sara Ganhão
- Pediatric and Young Adult Rheumatology Unit, Pediatrics Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Francisca Aguiar
- Pediatric and Young Adult Rheumatology Unit, Pediatrics Department, Centro Hospitalar Universitário São João, Porto; Faculty of Medicine, University of Porto, Portugal
| | - Mariana Rodrigues
- Pediatric and Young Adult Rheumatology Unit, Pediatrics Department, Centro Hospitalar Universitário São João, Porto; Faculty of Medicine, University of Porto, Portugal
| | - Iva Brito
- Pediatric and Young Adult Rheumatology Unit, Pediatrics Department, Centro Hospitalar Universitário São João, Porto; Faculty of Medicine, University of Porto, Portugal
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Baba O, Kisaoglu H, Kalyoncu M. Letrozole-induced inflammatory arthritis and tendinopathy in pediatric rheumatology setting. Int J Rheum Dis 2023; 26:2314-2316. [PMID: 37218595 DOI: 10.1111/1756-185x.14748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023]
Abstract
Musculoskeletal symptoms associated with the use of aromatase inhibitors are a well-known side effect of these drugs and are more prevalent in postmenopausal women. Aromatase inhibitor-associated symptoms are not overt inflammatory processes so are described as arthralgia syndrome. In contrast, aromatase inhibitor-associated inflammatory conditions such as myopathies, vasculitis, and rheumatoid arthritis were also reported. To our knowledge, inflammatory arthritis or tendinopathy associated with aromatase inhibitors were not reported in children despite their increased off-label use in the pediatric setting. Herein, we report a girl with inflammatory arthritis and tendinopathy associated with letrozole treatment.
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Affiliation(s)
- Ozge Baba
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Rheumatology, Karadeniz Technical University, Trabzon, Turkey
| | - Hakan Kisaoglu
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Rheumatology, Karadeniz Technical University, Trabzon, Turkey
| | - Mukaddes Kalyoncu
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Rheumatology, Karadeniz Technical University, Trabzon, Turkey
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Di Gennaro S, Di Matteo G, Stornaiuolo G, Anselmi F, Lastella T, Orlando F, Alessio M, Naddei R. Advances in the Diagnosis and Treatment of Enthesitis-Related Arthritis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1647. [PMID: 37892310 PMCID: PMC10605472 DOI: 10.3390/children10101647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
Enthesitis-related arthritis (ERA) represents 5-30% of all cases of juvenile idiopathic arthritis (JIA) and belongs to the spectrum of the disorders included in the group of juvenile spondyloarthritis. In the last decade, there have been considerable advances in the classification, diagnosis, monitoring, and treatment of ERA. New provisional criteria for ERA have been recently proposed by the Paediatric Rheumatology INternational Trials Organisation, as part of a wider revision of the International League of Associations for Rheumatology criteria for JIA. The increased use of magnetic resonance imaging has shown that a high proportion of patients with ERA present a subclinical axial disease. Diverse instruments can be used to assess the disease activity of ERA. The therapeutic recommendations for ERA are comparable to those applied to other non-systemic JIA categories, unless axial disease and/or enthesitis are present. In such cases, the early use of a TNF-alpha inhibitor is recommended. Novel treatment agents are promising, including IL-17/IL-23 or JAK/STAT pathways blockers.
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Affiliation(s)
- Simona Di Gennaro
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy; (S.D.G.); (G.D.M.); (G.S.); (T.L.); (M.A.)
| | - Gennaro Di Matteo
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy; (S.D.G.); (G.D.M.); (G.S.); (T.L.); (M.A.)
| | - Gianmarco Stornaiuolo
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy; (S.D.G.); (G.D.M.); (G.S.); (T.L.); (M.A.)
| | - Federica Anselmi
- Unit of Pediatric Infectious Diseases, Mother and Child Department, University Hospital Federico II, 80131 Naples, Italy;
| | - Teresa Lastella
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy; (S.D.G.); (G.D.M.); (G.S.); (T.L.); (M.A.)
| | - Francesca Orlando
- General Pediatrics and Immuno-Rheumatology Unit, Santobono-Pausilipon Hospital, 80129 Naples, Italy;
| | - Maria Alessio
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy; (S.D.G.); (G.D.M.); (G.S.); (T.L.); (M.A.)
| | - Roberta Naddei
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy; (S.D.G.); (G.D.M.); (G.S.); (T.L.); (M.A.)
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Polat MC, Ekici Tekin Z, Çelikel E, Güngörer V, Kurt T, Kaplan MM, Tekgöz N, Sezer M, Karagöl C, Coşkun S, Öner N, Sezer S, Çelikel Acar B. The Juvenile Spondyloarthritis Disease Activity Index Is a Useful Tool in Enthesitis-Related Arthritis: Real-Life Data. J Clin Rheumatol 2023; 29:309-315. [PMID: 37496150 DOI: 10.1097/rhu.0000000000002001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To compare enthesitis-related arthritis (ERA) patients with active and inactive disease at 6 months and define baseline predictors for disease inactivity. In addition, to evaluate the demographic, clinical, and laboratory characteristics of ERA patients and to identify the real-life impact of the Juvenile Spondyloarthritis Disease Activity Index (JSpADA) in predicting active disease in ERA. METHODS This medical record review study was conducted with 56 patients who were diagnosed with ERA at our clinic between June 2009 and June 2022. Demographic and clinical characteristics, laboratory parameters, treatment, and JSpADA were recorded. RESULTS The patients were divided into 2 groups as active (n = 34) and inactive (n = 22) according to their disease activity at month six. Sex, age at diagnosis, number and type of affected joints, and presence of sacroiliitis were similar in both groups. There was no difference in baseline erythrocyte sedimentation rate, but there was a significant difference in erythrocyte sedimentation rate at the third month ( p = 0.52 and p = 0.018, respectively). The median JSpADA values at disease onset were 3.5 (interquartile range [IQR], 3.0-4.5) and 3.3 (IQR, 2.5-4.0) in the active and inactive groups, respectively ( p = 0.27). At the third month, the median JSpADA values were 1.5 (IQR, 0.5-2.1) in the active group and 0.5 (IQR, 0.5-1.5) in the inactive group ( p = 0.037). The cutoff value for JSpADA at the third month for active disease persisting at the month six was determined as 1 point (area under the curve, 0.662 ± 0.06; p = 0.042; 95% confidence interval, 0.51-0.80) by receiver operating characteristic curve analysis. CONCLUSION In ERA patients, a persistently high JSpADA value at follow-up is a predictive factor for active disease at the sixth month.
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Affiliation(s)
- Merve Cansu Polat
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Zahide Ekici Tekin
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Elif Çelikel
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Vildan Güngörer
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Tuba Kurt
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Melike Mehveş Kaplan
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Nilüfer Tekgöz
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Müge Sezer
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Cüneyt Karagöl
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Serkan Coşkun
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Nimet Öner
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
| | - Serdar Sezer
- Division of Rheumatology, Department of Internal Medicine, Ankara Training and Research Hospital, Ankara, Turkey
| | - Banu Çelikel Acar
- From the Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital
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Avar-Aydin PO, Ozcakar ZB, Kaynak Sahap S, Aydin F, Cakar N, Arslanoglu C, Yalcinkaya F, Fitoz S. Childhood-Onset Sacroiliitis: Causes and Correlation Between Clinical Findings and Magnetic Resonance Imaging. J Clin Rheumatol 2023; 29:e71-e77. [PMID: 36881849 DOI: 10.1097/rhu.0000000000001955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The aims of this study were to describe disease associations of magnetic resonance imaging (MRI)-confirmed and clinically symptomatic sacroiliitis in pediatric patients with rheumatic diseases and to examine the relationship between patient characteristics and MRI findings of the sacroiliac joint (SIJ). METHODS Demographic and clinical data were extracted from the electronic medical records of the patients with sacroiliitis followed in the last 5 years. Active inflammatory and structural damage lesions of the SIJ-MRI were examined by the modified Spondyloarthritis Research Consortium of Canada scoring system, and correlation analysis of these results with clinical characteristics was evaluated. RESULTS A total of 46 symptomatic patients were found to have MRI-proven sacroiliitis of 3 different etiologies: juvenile idiopathic arthritis (JIA) (n = 17), familial Mediterranean fever (FMF) (n = 14), and chronic nonbacterial osteomyelitis (CNO) (n = 8). Seven patients, FMF and JIA (n = 6) and FMF and CNO (n = 1), had a co-diagnosis that might cause sacroiliitis. Although inflammation scores and structural damage lesions did not statistically differ between the groups, capsulitis and enthesitis on the MRI were more frequently detected in the CNO group. There was a negative correlation between symptom onset and inflammation scores of bone marrow edema. Disease composite scores and acute phase reactants were correlated with MRI inflammation scores. CONCLUSIONS We demonstrated that JIA, FMF, and CNO were the major rheumatic causes of sacroiliitis in children originating from the Mediterranean region. Quantitative MRI scoring tools can be used to assess the inflammation and damage of the SIJ in rheumatic diseases, show discrepancies between them, and have an important correlation with various clinical and laboratory features.
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Affiliation(s)
| | | | - Seda Kaynak Sahap
- Pediatric Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Fatma Aydin
- From the Departments of Pediatric Rheumatology
| | | | | | | | - Suat Fitoz
- Pediatric Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
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Guo Y, Fang Y, Zhang T, Pan Y, Wang P, Fan Z, Yu H. Axial involvement in enthesitis-related arthritis: results from a single-center cohort. Pediatr Rheumatol Online J 2023; 21:13. [PMID: 36747282 PMCID: PMC9903626 DOI: 10.1186/s12969-023-00792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/15/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Axial involvement in children with enthesitis-related arthritis (ERA) has characteristics that differ from those of peripheral involvement. This study characterized their clinical characteristics and treatment. METHODS Patients with ERA at the Children's Hospital of Nanjing Medical University between January 2018 and December 2020 were included. The ERA cohort was divided into two based on the presence or absence of axial joint involvement. Demographic characteristics, clinical features, and treatments were described and compared. RESULTS In total, 105 children with ERA were enrolled (axial ERA, n = 57; peripheral ERA, n = 48). The age at disease onset of the axial group tended to be higher (11.93 ± 1.72 vs. 11.09 ± 1.91 years) and the diagnosis delay was bigger in patients with axial ERA (10.26 ± 11.66 months vs. 5.13 ± 7.92 months). The inflammatory marker levels were significantly higher in patients with axial. There were no differences in HLA-B27 positivity between the groups (34 [59.65%] vs. 28 [58.33%], P > 0.05). Hip involvement was more frequent in the axial group (52.63% vs 27.08%; X2 = 7.033). A total of 38 (66.67%) and 10 (20.83%) patients with axial and peripheral ERA, respectively, were treated with biological disease-modifying anti-rheumatic drugs (DMARDs) at diagnosis. The administration of biologics increased gradually in the axial ERA group, peaking at 18 months and decreasing thereafter, whereas that in the peripheral ERA group peaked at 6 months and began to decline thereafter. CONCLUSIONS Axial ERA is a persistent active disease and requires a more aggressive treatment. Classification and early recognition of axial involvement may help with timely diagnosis and appropriate management.
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Affiliation(s)
- Yanli Guo
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Yuying Fang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Tonghao Zhang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Yuting Pan
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Panpan Wang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Zhidan Fan
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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Antibodies Recognizing Yersinia enterocolitica Lipopolysaccharides of Various Chemotypes in Synovial Fluids From Patients With Juvenile Idiopathic Arthritis. J Immunol Res 2022; 2022:9627934. [PMID: 36189145 PMCID: PMC9519298 DOI: 10.1155/2022/9627934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/01/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Yersinia enterocolitica O:3 (YeO3) is considered to be associated with reactive arthritis (ReA), and its lipopolysaccharide (LPS) has been detected in synovial fluids from patients. Interestingly, YeO3 wild-type LPS was processed by host cells, resulting in truncated LPS molecules presenting the core region. Previously, we reported the immunogenicity but not adjuvanticity of YeO3 LPSs of wild (S) type, Ra, Rd, or Re chemotypes in mice. Here, we demonstrate the presence of YeO3 LPS chemotype-specific antibodies in all analyzed synovial fluids (SF) from patients with juvenile idiopathic arthritis (JIA). Interestingly, the high titer of antibodies specific for the Kdo-lipid A region was found in most tested SF. In contrast, only a few were positive for antibodies recognizing O-specific polysaccharides. Western blot analysis revealed the presence of antibodies reacting with fast-migrating LPS fractions and enterobacterial common antigen (ECA) in synovial fluid samples. Our data also suggest the importance of LPS-associated ECA for the antigenicity of endotoxin. Furthermore, we confirmed in vitro that Yersinia LPS processing leads to the exposure of its core region and enhanced potency of complement lectin pathway activation.
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Analysis of N6-Methyladenosine RNA Methylation Regulators in Diagnosis and Distinct Molecular Subtypes of Ankylosing Spondylitis. DISEASE MARKERS 2022; 2022:4942599. [PMID: 36157216 PMCID: PMC9507730 DOI: 10.1155/2022/4942599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/17/2022] [Accepted: 08/27/2022] [Indexed: 12/02/2022]
Abstract
The most frequent internal modification in eukaryotic mRNA is N6-methyladenosine (m6A). However, what we know about the m6A regulators in Ankylosing spondylitis (AS) is still limited. In our study, eight distinct m6A regulators were selected utilizing Differentially Expressed Gene (DEG) analysis of the Gene Expression Omnibus GSE73754 dataset for making comparisons between AS (Ankylosing spondylitis) and non-AS patients. The random forest model and the nomogram model were used to screen the eight candidate m6A regulators and evaluate their prediction accuracy for the occurrence of AS. Furthermore, based on the selected m6A regulators, the AS patients were divided into two subgroups, and we applied principal component analysis algorithms to calculate their m6A score and evaluate the m6A patterns. Our findings revealed that patients in cluster A were linked to activated CD4 T cell immunity and activated CD8 T cell immunity. With its major contributions in the area of immunology, our research in m6A patterns may benefit the future diagnosis and treatment strategies of AS.
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[Midterm follow-up outcomes of total hip arthroplasty in treatment for patients with juvenile-onset ankylosing spondylitis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:548-554. [PMID: 35570627 PMCID: PMC9108648 DOI: 10.7507/1002-1892.202111062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess the midterm follow-up outcomes of total hip arthroplasty (THA) for the treatment of patients with juvenile-onset ankylosing spondylitis (JAS). METHODS The clinical data of 81 patients (127 hips) with JAS (age≤16 years, JAS group) and 267 patients (391 hips) with adult onset ankylosing spondylitis (AAS) (age>16 years, AAS group) between January 2004 and March 2018 were retrospectively analysed. The baseline demographics, clinical, radiographic, and laboratory parameters were collected. Before operation and at last follow-up, the overall disease activity [Bath ankylosing spondylitis disease activity index (BASDAI)] and function status [Bath ankylosing spondylitis functional index (BASFI)], hip subjective score [Harris hip score (HHS)] and objective score [12-item short form health survey (SF-12), including physical component score (PCS) and mental component score (MCS)], and patient satisfaction for THA were reviewed. The major orthopedic complications, including periprosthetic infection, dislocation, periprosthetic fractures, and poor incision healing, were also recorded during the follow-up period. RESULTS The comparison of preoperative baseline parameters showed that the body mass, body mass index, age of onset, age of surgery, disease duration, and the proportion of combined smoking history in the JAS group were significantly lower than those in the AAS group ( P<0.05), the proportion of bilateral surgeries, proportion of uveitis, proportion of combined family history, C-reactive protein, albumin, and preoperative BASFI were significantly higher than those in the AAS group ( P<0.05). Both groups were followed up. The follow-up time in the JAS group was 29-199 months, with an average of 113 months; in the AAS group was 35-199 months, with an average of 98 months. Incisions in both groups healed by first intention. During the follow-up period, there were 1 case of periprosthetic fracture, 1 case of dislocation, and 1 case of ceramic fragmentation in the JAS group, 1 case of periprosthetic infection and 6 cases of periprosthetic fracture in the AAS group. There was no significant difference in the incidence of complications between the two groups ( P>0.05). At last follow-up, the BASDAI, BASFI, SF-12 MCS, SF-12 PCS, and HHS score of the two groups were significantly improved when compared with those before operation ( P<0.05); but there was no significan difference in the difference of the above parameters before and after operation and the patient satisfaction between the two groups ( P>0.05). CONCLUSION The midterm follow-up outcomes of THA for the treatment of JAS patients were reliable. A low age at disease onset did not exert a significant negative effect on THA reconstruction for the treatment of ankylosing spondylitis.
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Moura RA, Fonseca JE. B Cells on the Stage of Inflammation in Juvenile Idiopathic Arthritis: Leading or Supporting Actors in Disease Pathogenesis? Front Med (Lausanne) 2022; 9:851532. [PMID: 35449805 PMCID: PMC9017649 DOI: 10.3389/fmed.2022.851532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a term that collectively refers to a group of chronic childhood arthritides, which together constitute the most common rheumatic condition in children. The International League of Associations for Rheumatology (ILAR) criteria define seven categories of JIA: oligoarticular, polyarticular rheumatoid factor (RF) negative (RF-), polyarticular RF positive (RF+), systemic, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated arthritis. The ILAR classification includes persistent and extended oligoarthritis as subcategories of oligoarticular JIA, but not as distinct categories. JIA is characterized by a chronic inflammatory process affecting the synovia that begins before the age of 16 and persists at least 6 weeks. If not treated, JIA can cause significant disability and loss of quality of life. Treatment of JIA is adjusted according to the severity of the disease as combinations of non-steroidal anti-inflammatory drugs (NSAIDs), synthetic and/ or biological disease modifying anti-rheumatic drugs (DMARDs). Although the disease etiology is unknown, disturbances in innate and adaptive immune responses have been implicated in JIA development. B cells may have important roles in JIA pathogenesis through autoantibody production, antigen presentation, cytokine release and/ or T cell activation. The study of B cells has not been extensively explored in JIA, but evidence from the literature suggests that B cells might have indeed a relevant role in JIA pathophysiology. The detection of autoantibodies such as antinuclear antibodies (ANA), RF and anti-citrullinated protein antibodies (ACPA) in JIA patients supports a breakdown in B cell tolerance. Furthermore, alterations in B cell subpopulations have been documented in peripheral blood and synovial fluid from JIA patients. In fact, altered B cell homeostasis, B cell differentiation and B cell hyperactivity have been described in JIA. Of note, B cell depletion therapy with rituximab has been shown to be an effective and well-tolerated treatment in children with JIA, which further supports B cell intervention in disease development.
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Affiliation(s)
- Rita A Moura
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal
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13
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Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis of unknown origin, lasting for >6 weeks with onset before 16 years of age. JIA is the most common chronic inflammatory rheumatic condition of childhood. According to the International League Against Rheumatism (ILAR) classification, seven mutually exclusive categories of JIA exist based on disease manifestations during the first 6 months of disease. Although the ILAR classification has been useful to foster research, it has been criticized mainly as it does not distinguish those forms of chronic arthritis observed in adults and in children from those that may be unique to childhood. Hence, efforts to provide a new evidence-based classification are ongoing. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms. The field has witnessed a remarkable improvement in therapeutic possibilities of JIA owing to the availability of new potent drugs and the possibility to perform controlled trials with support from legislative interventions and large networks availability. The goal of drug therapy in JIA is to rapidly reduce disease activity to inactive disease or clinical remission, minimize drug side effects and achieve a quality of life comparable to that of healthy peers. As JIA can influence all aspects of a child's and their family's life, researchers increasingly recognize improvement of health-related quality of life as a key treatment goal.
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14
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Glerup M, Arnstad ED, Rypdal V, Peltoniemi S, Aalto K, Rygg M, Nielsen S, Fasth A, Berntson L, Nordal E, Herlin T. Changing patterns in treatment, remission status and categories in a long‐term Nordic cohort study of juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2022; 74:719-727. [DOI: 10.1002/acr.24857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 11/22/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Mia Glerup
- Department of Pediatrics Aarhus University Hospital Aarhus Denmark
| | - Ellen D. Arnstad
- Department of Clinical and Molecular Medicine NTNU ‐ Norwegian University of Science and Technology Trondheim Norway
- Department of Pediatrics Levanger Hospital, Nord‐Trøndelag Hospital Trust Levanger Norway
| | - Veronika Rypdal
- Department of Pediatrics, University Hospital of North Norway, and Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway
| | - Suvi Peltoniemi
- Department of Rheumatology Helsinki University Hospital Helsinki Finland
| | - Kristiina Aalto
- Hospital for Children and Adolescents University of Helsinki, and Pediatric Research Center, University of Helsinki Helsinki Finland
| | - Marite Rygg
- Department of Clinical and Molecular Medicine NTNU ‐ Norwegian University of Science and Technology Trondheim Norway
- Department of Pediatrics, St. Olavs Hospital University hospital of Trondheim Trondheim Norway
| | - Susan Nielsen
- Department of Pediatrics, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Lillemor Berntson
- Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
| | - Ellen Nordal
- Department of Pediatrics, University Hospital of North Norway, and Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway
| | - Troels Herlin
- Department of Pediatrics Aarhus University Hospital Aarhus Denmark
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15
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Kocatürk B, Balık Z, Pişiren G, Kalyoncu U, Özmen F, Özen S. Spondyloarthritides: Theories and beyond. Front Pediatr 2022; 10:1074239. [PMID: 36619518 PMCID: PMC9816396 DOI: 10.3389/fped.2022.1074239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
Spondyloarthritides (SpA) are a family of interrelated rheumatic disorders with a typical disease onset ranging from childhood to middle age. If left untreated, they lead to a severe decrease in patients' quality of life. A succesfull treatment strategy starts with an accurate diagnosis which is achieved through careful analysis of medical symptoms. Classification criterias are used to this process and are updated on a regular basis. Although there is a lack of definite knowledge on the disease etiology of SpA, several studies have paved the way for understanding plausible risk factors and developing treatment strategies. The significant increase of HLA-B27 positivity in SpA patients makes it a strong candidate as a predisposing factor and several theories have been proposed to explain HLA-B27 driven disease progression. However, the presence of HLA-B27 negative patients underlines the presence of additional risk factors. The current treatment options for SpAs are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), TNF inhibitors (TNFis), Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and physiotherapy yet there are ongoing clinical trials. Anti IL17 drugs and targeted synthetic DMARDs such as JAK inhibitors are also emerging as treatment alternatives. This review discusses the current diagnosis criteria, treatment options and gives an overview of the previous findings and theories to clarify the possible contributors to SpA pathogenesis with a focus on Ankylosing Spondylitis (AS) and enthesitis-related arthritis (ERA).
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Affiliation(s)
- Begüm Kocatürk
- Department of Basic Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Zeynep Balık
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gaye Pişiren
- Department of Basic Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Füsun Özmen
- Department of Basic Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Seza Özen
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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16
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Açarı C, Çomak E, Çekiç Ş, Türkuçar S, Adıgüzel Dündar H, Şebnem Kılıç S, Akman S, Makay B, Erbil Ünsal Ş. Clinical features of children with chronic non-bacterial osteomyelitis: A multicenter retrospective case series from Turkey. Arch Rheumatol 2021; 36:419-426. [PMID: 34870174 PMCID: PMC8612500 DOI: 10.46497/archrheumatol.2021.8137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives
This study aims to evaluate demographic, clinical, and radiological characteristics of Turkish children with chronic non-bacterial osteomyelitis. Patients and methods
Between January 2008 and December 2018, a total of 28 patients (10 males, 18 females; median age: 12.5 years; range, 4.5 to 21 years) who were diagnosed with chronic non-bacterial osteomyelitis in three pediatric rheumatology centers were retrospectively analyzed. The demographic, clinical, and laboratory findings of the patients were recorded. Results
The median age at the time of diagnosis was 10.2 years. The median time from symptom onset to diagnosis was 6.5 months. The median follow-up was 18.5 months. The most frequent symptom at onset was arthralgia (75.0%). The most frequently involved bone was the femur (67.9%). Eight (63.6%) of 12 patients had at least one Mediterranean fever gene (MEFV) mutation, indicating a significantly higher prevalence than the Turkish population (14.8%). Five of these patients fulfilled the diagnostic criteria for familial Mediterranean fever (FMF). All patients received non-steroidal anti-inflammatory drugs. Other drugs were methotrexate (46.4%), sulfasalazine (39%), corticosteroids (25%), anti-tumor necrosis factor (anti-TNF) agents (32%), pamidronate (25%), and colchicine (21.4%). Six of eight patients with MEFV mutations were administered with colchicine, and all of them responded to treatment. Conclusion
Clinical evolution and imaging investigations should be carefully performed to prevent any delay in the diagnosis of patients with chronic non-bacterial osteomyelitis. Based on our study results, FMF coexistence is worth investigating in patients with chronic non-bacterial osteomyelitis, particularly in the Turkish population.
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Affiliation(s)
- Ceyhun Açarı
- Department of Pediatrics, Division of Pediatric Rheumatology, Dokuz Eylül University, Faculty of Medicine, Izmir, Turkey
| | - Elif Çomak
- Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Şükrü Çekiç
- Department of Pediatrics, Division of Pediatric Allergy-Immunology, Uludağ University, Faculty of Medicine, Bursa, Turkey
| | - Serkan Türkuçar
- Department of Pediatrics, Division of Pediatric Rheumatology, Dokuz Eylül University, Faculty of Medicine, Izmir, Turkey
| | - Hatice Adıgüzel Dündar
- Department of Pediatrics, Division of Pediatric Rheumatology, Dokuz Eylül University, Faculty of Medicine, Izmir, Turkey
| | - Sara Şebnem Kılıç
- Department of Pediatrics, Division of Pediatric Allergy-Immunology, Uludağ University, Faculty of Medicine, Bursa, Turkey
| | - Sema Akman
- Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Balahan Makay
- Department of Pediatrics, Division of Pediatric Rheumatology, Dokuz Eylül University, Faculty of Medicine, Izmir, Turkey
| | - Şevket Erbil Ünsal
- Department of Pediatrics, Division of Pediatric Rheumatology, Dokuz Eylül University, Faculty of Medicine, Izmir, Turkey
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Herregods N, Jans LBO, Paschke J, De Buyser SL, Renson T, Dehoorne J, Joos R, Lambert RGW, Jaremko JL. Magnetic resonance imaging findings in the normal pediatric sacroiliac joint space that can simulate disease. Pediatr Radiol 2021; 51:2530-2538. [PMID: 34549314 DOI: 10.1007/s00247-021-05168-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 05/24/2021] [Accepted: 07/31/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) features of active sacroiliac joint inflammation include joint space fluid and enhancement, but it is unclear to what extent these are present in normal children. OBJECTIVE To describe normal MRI appearances of pediatric sacroiliac joint spaces in boys and girls of varying ages. MATERIALS AND METHODS In this ethics-approved prospective study, 251 children (119 boys, 132 girls; mean age: 12.4 years, range: 6.1-18.0 years), had both oblique-coronal T1-weighted and short tau inversion recovery (STIR) sacroiliac joint MRI. Of these, 127 were imaged for other reasons and had asymptomatic sacroiliac joints ("normal cohort") while 124 had low back pain with no features of sacroiliitis on initial clinical MRI review ("low-back-pain cohort"). Post-gadolinium T1-weighted sequences were available in 16/127 normal and 124/124 low-back-pain subjects. Three experienced radiologists scored high signal in the sacroiliac joint space on STIR (score 0=absent; 1=high signal compared to normal bone marrow present anywhere in the joint but not as bright as fluid [compared to vessels, cerebrospinal fluid]; 2=definite fluid signal in part of the joint; 3=definite fluid signal, entire vertical height, majority of slices) and, when available, joint space post-contrast enhancement (0=no high signal/enhancement; 1=thin, symmetrical, mildly increased linear high signal present in the joint space; 2=focal, thick or intense enhancement). Associations between joint signal scores, age, gender and sacral apophyseal closure were analysed. RESULTS Increased signal on STIR (score 1-3) was present in 74.7% of pediatric sacroiliac joint spaces, as intense as fluid in 18.4%. There was no significant difference in proportion by gender, side or cohort, but girls showed peak signal earlier than boys (10 years old vs. 12 years old, respectively). On post-gadolinium T1-weighted sequences, a thin rim of increased signal was nearly universally seen in sacroiliac joint spaces without focal, intense or thick post-contrast enhancement. CONCLUSION Sacroiliac joint spaces of most children demonstrate mildly increased signal on STIR, compared to normal bone marrow, and thin rim-like enhancement on post-contrast T1 images, likely related to cartilage. These findings should not be confused with sacroiliitis.
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Affiliation(s)
- Nele Herregods
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Lennart B O Jans
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | | | - Stefanie L De Buyser
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Thomas Renson
- Department of Pediatric Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Joke Dehoorne
- Department of Pediatric Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Rik Joos
- Department of Pediatric Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Robert G W Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,Medical Imaging Consultants, Edmonton, Alberta, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.,Medical Imaging Consultants, Edmonton, Alberta, Canada
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Srinivasalu H, Sikora KA, Colbert RA. Recent Updates in Juvenile Spondyloarthritis. Rheum Dis Clin North Am 2021; 47:565-583. [PMID: 34635292 DOI: 10.1016/j.rdc.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Spondyloarthritis represents a group of disorders characterized by enthesitis and axial skeletal involvement. Juvenile spondyloarthritis begins before age 16. Joint involvement is usually asymmetric. Bone marrow edema on noncontrast MRI of the sacroiliac joints can facilitate diagnosis. The most significant risk factor for axial disease is HLA-B27. Most patients have active disease into adulthood. Enthesitis and sacroiliitis correlate with greater pain intensity and poor quality-of-life measures. Tumor necrosis factor inhibitors are the mainstay of biologic therapy. Although other biologics such as IL-17 blockers have shown benefit in adult spondyloarthritis, none are approved by the US Food and Drug Administration.
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Affiliation(s)
- Hemalatha Srinivasalu
- Division of Rheumatology, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Avenue Northwest, Washington, DC, USA
| | - Keith A Sikora
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10, Room 12N240, 10 Center Drive, Bethesda, MD 20892, USA
| | - Robert A Colbert
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10, Room 12N240E, 10 Center Drive, Bethesda, MD 20892, USA.
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19
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Chen Y, Ma Y, Zhang Z, Zhang Y, Jia J. The efficacy and safety of Yijinjing exercise in the adjuvant treatment of ankylosing spondylitis: A protocol of randomized controlled trial. Medicine (Baltimore) 2021; 100:e27109. [PMID: 34559101 PMCID: PMC8462643 DOI: 10.1097/md.0000000000027109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Ankylosing spondylitis (AS) is a chronic systemic autoimmune disease with high disability rate. Conventional treatment regimens have long medication cycles and are associated with adverse reactions. Therapeutic exercise is also considered to be an effective treatment for AS. Evidence suggests that Yijinjing as a low-energy exercise has advantages in adjuncting AS, but there is a lack of standard clinical studies to evaluate its efficacy and safety. METHODS This is a prospective randomized controlled trial to investigate the efficacy and safety of Yijinjing in the adjuvant treatment of AS. Approved by the Clinical Research Ethics Association of our hospital, patients were randomly divided into treatment or control groups in a ratio of 1:1. The treatment group received 4-month Yijinjing training on the basis of conventional treatment, while the control group received conventional treatment and maintained their current lifestyle. The outcome indicators included: activity index, functional ability, Bath Ankylosing Spondylitis Metrology Index, adverse reaction, etc. Finally, SPASS 22.0 software was used for statistical analysis of the data. DISCUSSION This study evaluated the clinical efficacy of Yijinjing exercise in the adjuvant treatment of AS, and the results of our study will provide a reference for the clinical use of Yijinjing exercise as an effective complementary alternative for the treatment of AS.
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Affiliation(s)
- Yuxuan Chen
- Linfen People's Hospital, Linfen, Shanxi Province, China
| | - Yixiao Ma
- Linfen People's Hospital, Linfen, Shanxi Province, China
| | - Zhiqiang Zhang
- The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Yaning Zhang
- Linfen People's Hospital, Linfen, Shanxi Province, China
| | - Jian Jia
- Linfen People's Hospital, Linfen, Shanxi Province, China
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20
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Chen S, Deng L. Risk factors for radiological hip involvement in patients with ankylosing spondylitis. Rev Assoc Med Bras (1992) 2021; 67:1293-1298. [PMID: 34816923 DOI: 10.1590/1806-9282.20210585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/18/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Our study aimed to explore the potential risk factors for radiological hip joint involvement in patients with ankylosing spondylitis (AS). METHODS This cross-sectional convey collected the clinical data, laboratory indicators, and radiographic data of patients with AS. Radiographic hip joint involvement was defined as a Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-hip) score ≥2. Multivariate logistic regression analyses were conducted to explore the potential risk factors for radiological hip involvement in patients with AS. RESULTS Based on BASRI-hip score, all enrolled 386 patients with AS were classified as patients involving with radiological hip joint involvement (BASRI-hip ≥2; n=203) and those without it (BASRI-hip ≤1; n=183). Mean age of enrolled patients with AS were 36.7±11.9 years, and 320 (82.9%) patients were male. Mean course of disease was 10.7±8.3 years, and 349 (90.4%) patients were with a positive HLAB27. Multivariate analyses indicated that Juvenile onset (onset age ≤16 years) (odds ratio [OR]=4.159, 95% confidence interval [CI], 1.779-9.721, p<0.001), body mass index (BMI) <18.5 kg/m2 (OR=1.986, 95%CI 1.187-3.323, p=0.009), continuous nonsteroidal anti-inflammatory drug (NSAID) use (OR=0.351, 95%CI 0.155-0.794, p=0.012), and bone mass below the expected range for age (Z score ≤-2) (OR=2.791, 95%CI 1.456-5.352, p=0.002) were independently associated with radiological hip joint involvement in patients with AS. CONCLUSIONS The potential risk factors for radiological hip joint involvement were juvenile onset, lower BMI, and bone mass below the expected range for age. Furthermore, continuous NSAID use was the protective factor for radiological hip joint involvement in these population.
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Affiliation(s)
- Shijun Chen
- Ankang Central Hospital, Department of Hematology and Rheumatology - Shaanxi Province, China
| | - Lei Deng
- Ankang Central Hospital, Department of Hematology and Rheumatology - Shaanxi Province, China
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21
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Fisher C, Ciurtin C, Leandro M, Sen D, Wedderburn LR. Similarities and Differences Between Juvenile and Adult Spondyloarthropathies. Front Med (Lausanne) 2021; 8:681621. [PMID: 34136509 PMCID: PMC8200411 DOI: 10.3389/fmed.2021.681621] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/26/2021] [Indexed: 12/17/2022] Open
Abstract
Spondyloarthritis (SpA) encompasses a broad spectrum of conditions occurring from childhood to middle age. Key features of SpA include axial and peripheral arthritis, enthesitis, extra-articular manifestations, and a strong association with HLA-B27. These features are common across the ages but there are important differences between juvenile and adult onset disease. Juvenile SpA predominantly affects the peripheral joints and the incidence of axial arthritis increases with age. Enthesitis is important in early disease. This review article highlights the similarities and differences between juvenile and adult SpA including classification, pathogenesis, clinical features, imaging, therapeutic strategies, and disease outcomes. In addition, the impact of the biological transition from childhood to adulthood is explored including the importance of musculoskeletal and immunological maturation. We discuss how the changes associated with adolescence may be important in explaining age-related differences in the clinical phenotype between juvenile and adult SpA and their implications for the treatment of juvenile SpA.
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Affiliation(s)
- Corinne Fisher
- Centre for Adolescent Rheumatology Versus Arthritis at University College London, University College London Hospital and Great Ormond Street Hospital, London, United Kingdom.,Department of Adolescent Rheumatology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis at University College London, University College London Hospital and Great Ormond Street Hospital, London, United Kingdom.,Department of Adolescent Rheumatology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,Division of Medicine, Department of Rheumatology (Bloomsbury), University College London, London, United Kingdom
| | - Maria Leandro
- Centre for Adolescent Rheumatology Versus Arthritis at University College London, University College London Hospital and Great Ormond Street Hospital, London, United Kingdom.,Department of Adolescent Rheumatology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,Division of Medicine, Department of Rheumatology (Bloomsbury), University College London, London, United Kingdom
| | - Debajit Sen
- Centre for Adolescent Rheumatology Versus Arthritis at University College London, University College London Hospital and Great Ormond Street Hospital, London, United Kingdom.,Department of Adolescent Rheumatology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Lucy R Wedderburn
- Centre for Adolescent Rheumatology Versus Arthritis at University College London, University College London Hospital and Great Ormond Street Hospital, London, United Kingdom.,National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children, London, United Kingdom.,Infection, Immunity & Inflammation Teaching and Research Department University College London Great Ormond Street Institute of Child Health, London, United Kingdom
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22
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Schiettecatte E, Jans L, Jaremko JL, Chen M, Vande Walle C, Herregods N. MR Imaging of Rheumatic Diseases Affecting the Pediatric Population. Semin Musculoskelet Radiol 2021; 25:82-93. [PMID: 34020470 DOI: 10.1055/s-0041-1726435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article reviews the application of magnetic resonance imaging (MRI) to pediatric rheumatic diseases. MRI can detect early manifestations of arthritis, evaluate the extent of disease, and monitor disease activity and response to treatment.Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disorder, representing a diverse group of related diseases that share a definition of joint inflammation of unknown origin with onset before 16 years of age and lasting > 6 weeks. JIA may lead to significant functional impairment and is increasingly imaged with MRI to assess for active inflammation as a target for therapy. This is particularly true for juvenile spondyloarthritis that includes multiple subgroups of JIA and primarily involves the spine and sacroiliac joints.Other less common pediatric rheumatic diseases considered here are chronic recurrent multifocal osteomyelitis and collagen vascular diseases including polymyositis, dermatomyositis, scleroderma, and juvenile systemic lupus erythematosus.
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Affiliation(s)
- Eva Schiettecatte
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Lennart Jans
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Jacob Lester Jaremko
- Department of Radiology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Min Chen
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Caroline Vande Walle
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Nele Herregods
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
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Pagnini I, Scavone M, Maccora I, Mastrolia MV, Marrani E, Bertini F, Lamot L, Simonini G. The Development of Extra-Articular Manifestations in Children With Enthesitis-Related Arthritis: Natural Course or Different Disease Entity? Front Med (Lausanne) 2021; 8:667305. [PMID: 34055840 PMCID: PMC8155293 DOI: 10.3389/fmed.2021.667305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction: Enthesitis-related Arthritis (ERA) is a specific category of juvenile idiopathic arthritis (JIA) characterized by axial and/or peripheral arthritis, and enthesitis, although other different extra-articular manifestations may encompass its clinical spectrum. Materials and Methods: In order to examine if ERA-JIA with extra-articular involvement may represent a different entity from ERA without extra-articular involvement, we performed a retrospective, observational, monocentric study, in a cohort of ERA patients followed between 2001 and September 2020 at the Pediatric Rheumatology Unit of Meyer Children Hospital of Florence. We analyzed the demographic, clinical, laboratory and imaging data at the disease onset, as well as after 3, 6, and 12 months follow up. Results: We have enrolled 53 patients, 33 males. At the time of diagnosis, average age was 10.9 years, 53 patients had active arthritis and 25 active enthesitis. The middle foot involvement was present in 20 patients. Twenty-five children achieved clinical remission on medication. Extra-articular manifestations were observed in 14 patients, of whom 3 had inflammatory bowel disease, 5 uveitis, one uveitis associated with Crohn disease, 4 SAPHO syndrome, one celiac disease. The cohort was stratified according to the presence/absence of extra-articular manifestations. It was observed that middle foot involvement was more frequent in patients with no extra-articular manifestations (18/39 vs. 2/14; χ2 = 4.45, p = 0.05). Additionally, patients presenting extra-articular manifestation needed more frequently (12/14 vs. 21/39, χ2= 4.45, p = 0.05), and preciously (months: 3.7 ± 5.4 vs. 16.7 ± 26.5, p = 0.02), treatment with biologic agents. Finally, these patients achieved belatedly (months: 31.6 ± 32.3 vs. 22.9 ± 18.3, p = 0.01) and less frequently (3/14 vs. 22/39; χ2= 5.50, p = 0.03) the clinical remission on medication. Eventually, extra-articular involvement inversely correlated with the middle-foot arthritis (ρs −0.29, p = 0.03), the chance to achieve remission on medication (ρs −0.31 e p = 0.02), as well as the chance to keep overall remission, with and without medication (ρs −0.28, p = 0.04). Conclusion: In our cohort, children diagnosed with ERA-JIA at the onset of disease and then developed extra-articular manifestations show the absence of middle foot involvement and worse prognosis with an early need for the use of biologic agents, and overall low chance to achieve remission.
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Affiliation(s)
- Ilaria Pagnini
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | - Mariangela Scavone
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | - Ilaria Maccora
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | | | - Edoardo Marrani
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | - Federico Bertini
- Radiology Unit, Meyer Children Hospital of Florence, Florence, Italy
| | - Lovro Lamot
- Department of Pediatrics, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
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24
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Biological classification of childhood arthritis: roadmap to a molecular nomenclature. Nat Rev Rheumatol 2021; 17:257-269. [PMID: 33731872 DOI: 10.1038/s41584-021-00590-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 12/21/2022]
Abstract
Chronic inflammatory arthritis in childhood is heterogeneous in presentation and course. Most forms exhibit clinical and genetic similarity to arthritis of adult onset, although at least one phenotype might be restricted to children. Nevertheless, paediatric and adult rheumatologists have historically addressed disease classification separately, yielding a juvenile idiopathic arthritis (JIA) nomenclature that exhibits no terminological overlap with adult-onset arthritis. Accumulating clinical, genetic and mechanistic data reveal the critical limitations of this strategy, necessitating a new approach to defining biological categories within JIA. In this Review, we provide an overview of the current evidence for biological subgroups of arthritis in children, delineate forms that seem contiguous with adult-onset arthritis, and consider integrative genetic and bioinformatic strategies to identify discrete entities within inflammatory arthritis across all ages.
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25
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Weiss PF, Fuhlbrigge RC, von Scheven E, Lovell DJ, Colbert RA, Brunner HI. Children with enthesitis-related arthritis could benefit from treatments targeted for adults with spondyloarthritis. Arthritis Care Res (Hoboken) 2020; 74:1058-1064. [PMID: 33278336 DOI: 10.1002/acr.24529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/13/2020] [Accepted: 12/01/2020] [Indexed: 12/22/2022]
Abstract
This review will summarize clinical, genetic and pathophysiologic characteristics that are shared between children with enthesitis related arthritis (ERA) with axial involvement and adults with non-radiographic, and in some cases radiographic, axial spondyloarthritis (SpA); and between children with ERA and primarily peripheral disease manifestations and adults with peripheral SpA. Due to the differences in classification criteria for children with ERA and adults with axial and peripheral SpA, the FDA granted automatic full waivers of studies in children for new medications for "axial spondyloarthropathies including ankylosing spondylitis" up until July 2020. Thus, although current juvenile idiopathic arthritis (JIA) treatment guidelines recommend the use of biologic disease modifying anti-rheumatic drugs (DMARDs) as part of the early treatment for patients with ERA, none of the FDA-approved therapies for peripheral SpA or non-radiographic axial SpA (certolizumab pegol, ixekizumab, and secukinumab) have been studied or are labelled for use in children with ERA. Considering the similarities between adult spondyloarthritis and ERA in terms of etiology, genetics, pathogenesis and clinical manifestations summarized in this review, medications approved for axial SpA or peripheral SpA should also be studied in children with active ERA involving axial or peripheral joints, respectively, with the intent to achieve labeling for use in children. Considering the current lack of effective FDA-approved therapies for ERA, the FDA should also consider requiring pediatric studies for medications that have already been approved for the treatment of adults with SpA.
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Affiliation(s)
- Pamela F Weiss
- Children's Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Robert C Fuhlbrigge
- Children's Hospital Colorado, University of Colorado School of Medicine, Colorado, USA, Cincinnati
| | - Emily von Scheven
- University of California, San Francisco. California, USA, Cincinnati
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
| | - Robert A Colbert
- National Institute of Arthritis, Musculoskeletal, and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
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26
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Kittiratchakool N, Kulpokin D, Chanjam C, Vilaiyuk S, Charuvanij S, Phongsamart G, Khaosut P, Tanya M, Nanagara R, Nantapaisarn S, Leelahavarong P. Cost-utility and budget impact analysis of tocilizumab for the treatment of refractory systemic juvenile idiopathic arthritis in Thailand. BMJ Open 2020; 10:e037588. [PMID: 32933962 PMCID: PMC7493110 DOI: 10.1136/bmjopen-2020-037588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES This study aimed to analyse the cost-utility and budget impact of adding tocilizumab to the standard treatment for patients with refractory systemic juvenile idiopathic arthritis (sJIA) in Thailand. DESIGN Economic evaluation using a decision-analytical model. SETTING Thailand. PARTICIPANTS Patients with refractory sJIA who were ≥2 years old. METHODS The use of tocilizumab as an add-on therapy to standard treatment was compared with standard treatment alone. A simulated health state transition model was used to estimate the lifetime costs and health outcomes from a societal perspective. Direct medical costs were collected from tertiary hospital databases while direct non-medical costs were derived from interviews. Health-related quality of life (QoL) was measured using the proxy version of three-level EuroQol five-dimensional questionnaire (EQ-5D-3L). Future costs and outcomes were discounted at an annual rate of 3%. The base case population was patients aged 9.41 years old at refractory disease onset. The results were reported as incremental cost-effectiveness ratios (ICER) in US dollar (USD). One-way and probabilistic sensitivity analysis were conducted to investigate parameter uncertainty. The 5-year budget impact was estimated from a governmental perspective. RESULTS The ICER of standard treatment plus tocilizumab was US$35 799 per quality-adjusted life-year (QALY) gained compared with standard treatment alone, which was not cost-effective at the threshold of US$5128 per QALY gained. The estimated 5 years budget impact was approximately US$4.8 million. CONCLUSIONS The use of standard treatment plus tocilizumab was not cost-effective in the Thai context, which has limited data. However, there is currently no second-line treatment for refractory sJIA in the Thai National List of Essential Medicines; thus, patients must receive higher doses of standard treatment which can cause many side effects. In contrast, tocilizumab showed obvious efficacy in clinical trials in improving treatment response and QoL. Therefore, the price of tocilizumab should be negotiated to reduce the financial impact on the healthcare system.
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Affiliation(s)
| | - Disorn Kulpokin
- Health Intervention and Technology Assessment Program, Nonthaburi, Thailand
| | - Chonticha Chanjam
- Health Intervention and Technology Assessment Program, Nonthaburi, Thailand
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirirat Charuvanij
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gun Phongsamart
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand
| | - Parichat Khaosut
- Pediatric Allergy & Clinical Immunology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Manasita Tanya
- Department of Pediatrics, Khon Kaen Hospital, Khon Kaen, Thailand
| | - Ratanavadee Nanagara
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sira Nantapaisarn
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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Verma J, Bhoyar B. Management of juvenile spondyloarthropathy through Ayurveda:- a case report. J Ayurveda Integr Med 2020; 12:143-147. [PMID: 32768345 PMCID: PMC8039353 DOI: 10.1016/j.jaim.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2020] [Accepted: 06/11/2020] [Indexed: 11/25/2022] Open
Abstract
Juvenile Spondyloarthropathies are the inflammatory arthritis before the age of 16 years and are characterized by the involvement of both synovium and enthesis leading to spinal and oligoarticular peripheral arthritis, principally in genetically predisposed (HLA-B27) individuals. These arthropathies are having poorer chance of remission with conventional treatment in comparison to other juvenile arthritis; with less than 20% going into remission within five years of diagnosis. This paper is a retrospective observational study of this condition in one patient receiving Ayurvedic treatment in Paediatric Unit of Ch. Brahm Prakash Ayurved Charak Sansthan. A 15 years adolescent boy with the complaints of inability to stand and walk due to pain and swelling in large joints of body; was carried to Balroga OPD by parents. On the basis of history, physical examination and investigations, the condition is diagnosed Aamavata as per ayurvedic approach and juvenile spondyloarthropathy as per modern medical science. This case is managed on the principle of treatment of Aamavata with administration of Ajamodadi churnam and Mishreya ark as deepana-pachana drugs followed by administration of Simhnad Guggulu and Lakshadi Guggulu with Maharasnadi kashayam and Dashmoolaristam for 3 months. Rheumayoga gold was also given from 4th week onward for 3 months. Panchkarma in the form of Baluka swedana and Kshara basti was also administered for 2 weeks after one month of oral medication. This treatment results in complete remission of all the signs and symptoms including pain and swelling of joints. The case is followed up for next three years without any relapse or progression in the disease. The case study infers that early intervention of Ayurvedic treatment in juvenile spondyloarthropathies may result in complete remission as well as may prevent progression of the disease. The case study provides a good hope for the management of this ailment as well as new ray for research.
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Affiliation(s)
- Jitesh Verma
- Department of Kaumarbhritya, Ch. Brahm Prakash Ayurved Charak Sansthan, Khera Dabar, Najafgarh, New Delhi, 73, India.
| | - Bharat Bhoyar
- Department of Kaumarbhritya, Ch. Brahm Prakash Ayurved Charak Sansthan, Khera Dabar, Najafgarh, New Delhi, 73, India
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28
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Sundaram TG, Muhammed H, Aggarwal A, Gupta L. A prospective study of novel disease activity indices for ankylosing spondylitis. Rheumatol Int 2020; 40:1843-1849. [PMID: 32757024 DOI: 10.1007/s00296-020-04662-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
There is an ongoing quest for robust disease activity measures in Ankylosing spondylitis (AS). Thus, we prospectively validated two new disease activity indices, Simplified AS Disease Activity Score (SASDAS) and modified Juvenile Spondyloarthritis Disease Activity Score (JSpADA). Patients with AS were assessed for BASDAI, ASDAS and other outcome measures at baseline and 3 months. Comparisons were drawn between those with juvenile onset, early disease and peripheral involvement, with the rest. Fisher's r to Z transformation was used to compare correlations. Receiver-operating characteristic (ROC) curves were used to calculate cutoffs for inactive, low, high and very high disease activity. Of the 107 patients (mean age-29 years) of 6-years long disease, 38.3% had a juvenile onset. SASDAS and modified JSpADA exhibited excellent correlation with BASDAI and ASDAS (all p < 0.001) and were higher in active vs. inactive disease. Treatment responders had a greater fall in SASDAS and modified JSpADA as compared to non-responders. The novel scores were higher in those with peripheral disease. Only SASDAS could discriminate early from late disease. Based on the previously proposed cutoffs, optimal scores for inactive, moderate, high and very high disease activity were deduced. SASDAS-CRP showed better internal consistency than SASDAS-ESR and correlated better with ASDAS-CRP in late disease (Z = 3.04; p = 002) and those with adult onset disease (Z = 2.18; p = 0.03). SASDAS and Modified JSpADA perform as well as standard complex scores and have potential for simpler daily use. From our analyses, SASDAS with CRP performs better than SASDAS-ESR, pending further validation.
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Affiliation(s)
- T G Sundaram
- Departments of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Hafis Muhammed
- Departments of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Amita Aggarwal
- Departments of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Latika Gupta
- Departments of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India.
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29
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Maniscalco V, Marrani E, Lamot L, Lionetti P, Simonini G. The conundrum of juvenile spondyloarthritis classification: Many names for a single disease? Lesson learned from an instructive clinical case. Int J Rheum Dis 2020; 23:1248-1251. [PMID: 32715627 DOI: 10.1111/1756-185x.13922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 01/20/2023]
Abstract
Pediatric rheumatic diseases are often characterized by an evolving phenotype, resulting in diagnostic dilemma for physicians involved in their management. Although several classification criteria are used in childhood to uniform patients' diagnoses, several conditions share similar clinical features and therefore their classifications may overlap or be ambiguous. This is particularly paradigmatic for the classification of juvenile spondyloarthritis (JSpA), as the currently available criteria do not encompass their complexity. The differential diagnosis of sacroiliitis is often challenging for clinicians and requires considering several conditions, which include infective, neoplastic and rheumatic diseases. We report the case of a 13-year-old boy with an evolving clinical phenotype; its progression shows the wide differential diagnosis required in pediatric rheumatic diseases and emphasizes the issues of the actual classification system.
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Affiliation(s)
- Valerio Maniscalco
- Rheumatology Unit, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Lovro Lamot
- Division of Clinical Immunology and Rheumatology, Department of Pediatrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia.,Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Paolo Lionetti
- Gastroenterology Unit, Anna Meyer Children's University Hospital, Florence, Italy.,NEUROFARBA Department, University of Florence, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy.,NEUROFARBA Department, University of Florence, Florence, Italy
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30
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Debrach AC, Rougelot A, Beaumel A, Cabrera N, Belot A, Duquesne A, Aubry-Rozier B, Hofer M, Couret M, Larbre JP, Coury F. Comparison of paediatric and adult classification criteria in juvenile idiopathic arthritis during the transition from paediatric to adult care. Joint Bone Spine 2020; 88:105047. [PMID: 32653654 DOI: 10.1016/j.jbspin.2020.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/23/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine the characteristics of juvenile idiopathic arthritis (JIA) patients seen during the transition period in order to compare paediatric classification criteria with those for adults. METHODS Patients with JIA according to the ILAR classification and who had a consultation at transition between 2010 and 2017 were included in a retrospective bi-centre (Lyon, Lausanne) study. JIA classification criteria were compared to ACR/EULAR 2010 criteria for rheumatoid arthritis (RA), Yamaguchi criteria for adult-onset Still's disease (AOSD), ASAS criteria for spondyloarthritis and CASPAR criteria for psoriatic arthritis. RESULTS One hundred and thirty patients were included: 13.9% with systemic JIA, 22.3% with polyarticular JIA, 22.3% with oligoarticular JIA, 34.6% with enthesitis-related arthritis (ERA) and 6.9% with psoriatic arthritis; 13.1% had suffered from uveitis; 14.5% of patients had erosions or carpitis, mainly those with psoriatic arthritis, polyarticular or systemic JIA; 37.5% of patients with ERA displayed radiological sacroiliitis. When comparing paediatric JIA criteria with adult classifications, we found that: 66.6% of patients with systemic JIA fulfilled the criteria for AOSD, 87.5% of rheumatoid factor-positive polyarticular JIA and 9.5% of rheumatoid factor-negative polyarticular JIA met the criteria for RA, and 34.5% of oligoarticular JIA fulfilled the criteria for spondyloarthritis. Finally, 77.7% of patients with ERA met the criteria for spondyloarthritis, and 100% of patients with psoriatic arthritis JIA met the criteria for psoriatic arthritis. CONCLUSION Oligoarticular JIA and rheumatoid factor-negative polyarticular JIA seem to be paediatric entities, whereas the other types of JIA tended to meet the respective adult classification criteria.
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Affiliation(s)
- Anne-Cécile Debrach
- Department of Rheumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Adrien Rougelot
- Department of Rheumatology, Lyon University Hospital and University of Lyon 1, Lyon, France
| | - Amandine Beaumel
- Department of Rheumatology, Lyon University Hospital and University of Lyon 1, Lyon, France
| | | | - Alexandre Belot
- Paediatric Nephrology, Rheumatology, Dermatology Unit, National Referral Centre for rare Juvenile Rheumatological and Autoimmune Disease (RAISE), Lyon University Hospital and University of Lyon, Lyon, France
| | - Agnès Duquesne
- Paediatric Nephrology, Rheumatology, Dermatology Unit, National Referral Centre for rare Juvenile Rheumatological and Autoimmune Disease (RAISE), Lyon University Hospital and University of Lyon, Lyon, France
| | - Bérengère Aubry-Rozier
- Department of Rheumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Hofer
- Romand Unit of Paediatric Immuno-Rheumatology, Department of Medico-Surgical Paediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Marie Couret
- Department of Rheumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Paul Larbre
- Department of Rheumatology, Lyon University Hospital and University of Lyon 1, Lyon, France
| | - Fabienne Coury
- Department of Rheumatology, Lyon University Hospital and University of Lyon 1, Lyon, France.
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31
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Giani T, Bernardini A, Basile M, Di Maurizo M, Perrone A, Renzo S, Filistrucchi V, Cimaz R, Lionetti P. Usefulness of magnetic resonance enterography in detecting signs of sacroiliitis in young patients with inflammatory bowel disease. Pediatr Rheumatol Online J 2020; 18:42. [PMID: 32493352 PMCID: PMC7268528 DOI: 10.1186/s12969-020-00433-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Arthritis is often an underestimated extraintestinal manifestation in pediatric inflammatory bowel disease (IBD), including sacroiliitis, whose early signs are well detectable at magnetic resonance imaging (MRI). Magnetic resonance enterography (MRE) is an accurate imaging modality for pediatric IBD assessment. We studied the possibility to detect signs of sacroiliac inflammation in a group of children with IBD who underwent MRE for gastrointestinal disease evaluation. METHODS We retrospectively reviewed MRE scans performed in pediatric patients with IBD. We looked for signs of sacroiliitis taking the ASAS (Assessment of SpondyloArthritis international Society) criteria as a model. Presence of bone marrow edema (using T2W sequences with fat suppression), diffusion restriction in Diffusion Weighted Imaging (DWI) or Diffusion Weighted Imaging with Background Suppression (DWIBS), and dynamic contrast enhancement were evaluated. Each SI joint was divided into 4 quadrants: upper iliac, lower iliac, upper sacral, and lower sacral. Two blinded observers with experience in pediatric and skeletal imaging independently evaluated the images. Cases upon which there was a disagreement were evaluated by the two reviewing radiologists and a third radiologist with similar experience together. RESULTS We enrolled 34 patients (24 males and 10 females, with mean age at scanning 14.3 years, median 15.3 years; 2 affected by ulcerative colitis, 32 by Crohn's disease) for a total of 59 examinations performed at the time of their first diagnosis or at symptom exacerbations. No patient complained of musculoskeletal symptoms, neither had pathological findings at articular examination. At the time of MRE 25 patients were under treatment for their IBD. Five patients had radiological signs of SI inflammation at MRE, albeit of mild degree. All patients with SI joint edema also had a restricted diffusion in DWIBS or DWI and almost everyone had contrast media uptake. CONCLUSIONS Sacroiliitis is one of the extraintestinal manifestation associated with IBD; it is often asymptomatic and clinically underdetected, with an unrelated progression with respect to the underlying IBD. MRE offers the possibility to study SI joints in young patients with IBD who undergo MRE for the investigation of their intestinal condition. Furthermore, we observed that gadolinium enhancement does not improve diagnostic specificity in sacroiliiitis detection.
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Affiliation(s)
- Teresa Giani
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy ,grid.9024.f0000 0004 1757 4641Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Azzurra Bernardini
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy
| | - Massimo Basile
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy
| | - Marco Di Maurizo
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy
| | - Anna Perrone
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy
| | - Sara Renzo
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy
| | - Viola Filistrucchi
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health and Research Center for Adult and Rheumatic Diseases, University of Milan, Milan, Italy.
| | - Paolo Lionetti
- grid.413181.e0000 0004 1757 8562Anna Meyer Children’s Hospital, Florence, Italy ,grid.8404.80000 0004 1757 2304Neurofarba Department, University of Florence, Florence, Italy
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Tripalo Batoš A, Potočki K, Žutelija Fattorini M, Posarić V, Roić G, Gagro A. Is axial magnetic resonance imaging useful in early juvenile spondyloarthritis-preliminary report. Clin Rheumatol 2020; 39:3017-3025. [PMID: 32297033 DOI: 10.1007/s10067-020-05037-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 12/23/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION/OBJECTIVES Magnetic resonance imaging (MRI) is recommended for evaluation of changes in juvenile spondyloarthropathies (JSpA). To our knowledge, there is no previous prospective study analysing early changes on axial MRI. The objective is to investigate incidence of reparable changes on axial MRI in patients with established JSpA, lasting for less than 6 months. MATERIALS AND METHODS The pilot study included 27 patients with confirmed diagnosis of JSpA examined within 2 years. Prior to imaging, basic demographic and laboratory data and HLA-B27 were collected. Patients filled out a visual analogue scale for pain and a childhood health assessment questionnaire. A paediatric rheumatologist and a paediatric physiatrist examined patients and measured indices of flexion, extension and sagittal flexibility. Contrast-enhanced axial MRI examination and cervical x-ray were performed. Three experienced paediatric radiologists independently reviewed x-ray and MRI images of all patients. RESULTS There was no significant correlation between early changes detected on MRI and other parameters. The study revealed early changes of the cervical spine to be the most common finding. More patients had positive cervical MRI than positive sacroiliac joint (SIJ) MRI. Cervical x-ray and MRI were equally useful for diagnosis regardless of other parameters. CONCLUSION Study showed new information on axial involvement, striking cervical spine as the most involved part. The biggest study limitation is the small number of patients. Establishing early JSpA diagnosis is of utmost importance, especially in the light of novel therapy introduced in every day practice. It seems that cervical spine involvement is more represented than previously described in literature, especially in comparison with SIJ. Key Points • Contrast-enhanced MRI is considered the gold standard for detection early changes in JSpA. • Standardization of diagnostic criteria and better classification of changes using the unique scoring system for children are necessary. • It seems that cervical spine involvement is more represented than previously described in the literature, especially in comparison with SIJ involvement.
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Affiliation(s)
- Ana Tripalo Batoš
- Department of Paediatric Radiology, Children's Hospital Zagreb, Klaićeva 16, Zagreb, Croatia.,University of Applied Health Sciences, Mlinarska 38, Zagreb, Croatia
| | - Kristina Potočki
- School of Medicine, University of Zagreb, Šalata 3, Zagreb, Croatia.,Department for Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, Croatia
| | - Matija Žutelija Fattorini
- Department of Orthopaedic, Children's Hospital Zagreb, Klaićeva 16, Zagreb, Croatia.,Fattorini Clinic For Paediatric and Adolescent Physical Therapy and Rehabilitation, Zagreb, Croatia
| | - Vesna Posarić
- Department of Paediatric Radiology, Children's Hospital Zagreb, Klaićeva 16, Zagreb, Croatia
| | - Goran Roić
- Department of Paediatric Radiology, Children's Hospital Zagreb, Klaićeva 16, Zagreb, Croatia.,University of Applied Health Sciences, Mlinarska 38, Zagreb, Croatia.,School of Medicine, University of Zagreb, Šalata 3, Zagreb, Croatia
| | - Alenka Gagro
- School of Medicine, University of Zagreb, Šalata 3, Zagreb, Croatia. .,Department of Pulmonology, Allergology, Immunology and Rheumatology, Department of Paediatrics, Children's Hospital Zagreb, Klaićeva 16, 10000, Zagreb, Croatia. .,Faculty of Medicine, Josip Juraj Strossmayerr, Josipa Huttlera 4, University of Osijek, Osijek, Croatia.
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Stoll ML, Mellins ED. Psoriatic arthritis in childhood: A commentary on the controversy. Clin Immunol 2020; 214:108396. [PMID: 32229291 DOI: 10.1016/j.clim.2020.108396] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 12/28/2022]
Abstract
Approximately 5% of children with juvenile idiopathic arthritis (JIA) are diagnosed with the psoriatic form of the disease. In recent years, there has been substantial scholarship demonstrating both heterogeneity within the disease as well as similarities with other forms of JIA, culminating in a recent proposal for the categorization of JIA that excluded the psoriatic form altogether. The purpose of the review is to summarize the clinical, epidemiologic, and genetic features of psoriatic JIA (PsJIA), comparing it with other categories of JIA including spondyloarthritis. We conclude that there are sufficient unique clinical and genetic features within PsJIA as well as similarities with its adult counterpart that warrant including it within the JIA paradigm.
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Affiliation(s)
- Matthew L Stoll
- Department of Pediatrics, University of Alabama at Birmingham, 1600 7(th) Avenue South, Children's Park Place North Suite G10, Birmingham, AL 35233, USA.
| | - Elizabeth D Mellins
- Department of Pediatrics, Program in Immunology, Stanford University, 269 Campus Drive, CCSR Rm 2105c, Stanford, CA 94305-5164, USA.
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Walscheid K, Glandorf K, Rothaus K, Niewerth M, Klotsche J, Minden K, Heiligenhaus A. Enthesitis-related Arthritis: Prevalence and Complications of Associated Uveitis in Children and Adolescents From a Population-based Nationwide Study in Germany. J Rheumatol 2020; 48:262-269. [DOI: 10.3899/jrheum.191085] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2020] [Indexed: 12/11/2022]
Abstract
Objective.Enthesitis-related arthritis (ERA) represents a subgroup of juvenile idiopathic arthritis (JIA) that is regularly accompanied by anterior uveitis. This study describes the prevalence and characteristics of ERA-related uveitis.Methods.Cross-sectional data from the National Pediatric Rheumatological Database (NPRD) were used to characterize ERA-related uveitis (ERA-U). In addition to sociodemographic variables, we documented the occurrence of uveitis and course of disease, including symptoms, visual acuity, and complications, as well as JIA characteristics such as disease activity (Juvenile Arthritis Disease Activity Score 10), functional ability (Childhood Health Assessment Questionnaire score), laboratory variables, and treatment.Results.In the years from 2002 to 2014, there were 3778 (15.2%) of a total of 24,841 JIA patients recorded in the NPRD who had ERA, and 280 (7.4%) of them had developed uveitis. Detailed ophthalmological documentation by a uveitis add-on module was available for 22.9% of these patients. Uveitis onset was acutely symptomatic in 63% of patients. Patients with uveitis were more frequently male, HLA-B27–positive, younger at ERA onset, and they had higher erythrocyte sedimentation rate values at first uveitis documentation than those without uveitis. Uveitis was diagnosed at a mean age of 11.5 (± 3.9) years (50% within 2 years after ERA onset). Systemic treatment with corticosteroids and synthetic and biologic disease-modifying antirheumatic drugs was associated with a (not significantly) lower risk of developing uveitis.Conclusion.The course of disease in ERA-U patients is frequently similar to HLA-B27–associated uveitis in adults; however, a subgroup of patients presents with asymptomatic uveitis.
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Schiettecatte E, Jaremko J, Sudoł-Szopińska I, Znajdek M, Mandegaran R, Swami V, Jans L, Herregods N. Common incidental findings on sacroiliac joint MRI in children clinically suspected of juvenile spondyloarthritis. Eur J Radiol Open 2020; 7:100225. [PMID: 32154331 PMCID: PMC7058907 DOI: 10.1016/j.ejro.2020.100225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/18/2020] [Accepted: 02/22/2020] [Indexed: 02/07/2023] Open
Abstract
What to look for on MRI of the sacroiliac (SI) joint. Incidental findings are common on MRI of the sacroiliac (SI) joint in children. There is more to see than sacroiliitis on MRI of the sacroiliac (SI) joint. Degeneration, inflammation, tumor and normal variants can be seen on MRI of SI joint.
Purpose To determine the prevalence of incidental findings on sacroiliac (SI) joint MRI in children clinically suspected of Juvenile Spondyloarthritis (JSpA). Methods In this retrospective multi-center study of 540 children clinically suspected of JSpA who underwent MRI of SI joints from February 2012 to May 2018, the prevalence of sacroiliitis and other incidental findings was recorded. Results In 106/540 (20 %) children MRI features of sacroiliitis were present. In 228 (42 %) patients MRI showed at least one incidental finding other than sacroiliitis. A total of 271 abnormal findings were reported. The most frequent incidental findings were at lumbosacral spine (158 patients, 29 %) and hip (43 patients, 8 %). The most common incidental finding was axial degenerative changes, seen in 94 patients (17 %). Other less frequent pathologies were: simple (bone) cyst in 15 (2,8 %) patients; enthesitis/tendinitis in 16 (3 %) patients; non-specific focal bone marrow edema (BME) away from SI joints in 10 (1,9 %) patients; ovarian cysts in 7 (1,3 %) patients; BME in the course of chronic recurrent multifocal osteomyelitis (CRMO) in 4 (0,7 %) patients; muscle pathology in 4 (0,7%) patients; benign tumors in 3 (0,6 %) patients; (old) fractures in 3 (0,6 %) patients; bony apophyseal avulsion in 2 (0,4 %) patients and malignant tumors in 2 (0,4 %) patients. Conclusion Incidental findings are common on MRI of the SI joints in children clinically suspected of JSpA, particularly at the lumbar spine and hips. They are seen even more frequently than sacroiliitis and can be relevant, as some will have clinical significance or require treatment.
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Key Words
- AVN, avascular necrosis
- BME, bone marrow edema
- CRMO, chronic recurrent multifocal osteomyelitis
- FOV, field of view
- Gd, gadolinium DTPA
- HLA-B27, human leukocyte antigen B27
- IV, intravenous
- Inflammation
- JSpA, juvenile spondyloarthritis
- Juvenile spondyloarthritis
- MRI, magnetic resonance imaging
- Magnetic resonance imaging (MRI)
- SI, sacroiliac
- ST, slice thickness
- STIR, short tau inversion recovery
- Sacroiliac joint
- Sacroiliitis
- TE, echo time
- TR, repetition time
- TSE, turbo spin echo
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Affiliation(s)
- E. Schiettecatte
- Department of Radiology and Medical Imaging, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Gent, Belgium
- Corresponding author.
| | - J.L. Jaremko
- Department of Radiology, University of Alberta Hospital, 8440-112 Street, Edmonton, T6G 2B7, Alberta, Canada
| | - I. Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - M. Znajdek
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - R. Mandegaran
- Department of Radiology, University of Alberta Hospital, 8440-112 Street, Edmonton, T6G 2B7, Alberta, Canada
| | - V. Swami
- Department of Radiology, University of Alberta Hospital, 8440-112 Street, Edmonton, T6G 2B7, Alberta, Canada
| | - L. Jans
- Department of Radiology and Medical Imaging, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Gent, Belgium
| | - N. Herregods
- Department of Radiology and Medical Imaging, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Gent, Belgium
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Rumsey DG, Guzman J, Rosenberg AM, Huber AM, Scuccimarri R, Shiff NJ, Bruns A, Feldman BM, Eurich DT, Benseler S, Berard R, Boire G, Bolaria R, Cabral D, Cameron B, Campillo S, Chan M, Chédeville G, Chetaille A, Dancey P, Dorval J, Duffy C, Ellsworth J, Feldman D, Gross K, Haddad E, Houghton K, Johnson N, Jurencak R, Lang B, Larché M, Laxer R, LeBlanc C, Levy D, Luca N, Miettunen P, Morishita K, Oen K, Petty R, Ramsey S, Roth J, Saint‐Cyr C, Schmeling H, Schneider R, Silverman E, Spiegel L, Stringer E, Tse S, Tucker L, Turvey S, Watanabe Duffy K, Yeung R. Worse Quality of Life, Function, and Pain in Children With Enthesitis, Irrespective of Their Juvenile Arthritis Category. Arthritis Care Res (Hoboken) 2020; 72:441-446. [DOI: 10.1002/acr.23844] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/05/2019] [Indexed: 11/07/2022]
Affiliation(s)
| | - Jaime Guzman
- University of British Columbia Vancouver British Columbia Canada
| | | | | | | | | | | | - Brian M. Feldman
- The Hospital for Sick Children and University of Toronto Toronto Ontario Canada
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Huang PY, Chang LS, Guo MMH, Kuo HC. Successful treatment in a child with enthesitis-related arthritis involving the sternoclavicular joint: a case report. BMC Pediatr 2019; 19:373. [PMID: 31647009 PMCID: PMC6806564 DOI: 10.1186/s12887-019-1770-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 10/02/2019] [Indexed: 01/01/2023] Open
Abstract
Background Although the sternoclavicular joint (SCJ) may be involved in ankylosing spondylitis, rheumatic arthritis, and Behçet’s disease and participates in the systemic inflammatory process of arthritis, it is often neglected during routine rheumatologic clinical examinations. To the best of our knowledge, this is the first study to report etanercept treatment in juvenile idiopathic arthritis (JIA) with SCJ involvement. Case presentation In this study, we describe an unusual case of a child with juvenile idiopathic arthritis with an initial presentation of sternoclavicular mass. The patient (age, 14 years 10 months) presented with an insidious onset atraumatic swelling of the left SCJ and complained of right hip and bilateral ankle tenderness without an apparent cause. Initial ultrasonography indicated a heterogeneous mass in the left SCJ, while computed tomography identified mild swelling of the left SCJ with a thickened synovial lining, mild bone erosion, and some turbid fluid. The patient ultimately underwent left SCJ arthrotomy, during which tapping of the SCJ revealed 2 cc of yellowish fluid, inflammation and necrosis of tissues within the SCJ. A clear yellow joint fluid was aspirated, and testing revealed a negative culture result. The patient was diagnosed with JIA. The joint tenderness improved and erythrocyte sedimentation rate decreased after administering anti-tumor necrosis factor etanercept. An additional ultrasonography demonstrated that the initial imaging findings have been resolved. At the end of a 2-year follow-up period, the patient was completely symptom-free. Conclusions JIA with SCJ involvement is an uncommon presentation in adolescents. Etanercept may be a beneficial treatment for SCJ involvement in patients with JIA. The upper limbs showed no signs of limited range of motion during the follow-up period. Further studies are warranted to elucidate the efficacy of etanercept in JIA with sternoclavicular joint involvement.
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Affiliation(s)
- Po-Yu Huang
- Department of Traditional Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, #123 Da-Pei Road, Niaosong District, Kaohsiung, 83301, Taiwan
| | - Ling-Sai Chang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, #123 Da-Pei Road, Niaosong District, Kaohsiung, 83301, Taiwan.
| | - Mindy Ming-Huey Guo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, #123 Da-Pei Road, Niaosong District, Kaohsiung, 83301, Taiwan
| | - Ho-Chang Kuo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, #123 Da-Pei Road, Niaosong District, Kaohsiung, 83301, Taiwan
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Shih YJ, Yang YH, Lin CY, Chang CL, Chiang BL. Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease. Pediatr Rheumatol Online J 2019; 17:58. [PMID: 31443722 PMCID: PMC6708211 DOI: 10.1186/s12969-019-0363-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/12/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) has been categorized into seven different categories according to the International League of Associations for Rheumatology (ILAR) criteria. Enthesitis-related arthritis (ERA) was found to represent the largest category in a Taiwanese cohort study. The aim in this study was to compare the clinical characteristics, treatments, and outcomes of ERA in a single tertiary center in Taiwan, as compared to those of other categories of JIA. Furthermore, we determined patients' characteristics and risk factors that can help assess the outcomes in ERA. METHODS A retrospective chart review of all patients with JIA referred to a pediatric rheumatology clinic in the National Taiwan University Hospital between 1993 and 2018 were identified according to ILAR criteria. Outcomes were assessed based on the Wallace criteria to categorize patients into active and non-active, including inactive, remission on medication, and remission off medication, groups. A subset of samples was further tested by DNA sequencing to identify HLA-B27 subtypes. RESULTS One-hundred and eighty-three patients were included in the study, with a mean of 8 years' follow-up. ERA was the single largest category of JIA (39.9%); psoriasis and undifferentiated JIA were both the least common type (0.5%). ERA was male predominant (86%), had a late age of onset (11.0 ± 3.2 years), and the majority of ERA patients was HLA-B27-positive (97%). Of 25 HLA-B27-positive ERA patients checked by HLA-B27 sequencing, 23 were B*27:04 and 2 were B*27:05. ERA patients were significantly less likely to achieve non-active status compared to patients with persistent oligoarthritis (P = 0.036). In terms of treatment response to TNF-α inhibitors in methotrexate-refractory ERA, 26 patients remained active and only 11 patients (30%) achieved a non-active status. Sacroiliitis was a risk factor contributing to poorer treatment response in ERA (P = 0.006). CONCLUSION ERA represented the most common category of JIA in Taiwan. Those ERA patients with sacroiliitis were likely to have persistent active disease and may require a more aggressive treatment strategy to improve their outcomes.
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Affiliation(s)
- Yang-Jen Shih
- Department of Pediatrics, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan ,0000 0004 0546 0241grid.19188.39Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Zhongshan South Road, Zhongzheng District, Taipei, 100 Taiwan
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Zhongshan South Road, Zhongzheng District, Taipei, 100, Taiwan. .,Department of Pediatrics, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.
| | - Chun-Ying Lin
- 0000 0004 0572 7815grid.412094.aDepartment of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ling Chang
- 0000 0004 0572 7815grid.412094.aDepartment of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- 0000 0004 0546 0241grid.19188.39Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Zhongshan South Road, Zhongzheng District, Taipei, 100 Taiwan
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Kan SL, Chen LX, Yuan ZF, Hu W, Zhu RS. Exercise interventions for ankylosing spondylitis: a protocol for a Bayesian network meta-analysis. BMJ Open 2019; 9:e029991. [PMID: 31209096 PMCID: PMC6588988 DOI: 10.1136/bmjopen-2019-029991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Ankylosing spondylitis (AS) is a universal chronic inflammatory rheumatic disease which predominantly results in chronic back pain and stiffness. However, some patients suffering from AS do not react well to pharmacological interventions. Exercise intervention has been employed for the treatment of AS and works as a complementary part of the management of AS. However, the effect of different types of exercise interventions remains unclear. The purpose of this study is to determine the relative efficacy of different types of exercise interventions for individuals with AS using a Bayesian network meta-analysis. METHODS AND ANALYSIS We will conduct a systematic literature review of randomised controlled trials that compare different types of exercise interventions for individuals with AS. PubMed, EMBASE and the Cochrane Library will be searched up to February 2019. The primary outcomes are functional capacity, pain and disease activity. The risk of bias for individual studies will be evaluated according to the Cochrane Handbook. A Bayesian network meta-analysis will be performed to compare the efficacy of different types of exercise interventions. The quality of evidence will be assessed by the Grading of Recommendations, Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION Ethical approval and patient consent are not required as this study is a meta-analysis based on published studies. The results of this network meta-analysis will be submitted to a peer-reviewed journal for publication. PROSPERO REGISTRATION NUMBER CRD42019123099.
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Affiliation(s)
- Shun-Li Kan
- Department of Spine Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Ling-Xiao Chen
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Zhi-Fang Yuan
- Department of Respiratory and Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Hu
- Department of Spine Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Ru-Sen Zhu
- Department of Spine Surgery, Tianjin Union Medical Center, Tianjin, China
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Kavadichanda CG, Seth G, Kumar G, Gulati R, Negi VS. Clinical correlates of HLA-B*27 and its subtypes in enthesitis-related arthritis variant of juvenile idiopathic arthritis in south Indian Tamil patients. Int J Rheum Dis 2019; 22:1289-1296. [PMID: 30884197 DOI: 10.1111/1756-185x.13551] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 02/02/2019] [Accepted: 02/24/2019] [Indexed: 01/12/2023]
Abstract
AIM The aim of the study was to assess the distribution of human leukocyte antigen (HLA)-B*27 subtypes and its correlation with disease phenotypes in children with enthesitis-related arthritis variant of juvenile idiopathic arthritis (JIA-ERA). METHOD One hundred and sixty patients (132 males, 28 females) satisfying the International League Against Rheumatism (ILAR) classification criteria for JIA-ERA were assessed and relevant demographic, clinical and radiographic data were documented. HLA-B*27 typing was done for all the patients and B*27 positive samples were subjected to high-resolution gene sequencing. The effect of duration of illness, HLA-B*27, its subtypes, and gender on the clinical phenotype were analyzed. RESULTS The mean age of disease onset was 12.69 ± 2.4 years with a male:female ratio of 4.7:1.0. HLA-B*27 was positive in 109/160 patients and HLA-B*27:04 was detected in 63% followed by B*27:05 (30%). Duration of illness was greater in patients with skeletal deformity, hip arthritis, sacroiliitis, cervical spine involvement and acute anterior uveitis (AAU) (P < 0.05). HLA-B*27 positivity was associated with a prolonged course of disease, higher incidence of AAU (14.7% vs 2%, P = 0.015), family history of spondyloarthritis (21.1% vs 5.9%; P = 0.015) and higher erythrocyte sedimentation rate as compared to HLA-B*27 negative patients (P < 0.01). The HLA-B*27:04 and *27:05 positive patients had similar clinical phenotypes. CONCLUSION Presence of HLA-B*27 and long duration of illness results in skeletal deformity, hip arthritis, sacroiliitis, cervical spine involvement and AAU. HLA-B*27:04 followed by B*27:05 are the most common HLA-B*27 subtypes in our study population and both have a similar clinical phenotype.
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Affiliation(s)
- Chengappa G Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Gaurav Seth
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Gunjan Kumar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Reena Gulati
- Genetic Services Unit, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
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Vlaic J, Lamot L, Simunic S, Harjacek M, Bojic D. Unusual localization and presentation of osteoid osteoma mimicking juvenile spondyloarthritis: a case report. BMC Musculoskelet Disord 2019; 20:17. [PMID: 30621690 PMCID: PMC6323825 DOI: 10.1186/s12891-018-2383-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 12/18/2018] [Indexed: 01/10/2023] Open
Abstract
Background Osteoid osteoma is a painful benign skeletal tumour of unknown aetiology. Most often it occurs in the long bones of extremities and responds well to nonsteroidal anti-inflammatory medications. However, unusual localization and atypical presentation of this tumour might present a diagnostic challenge, especially if symptoms mimic that indicative of juvenile spondyloarthritis. Case presentation A misdiagnosed ten-and-a-half-year-old girl with osteoid osteoma involving the distal phalanx of a little finger is presented. Her initial symptoms were pain and swelling of the little finger resembling dactylitis, while various imaging modalities showed signs of tenosynovitis, indicating a possible development of juvenile spondyloarthritis. Several trials of different non-steroid anti-inflammatory drugs gave no satisfactory results and ultrasound guided triamcinolone-hexacetonide injection provided only a short relief. Finally, almost three years after initial presentation, persistent clinical symptoms warranted repeated imaging that raised suspicion of an osteoid osteoma. Directed treatment with surgical intervention led to almost immediate and complete resolution of her symptoms. Conclusions Osteoid osteoma should be suspected in case of a tender swelling of a digit in children and adolescents, regardless of initial imaging findings and clinical presentation. Early diagnosis and treatment of this benign condition can have a substantial impact on quality of life of patients and their families and protect them from many unnecessary diagnostic procedures and treatment. Electronic supplementary material The online version of this article (10.1186/s12891-018-2383-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Josip Vlaic
- Division of Paediatric Orthopaedic Surgery, Children's Hospital Zagreb, Ulica Vjekoslava Klaica 16, 10000, Zagreb, Croatia.
| | - Lovro Lamot
- Division of Clinical Immunology and Rheumatology, Department of Paediatrics, Sestre milosrdnice University Hospital Centre, Vinogradska cesta, 29, Zagreb, Croatia.,Department of Paediatrics, University of Zagreb School of Medicine, Salata 3, Zagreb, Croatia
| | - Sven Simunic
- Division of Paediatric Orthopaedic Surgery, Children's Hospital Zagreb, Ulica Vjekoslava Klaica 16, 10000, Zagreb, Croatia
| | - Miroslav Harjacek
- Division of Clinical Immunology and Rheumatology, Department of Paediatrics, Sestre milosrdnice University Hospital Centre, Vinogradska cesta, 29, Zagreb, Croatia.,Department of Paediatrics, University of Zagreb School of Medicine, Salata 3, Zagreb, Croatia
| | - Davor Bojic
- Division of Paediatric Orthopaedic Surgery, Children's Hospital Zagreb, Ulica Vjekoslava Klaica 16, 10000, Zagreb, Croatia.,Josip Juraj Strossmayer University of Osijek - Faculty of Medicine, Ulica cara Hadrijana 10e, 31000, Osijek, Croatia.,Josip Juraj Strossmayer University of Osijek - Faculty of Dental Medicine and Health, Crkvena 21, 31000, Osijek, Croatia
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Rumsey DG, Guzman J, Rosenberg AM, Huber AM, Scuccimarri R, Shiff NJ, Bruns A, Feldman BM, Eurich DT. Characteristics and Course of Enthesitis in a Juvenile Idiopathic Arthritis Inception Cohort. Arthritis Care Res (Hoboken) 2019; 70:303-308. [PMID: 28426894 DOI: 10.1002/acr.23256] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/11/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To describe the prevalence, associated characteristics, and course of enthesitis in a juvenile idiopathic arthritis (JIA) inception cohort. METHODS Canadian children newly diagnosed with JIA between 2005 and 2010 were categorized using International League of Associations for Rheumatology criteria at the 6-month visit and followed in the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) cohort for up to 5 years. The presence of entheseal tenderness on examination at 33 sites shown on a homunculus was recorded at 0, 6, 12, 18, 24, 36, 48, and 60 months after enrollment. Enthesitis was defined as entheseal tenderness at more than 1 site or on more than 1 occasion. Analyses consisted of descriptive statistics and linear mixed models for longitudinal data. RESULTS Of 1,406 patients, 219 (16%) had enthesitis and, of those with enthesitis, 141 (64%) were classified as having enthesitis-related arthritis (ERA). Children with enthesitis were more often older (10.7 versus 7.5 years), male (57% versus 31%), and with polyarthritis (57% versus 41%) and sacroiliac involvement (30% versus 4%). Entheseal tenderness was most frequent at the calcaneal plantar fascial insertion (39%), Achilles tendon insertion (31%), and tibial tuberosity (30%). The mean number of tender entheseal sites decreased in parallel with active joint counts. There was no difference in active joint counts over time in children with or without enthesitis (P = 0.73). CONCLUSION Enthesitis was observed in 16% of patients with JIA, but only two thirds were categorized as having ERA. Contrary to expectations, most children with enthesitis had polyarticular involvement. The course of enthesitis paralleled the course of active joint counts.
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Affiliation(s)
- Dax G Rumsey
- University of Alberta, Edmonton, Alberta, Canada
| | - Jaime Guzman
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Adam M Huber
- IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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Idiopathic hip chondrolysis: a case report of a Caucasian HLA-B27 positive adolescent with a history of long walking. Rheumatol Int 2019; 39:751-755. [PMID: 30612148 DOI: 10.1007/s00296-018-04239-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
Idiopathic hip chondrolysis is a rare disorder, the pathophysiology of which has not been fully elucidated. Several theories have been proposed regarding the cause of the disease with some of them involving autoimmune-mediated cartilage destruction. There are several similar features between idiopathic hip chondrolysis and rheumatologic diseases such as juvenile idiopathic arthritis, so whether these two disorders are different or not is still debatable. This case report aims to help comprehending this complex disorder by presenting a case of idiopathic hip chondrolysis with apparent risk factors, such as repetitive microtrauma and presence of HLA-B27 antigens. A 15-year-old HLA-B27 positive male presented with idiopathic hip chondrolysis after excessive walking. Initial treatment consisted of medications including corticosteroids, protected weight bearing and surgical soft tissue release. After failure of all these modalities in restoring the decreased range of motion of the hip, a course of a TNF-inhibitor, etanercept was tried. Alleviation of pain achieved early in the treatment period, but range of motion remained mainly unchanged. Although there was a brief improvement of stiffness for a short period after surgery which lasted for about 3 months, stiffness came back afterwards. Administration of a TNF inhibitor in the following period significantly improved his range of motion. The presence of laboratory findings indicating an autoimmune tendency in this patient supports the hypothesis of susceptibility of these patients to autoimmune reactions, while excessive walking was an apparent trigger factor. In future, traditional treatments may be abandoned in favor of novel medications targeting immunologic pathways.
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Martini A, Ravelli A, Avcin T, Beresford MW, Burgos-Vargas R, Cuttica R, Ilowite NT, Khubchandani R, Laxer RM, Lovell DJ, Petty RE, Wallace CA, Wulffraat NM, Pistorio A, Ruperto N. Toward New Classification Criteria for Juvenile Idiopathic Arthritis: First Steps, Pediatric Rheumatology International Trials Organization International Consensus. J Rheumatol 2018; 46:190-197. [PMID: 30275259 DOI: 10.3899/jrheum.180168] [Citation(s) in RCA: 241] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To revise the current juvenile idiopathic arthritis (JIA) International League of Associations for Rheumatology (ILAR) classification criteria with an evidence-based approach, using clinical and routine laboratory measures available worldwide, to identify homogeneous clinical groups and to distinguish those forms of chronic arthritis typically seen only in children from the childhood counterpart of adult diseases. METHODS The overall project consists of 4 steps. This work represents Step 1, a Delphi Web-based consensus and Step 2, an international nominal group technique (NGT) consensus conference for the new provisional Pediatric Rheumatology International Trials Organization JIA classification criteria. A future large data collection of at least 1000 new-onset JIA patients (Step 3) followed by analysis and NGT consensus (Step 4) will provide data for the evidence-based validation of the JIA classification criteria. RESULTS In Step 1, three Delphi rounds of interactions were implemented to revise the 7 ILAR JIA categories. In Step 2, forty-seven questions with electronic voting were implemented to derive the new proposed criteria. Four disorders were proposed: (a) systemic JIA; (b) rheumatoid factor-positive JIA; (c) enthesitis/spondylitis-related JIA; and (d) early-onset antinuclear antibody-positive JIA. The other forms were gathered under the term "others." These will be analyzed during the prospective data collection using a list of descriptors to see whether the clustering of some of them could identify homogeneous entities. CONCLUSION An international consensus was reached to identify different proposed homogeneous chronic disorders that fall under the historical term JIA. These preliminary criteria will be formally validated with a dedicated project.
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Affiliation(s)
- Alberto Martini
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands. .,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO.
| | - Angelo Ravelli
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Tadej Avcin
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Michael W Beresford
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Ruben Burgos-Vargas
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Ruben Cuttica
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Norman T Ilowite
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Raju Khubchandani
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Ronald M Laxer
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Daniel J Lovell
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Ross E Petty
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Carol A Wallace
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Nico M Wulffraat
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Angela Pistorio
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
| | - Nicolino Ruperto
- From Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Direzione Scientifica; IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Pediatric Rheumatology International Trials Organization (PRINTO), and Università degli Studi di Genova; IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy; University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia; Department of Paediatric Rheumatology, Alder Hey Children's National Health Service (NHS) Foundation Trust; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Hospital General de Mexico, Departamento de Reumatología, Mexico City, Mexico; Hospital Pedro de Elizalde, Rheumatology Section, Buenos Aires, Argentina; Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics, New Hyde Park, New York; Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio; Seattle Children's Hospital, Seattle, Washington, USA; Jaslok Hospital and Research Centre, Department of Paediatrics, Mumbai, India; The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto, Toronto, Ontario; British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology, Utrecht, the Netherlands.,A. Martini, MD, Professor, IRCCS Istituto Giannina Gaslini, Direzione Scientifica; A. Ravelli, MD, Professor, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia and Università degli Studi di Genova; T. Avcin, MD, PhD, University Children's Hospital, University Medical Center Ljubljana, Department of Allergology, Rheumatology and Clinical Immunology; M.W. Beresford, MBChB, PhD, Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, and Institute of Translational Medicine, University of Liverpool; R. Burgos-Vargas, MD, Hospital General de Mexico, Departamento de Reumatología; R. Cuttica, MD, Hospital Pedro de Elizalde, Rheumatology Section; N.T. Ilowite, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Pediatrics; R. Khubchandani, MD, Jaslok Hospital and Research Centre, Department of Paediatrics; R.M. Laxer, MD, The Hospital for Sick Children, Division of Rheumatology, Department of Paediatrics, University of Toronto; D.J. Lovell, MD, MPH, Cincinnati Children's Hospital Medical Center, Division of Rheumatology; R.E. Petty, MD, PhD, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia; C.A. Wallace, MD, Seattle Children's Hospital; N.M. Wulffraat, MD, PhD, Wilhelmina Children's Hospital, Department of Pediatric Immunology and Rheumatology; A. Pistorio, MD, PhD, IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica; N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO
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Sudoł-Szopińska I, Eshed I, Jans L, Herregods N, Teh J, Vojinovic J. Classifications and imaging of juvenile spondyloarthritis. J Ultrason 2018; 18:224-233. [PMID: 30451405 PMCID: PMC6442218 DOI: 10.15557/jou.2018.0033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2018] [Indexed: 12/29/2022] Open
Abstract
Juvenile spondyloarthritis may be present in at least 3 subtypes of juvenile idiopathic arthritis according to the classification of the International League of Associations for Rheumatology. By contrast with spondyloarthritis in adults, juvenile spondyloarthritis starts with inflammation of peripheral joints and entheses in the majority of children, whereas sacroiliitis and spondylitis may develop many years after the disease onset. Peripheral joint involvement makes it difficult to differentiate juvenile spondyloarthritis from other juvenile idiopathic arthritis subtypes. Sacroiliitis, and especially spondylitis, although infrequent in childhood, may manifest as low back pain. In clinical practice, radiographs of the sacroiliac joints or pelvis are performed in most of the cases even though magnetic resonance imaging offers more accurate diagnosis of sacroiliitis. Neither disease classification criteria nor imaging recommendations have taken this advantage into account in patients with juvenile spondyloarthritis. The use of magnetic resonance imaging in evaluation of children and adolescents with a clinical suspicion of sacroiliitis would improve early diagnosis, identification of inflammatory changes and treatment. In this paper, we present the imaging features of juvenile spondyloarthritis in juvenile ankylosing spondylitis, juvenile psoriatic arthritis, reactive arthritis with spondyloarthritis, and juvenile arthropathies associated with inflammatory bowel disease.
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Affiliation(s)
- Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Iris Eshed
- Department of Radiology, Sheba Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lennart Jans
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Nele Herregods
- Nele Herregods, Ghent University Hospital, Ghent, Belgium
| | - James Teh
- Department of Radiology, Nuffield Orthopedic Center, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jelena Vojinovic
- University of Nis, Faculty of Medicine, Department of Pediatric Rheumatology and Immunology, Serbia
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Chi H, Teng J, Yang C, Su Y. Bone tumors developed in patients with juvenile inflammatory arthritis after anti-TNFα therapy. Immunotherapy 2018; 10:1033-1039. [PMID: 30185135 DOI: 10.2217/imt-2018-0022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Administration of anti-TNFα agents has become a mainstay in the treatment of chronic inflammatory arthritis such as rheumatoid arthritis (RA) and spondyloarthritis. Adverse events, including infections and allergic reactions, have been reported. Malignancies are rare but potentially life threatening. The existence of bone tumor in those patients is very rare, only five cases of bone tumors were mentioned in juvenile idiopathic arthritis (JIA) in the literature. We describe three patients in whom bone neoplasms developed after years of anti-TNFα therapy for JIA or juvenile ankylosing spondylitis (JAS). One patient developed chondroblastoma, and the other two were diagnosed with osteosarcoma. Rheumatologists should increase their awareness of bone neoplasia in JIA or juvenile ankylosing spondylitis patients after anti-TNFα treatment.
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Affiliation(s)
- Huihui Chi
- Department of Rheumatology & Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Number 197 Ruijin Second Road, Shanghai 200025, China
| | - Jialin Teng
- Department of Rheumatology & Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Number 197 Ruijin Second Road, Shanghai 200025, China
| | - Chengde Yang
- Department of Rheumatology & Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Number 197 Ruijin Second Road, Shanghai 200025, China
| | - Yutong Su
- Department of Rheumatology & Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Number 197 Ruijin Second Road, Shanghai 200025, China
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Nalbanti P, Kanakoudi-Tsakalidou F, Trachana M, Pratsidou-Gertsi P, Farmaki E, Bamidis P, Papachristou F. Juvenile idiopathic arthritis in the biologic era: predictors of the disease progression and need for early introduction of biologic treatment. Rheumatol Int 2018; 38:1241-1250. [PMID: 29845429 DOI: 10.1007/s00296-018-4062-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/23/2018] [Indexed: 12/21/2022]
Abstract
To assess longitudinally the course and outcome of juvenile idiopathic arthritis (JIA) in patients diagnosed and followed-up exclusively in the biologic era; also, to define possible predictors of the disease progression and need for early implementation of biologicals. Prospective and retrospective, monocentric cohort study of 120 JIA patients, diagnosed between 2001 and 2010, and followed-up for ≥ 4 years (median 8.04). Disease activity, cumulative articular/extra-articular damage and quality of life were evaluated by the assessment tools Juvenile Arthritis Disease Activity Score (JADAS71), Juvenile Arthritis Damage Index (JADI) and Childhood Health Assessment Questionnaire (CHAQ), respectively. Moreover, potential predictors of the disease progression and their relation to biologic therapy were investigated. High JADAS71 score (> 9) at diagnosis was indicative of progression to polyarticular course and the need for early introduction of biologic treatment. Other independent predictors of progression to polyarthritis, were: involvement of upper limb, hip and ankle within 6 months following JIA diagnosis and percentage of cumulative time with active disease > 35% within the first year. At the end of the study, both the median JADAS71 score and the Disability Index were significantly lower than the initial (p < 0.001) and remission off medication was achieved in 25% of the patients. Articular and extra-articular (only ocular) cumulative damage was demonstrated only in 5 and 7.5% of patients, respectively. Physical functional ability was found normal/mildly restricted in 93.3% and moderately restricted in 6.7% of the patients. We believe that these findings, fit in with a picture of JIA course and outcome under current conditions of objective "disease status" evaluation and of tightly controlled follow-up. Predictors emerged from our study could contribute to the identification of patients who will need early implementation of biologic treatment.
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Affiliation(s)
- Panayiota Nalbanti
- First Department of Pediatrics, School of Medicine, Pediatric Immunology and Rheumatology Referral Center, Ippokration General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos St, 54642, Thessaloniki, Greece.
| | - Florentia Kanakoudi-Tsakalidou
- First Department of Pediatrics, School of Medicine, Pediatric Immunology and Rheumatology Referral Center, Ippokration General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos St, 54642, Thessaloniki, Greece
| | - Maria Trachana
- First Department of Pediatrics, School of Medicine, Pediatric Immunology and Rheumatology Referral Center, Ippokration General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos St, 54642, Thessaloniki, Greece
| | - Polyxeni Pratsidou-Gertsi
- First Department of Pediatrics, School of Medicine, Pediatric Immunology and Rheumatology Referral Center, Ippokration General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos St, 54642, Thessaloniki, Greece
| | - Evangelia Farmaki
- First Department of Pediatrics, School of Medicine, Pediatric Immunology and Rheumatology Referral Center, Ippokration General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos St, 54642, Thessaloniki, Greece
| | - Panagiotis Bamidis
- Medical Education Informatics, Lab of Medical Physics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Papachristou
- First Department of Pediatrics, School of Medicine, Pediatric Immunology and Rheumatology Referral Center, Ippokration General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos St, 54642, Thessaloniki, Greece
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Cherqaoui B, Rossi-Semerano L, Georgin-Lavialle S, Dusser P, Galeotti C, Piram M, Hentgen V, Touitou I, Koné-Paut I. Boundaries between familial Mediterranean fever and juvenile spondyloarthritis: Analysis of three French retrospective cohorts. Joint Bone Spine 2018; 85:733-739. [PMID: 29452306 DOI: 10.1016/j.jbspin.2018.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 01/30/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Children with Familial Mediterranean fever may suffer from musculoskeletal involvement, somewhat difficult to distinguish from juvenile spondyloarthritis. The association of these two diseases has been scarcely reported in children. Objective of this work was to define the association of familial Mediterranean fever and juvenile spondyloarthritis in France. METHODS Three cohorts of children with familial Mediterranean fever, juvenile spondyloarthritis, familial Mediterranean fever related juvenile spondyloarthritis, were retrospectively identified in the French reference center of auto-inflammatory diseases. Familial Mediterranean fever was defined according to Tel-Hashomer or Turkish pediatric criteria with at least one exon-10 MEFV-gene mutation. Juvenile spondyloarthritis was defined according to ILAR criteria. Patients with familial Mediterranean fever or juvenile spondyloarthritis were respectively compared to familial Mediterranean fever related juvenile spondyloarthritis patients. RESULTS Sixteen children were identified as having familial Mediterranean fever related juvenile spondyloarthritis. The male/female-ratio was 0.6, with median age at spondyloarthritis onset of 7.5years (3-16years). All carried at least one M694V variant in MEFV gene; 16.7% were HLA-B27-carriers. Compared to 83 familial Mediterranean fever patients, familial Mediterranean fever related juvenile spondyloarthritis patients had less frequently fever (P<0.01) and more frequently arthritis (P<0.05), enthesitis (P<0.001), inflammatory back pain (P<0.001), inadequate response to colchicine (P<0.05). Compared to 20 juvenile spondyloarthritis patients, familial Mediterranean fever related juvenile spondyloarthritis patients less often received non-steroidal anti-inflammatory drugs (P<0.01) and anti-tumor necrosis factor drugs (P<0.001). CONCLUSIONS Familial Mediterranean fever may be associated with typical pattern of juvenile spondyloarthritis. These patients, with less response to colchicine, should be diagnosed earlier and treated as for jSpA.
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Affiliation(s)
- Bilade Cherqaoui
- Pediatric rheumatology, CHU de Bicêtre, AP-HP, 78, rue Gal-Leclerc, 94275 Le Kremlin-Bicêtre, France; CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France.
| | - Linda Rossi-Semerano
- Pediatric rheumatology, CHU de Bicêtre, AP-HP, 78, rue Gal-Leclerc, 94275 Le Kremlin-Bicêtre, France; CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France
| | - Sophie Georgin-Lavialle
- CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France; Internal medicine department, Tenon hospital, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - Perrine Dusser
- Pediatric immuno-rheumatology, CHUV Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland
| | - Caroline Galeotti
- Pediatric rheumatology, CHU de Bicêtre, AP-HP, 78, rue Gal-Leclerc, 94275 Le Kremlin-Bicêtre, France; CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France
| | - Maryam Piram
- Pediatric rheumatology, CHU de Bicêtre, AP-HP, 78, rue Gal-Leclerc, 94275 Le Kremlin-Bicêtre, France; CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France
| | - Véronique Hentgen
- CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France; Pediatric department, centre hospitalier Le Chesnay, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Isabelle Touitou
- CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France; Auto-inflammatory diseases center, CHU de Montpellier, 191 avenue Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Isabelle Koné-Paut
- Pediatric rheumatology, CHU de Bicêtre, AP-HP, 78, rue Gal-Leclerc, 94275 Le Kremlin-Bicêtre, France; CeRéMAIA, French reference center for auto-inflammatory diseases and inflammatory amyloidosis, 94270, Le Kremlin Bicêtre, France
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Kwon HJ, Bang MH, Kim KN. New Provisional Classification of Juvenile Idiopathic Arthritis Applying Rheumatoid Factor and Antinuclear Antibody. JOURNAL OF RHEUMATIC DISEASES 2018. [DOI: 10.4078/jrd.2018.25.1.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Hyuck Jin Kwon
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Myung Hoon Bang
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kwang Nam Kim
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
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