Changes in Treatments and Outcomes After Implementation of a National Universal Access Program for Juvenile Idiopathic Arthritis

OBJECTIVE

To evaluate the clinical and demographic characteristics of patients with juvenile idiopathic arthritis ( JIA) in Chile and compare treatments and outcomes before and after the introduction in 2010 of the Explicit Health Guarantees (GES) for JIA, a national universal access program for diagnosis and treatment of this condition.

METHODS

The clinical records of 280 patients with JIA followed at a private tertiary academic health network between 2007 and 2018 were reviewed.

RESULTS

Seventy percent of patients with JIA were female, mean age at diagnosis was 8.5 ± 4.8 years and mean follow-up was 4.0 ± 3.7 years. After GES implementation (post-GES), time to evaluation by pediatric rheumatologist and diagnostic delay were significantly reduced (15.0 ± 4.5 vs 9.0 ± 4.2 months, P = 0.004). In addition, use of magnetic resonance imaging significantly increased post-GES (P < 0.001). In terms of JIA treatments, before GES implementation, no patients received biologics. Of the 67 patients diagnosed before 2010 with continued follow-up at our center, 34% began biologic treatment after GES implementation. Of 196 patients diagnosed post-GES, 46% were treated with biologics. JIA remission rates were significantly higher in patients diagnosed post-GES compared to pre-GES (43% vs 29%, P = 0.02). Post-GES, we observed a significant decrease in uveitis complications among JIA patients (45% vs 13%, P = 0.04).

CONCLUSION

The implementation of a national government-mandated universal access program for guaranteed JIA diagnosis and treatment led to earlier access to a pediatric rheumatologist and JIA diagnosis, increased rates of treatment with biologic drugs, higher rates of clinical remission, and lower rates of uveitis complications in Chilean children with JIA.

[Diagnostic validity of fecal occult blood test in infants with food protein-induced allergic proctocolitis]

INTRODUCTION

Food protein-induced allergic proctocolitis (FPIAP) is the most frequent presenta tion of non-IgE mediated food allergy (FA). The diagnosis is made by oral food challenge, however, non-invasive diagnostic tests are not available. In Chile, the fecal occult blood test (FOBT) is fre quently used to confirm FPIAP, however, there are no studies that support this practice.

OBJECTIVE

To establish the diagnostic validity of FOBT in the evaluation of infants with FPIAP.

PATIENTS AND METHOD

Case-control study with prospective recruitment of infants with rectal bleeding and suspicion of FPIAP, and controls were healthy infants, in whom the FOBT was conducted. All cases underwent an elimination diet, after which the diagnosis of FPIAP was confirmed by oral food cha llenge.

RESULTS

25 cases and 29 controls were included without significant differences in age, gen der, type of delivery, feeding, and maternal age. The cases had higher rates of allergic comorbidities, medication use, and family history of allergy. The FOBT was positive in 84% of cases and in 34% of controls (p < 0.001). The sensitivity of the FOBT for the diagnosis of FPIAP was 84%, specificity was 66%, positive predictive value 68%, and the negative predictive value 83%. The area under the ROC curve was 0.75 (CI 95% 0.61-0.88).

CONCLUSIONS

Although the FOBT has an adequate sensitivity to diagnose FPIAP in infants with rectal bleeding, this test had abnormal results in more than a third of healthy infants. Therefore, the routine use of FOBT is not recommended for the diagnosis of FPIAP.

Symptomatic Rathke's cleft cyst with amyloid stroma

A patient with panhypopituitarism and visual field defects due to a Rathke's cleft cyst is presented. These cysts are commonly found in random pituitaries examined at necropsy, but rarely produce symptoms. Subtle endocrine deficiencies, however, may now be uncovered more frequently with modern diagnostic techniques. An unusual and unreported feature of this cyst was an apudamyloid stroma. This would imply that cells derived from the neural crest participate in the formation of the cyst. Recognition of these cysts at the time of operation is important in avoiding confusion with pituitary adenomas and unnecessarily aggressive treatment.