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Tarsia M, Zajc Avramovič M, Gazikalović A, Ključevšek D, Avčin T. A clinical perspective on imaging in juvenile idiopathic arthritis. Pediatr Radiol 2024; 54:490-504. [PMID: 38015293 PMCID: PMC10984900 DOI: 10.1007/s00247-023-05815-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity, and predict disease course and outcome in children with juvenile idiopathic arthritis (JIA). Over the past few decades, great efforts have been made to improve the quality of diagnostic imaging and to reach a consensus on which methods and scoring systems to use. However, there are still some critical issues, and the diagnosis, course, and management of JIA are closely related to clinical assessment. This review discusses the main indications for conventional radiography (XR), musculoskeletal ultrasound (US), and magnetic resonance imaging (MRI), while trying to maintain a clinical perspective. The diagnostic-therapeutic timing at which one or the other method should be used, depending on the disease/patient phenotype, will be assessed, considering the main advantages and disadvantages of each imaging modality according to the currently available literature. Some brief clinical case scenarios on the most frequently and severely involved joints in JIA are also presented.
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Affiliation(s)
- Maria Tarsia
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Mojca Zajc Avramovič
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva 20 SI-1525, 1000, Ljubljana, Slovenia
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ana Gazikalović
- Department of Radiology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva ulica 20, 1000, Ljubljana, Slovenia
| | - Damjana Ključevšek
- Department of Radiology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva ulica 20, 1000, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva 20 SI-1525, 1000, Ljubljana, Slovenia.
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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2
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Averill LW, Kraft DB, Sabado JJ, Atanda A, Long SS, Nazarian LN. Ultrasonography of the pediatric elbow. Pediatr Radiol 2023; 53:1526-1538. [PMID: 36869262 DOI: 10.1007/s00247-023-05623-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 03/05/2023]
Abstract
Ultrasound of the elbow can be incorporated into routine pediatric practice in the radiology department, emergency department, orthopedic clinic, and interventional suite. Ultrasound is complementary to radiography and magnetic resonance imaging for the evaluation of elbow pain in athletes with overhead activities or valgus stress, focusing on the ulnar collateral ligament medially and capitellum laterally. As a primary imaging modality, ultrasound can be used for a variety of indications including inflammatory arthritis, fracture diagnosis, and ulnar neuritis/subluxation. Ultrasound is also well-suited to guide diagnostic and therapeutic elbow joint interventions with precise localization of anatomic landmarks and needle placement. Here, we describe technical aspects of elbow ultrasound and illustrate its application in pediatric patients from infants to teen athletes.
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Affiliation(s)
- Lauren W Averill
- Department of Radiology, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Denver B Kraft
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Jeremiah J Sabado
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alfred Atanda
- Department of Orthopaedic Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Suzanne S Long
- Department of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Levon N Nazarian
- Department of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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3
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Foot and Ankle Conventional Radiography in Juvenile Idiopathic Arthritis: Does It Still Matter? J Belg Soc Radiol 2022; 106:87. [PMID: 36213368 PMCID: PMC9503895 DOI: 10.5334/jbsr.2729] [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: 12/10/2021] [Accepted: 08/27/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives: The aim of this study was to evaluate the residual value of Conventional Radiography in children with arthralgia clinically suspected of Juvenile Idiopathic Arthritis (JIA). Materials and Methods: Three hundred seventy-two patients aged 1–18 years suspected of JIA were retrospectively reviewed. All patients had foot and ankle plain films performed in standard two projections: ankle in antero-posterior and lateral, and foot in antero-posterior and oblique. The cohort was divided into two groups: patients with confirmed JIA and non-JIA control group of children with foot and ankle arthralgia without diagnosis of inflammatory connective tissue disease. Radiographic findings in both groups were compared. Results: In 40% of JIA and 70% of non-JIA patients radiographs were normal. All radiographic findings were significantly more common in JIA than in non-JIA group (p = 0.000). Soft tissue swelling was the most frequent abnormality found in JIA patients (31, 51%) and only in 2.41% of non-JIA patients (p = 0.000). Osteoporosis and joint space narrowing were also significantly more common in JIA group (p = 0.000). The majority of imaging findings in non-JIA group were non-inflammatory abnormalities. Conclusion: Conventional radiography is an important tool in differential diagnosis of arthralgia of unknown etiology, as soft tissue swelling, osteoporosis and joint space narrowing are significantly more common in JIA patients as compared with patients without the diagnosis of inflammatory connective tissue disease. However, in case of high clinical suspicion of JIA and normal radiography, we recommend subsequent ultrasound (US) and/or MRI to allow early treatment.
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Lassoued Ferjani H, Maatallah K, Miri S, Triki W, Nessib DB, Kaffel D, Hamdi W. Enthesitis-related arthritis: monitoring and specific tools. J Pediatr (Rio J) 2022; 98:223-229. [PMID: 34597529 PMCID: PMC9432174 DOI: 10.1016/j.jped.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES In this article, the authors aimed to review the different tools used in the monitoring of enthesitis-related arthritis. SOURCES The authors performed a literature review on PubMed, Google Scholar, and Scopus databases. The dataset included the original research and the reviews including patients with enthesitis-related arthritis or juvenile spondylarthritis up to October 2020. SUMMARY OF FINDING Enthesitis-related arthritis is a category of juvenile idiopathic arthritis. It is characterized by the presence of enthesitis, peripheral arthritis, as well as axial involvement. The only validated tool for disease activity measurement in juvenile idiopathic arthritis is the Disease Activity Score: It has proven its reliability and sensitivity. Nevertheless, due to an absence of validated evaluation tools, the extent of functional impairment, as well as the children and parents' perception of the disease, could not be objectively perceived. Despite the great progress in the field of imaging modalities, the role they play in the evaluation of disease activity is still controversial. This is partially due to the lack of validated scoring systems. CONCLUSIONS Further work is still required to standardize the monitoring strategy and validate the outcome measures in enthesitis-related arthritis.
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Affiliation(s)
- Hanène Lassoued Ferjani
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia.
| | - Kaouther Maatallah
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Sirine Miri
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia
| | - Wafa Triki
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Dorra Ben Nessib
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Dhia Kaffel
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Wafa Hamdi
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
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Serum Calprotectin a Potential Biomarker in Juvenile Idiopathic Arthritis: A Meta-Analysis. J Clin Med 2021; 10:jcm10214861. [PMID: 34768386 PMCID: PMC8584429 DOI: 10.3390/jcm10214861] [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: 09/28/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common inflammatory chronic disease affecting children and adolescents. Today, there are no specific biomarkers of inflammation. Therefore, it is important to identify new markers as predictors of disease activity. Recently, some researchers have directed their interest toward a protein, calprotectin (CLP), as a potential biomarker. The primary objective of our systematic review and meta-analysis was to analyze the possible role of CLP in JIA. Method: A literature search was conducted using PubMed, EMBASE, Scopus, Science Direct on 10 August 2021. The selection of studies was made using the PRISMA 2020 guidelines. Cohen’s d with 95% CI and p-value were used as a measure of effect size. The random effects model was used to account for different sources of variation among studies. Heterogeneity was assessed using Q statistics and I2. The publication bias was analyzed and represented by a funnel plot, and funnel plot symmetry was assessed with Egger’s test. Results: Our results at follow-up showed a statistically significant difference between patients with active disease compared to patients with inactive disease: 0.39 (0.16; 0.62), p = 0.001; without statistical heterogeneity. Another important aspect that emerged were the differences between the systemic disease form and any form of inactive disease showing a different concentration of calprotectin: 0.74 (0.40; 1.08), p < 0.001; without statistical heterogeneity. On the other hand, meta-regression analyses performed on gender, age, duration of disease, percentage of patients with ANA+ or RF+, medium value of ESR or CRP were not statistically significant. A statistically significant difference in serum calprotectin concentration between patients with JIA and healthy controls were observed. In fact, it presented lower values in the control group. Conclusions: The use of serum CLP could represent, in the future, a useful tool in JIA in order to stratify disease activity more accurately and may aid a more tailored approach to drug of choice in children with JIA. Further studies are needed to evaluate CLP as a predictor of flare in combination with other potential biomarkers of subclinical disease activity.
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Choida V, Hall-Craggs M, Jebson BR, Fisher C, Leandro M, Wedderburn LR, Ciurtin C. Biomarkers of Response to Biologic Therapy in Juvenile Idiopathic Arthritis. Front Pharmacol 2021; 11:635823. [PMID: 33603671 PMCID: PMC7884612 DOI: 10.3389/fphar.2020.635823] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/31/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory arthritis of childhood, characterized by various clinical phenotypes associated with variable prognosis. Significant progress has been achieved with the use of biologic treatments, which specifically block pro-inflammatory molecules involved in the disease pathogenesis. The most commonly used biologics in JIA are monoclonal antibodies and recombinant proteins targeting interleukins 1 (IL-1) and 6 (IL-6), and tumor necrosis factor α (TNF-α). Several biomarkers have been investigated in JIA. Aims: To assess the level of evidence available regarding the role of biomarkers in JIA related to guiding clinical and therapeutic decisions, providing disease prognostic information, facilitating disease activity monitoring and assessing biologic treatment response in JIA, as well as propose new strategies for biologic therapy-related biomarker use in JIA. Methods: We searched PubMed for relevant literature using predefined key words corresponding to several categories of biomarkers to assess their role in predicting and assessing biologic treatment response and clinical remission in JIA. Results: We reviewed serological, cellular, genetic, transcriptomic and imaging biomarkers, to identify candidates that are both well-established and widely used, as well as newly investigated in JIA on biologic therapy. We evaluated their role in management of JIA as well as identified the unmet needs for new biomarker discovery and better clinical applications. Conclusion: Although there are no ideal biomarkers in JIA, we identified serological biomarkers with potential clinical utility. We propose strategies of combining biomarkers of response to biologics in JIA, as well as routine implementation of clinically acceptable imaging biomarkers for improved disease assessment performance.
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Affiliation(s)
- Varvara Choida
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
| | | | - Bethany R. Jebson
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- University College London Great Ormond Street Institute for Child Health, London, United Kingdom
| | - Corinne Fisher
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
| | - Maria Leandro
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
| | - Lucy R. Wedderburn
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- University College London Great Ormond Street Institute for Child Health, London, United Kingdom
- NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, United Kingdom
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
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7
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Evaluation of the thicknesses of cartilage and enthesis in familial Mediterranean fever and enthesitis-related arthritis. North Clin Istanb 2020; 7:591-596. [PMID: 33381699 PMCID: PMC7754861 DOI: 10.14744/nci.2020.54037] [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: 08/22/2019] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE: Subclinical inflammation is still a controversial issue in inflammatory diseases. There is no reliable, easy, and cheap inflammation marker in daily clinical practices currently. This study aims to predict clinical remission using cartilage and tendon thicknesses. METHODS: Eleven patients with Familial Mediterranean Fever (FMF) who had musculoskeletal involvement before and 11 patients with Enthesitis-Related Arthritis (ERA) were included in this study. They were on remission with clinical and laboratory evaluations for at least three months. Demographic and clinical features of the subjects, including age, sex, body mass index, disease duration, age at onset, medical treatment, and laboratory evaluations, were all noted. Healthy children of the same age were included as the control group. The thicknesses of the bilateral knee, second metacarpophalangeal and ankle joints cartilages, quadriceps, superior and inferior patellar, and the Achilles tendons were measured with a linear probe. A total of 198 joint and 264 tendon thicknesses were measured. RESULTS: The thicknesses of metacarpophalangeal, knee, and ankle cartilages were higher in the FMF group than in the others. In the FMF group, the quadriceps tendon thickness was higher than in the ERA group, and the superior patellar tendon thickness was higher than in the control group (p<0.05). CONCLUSION: According to our preliminary findings, an increased thickness of the cartilage and tendon in FMF patients may be an indicator of subclinical inflammation. Increased thickness of the enthesis in FMF patients may also indicate that enthesitis-related arthritis will also develop in the future.
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Windschall D, Collado P, Vojinovic J, Magni‐Manzoni S, Balint P, Bruyn GAW, Hernandez‐Diaz C, Nieto JC, Ravagnani V, Tzaribachev N, Iagnocco A, D'Agostino MA, Naredo E. Age‐Related Vascularization and Ossification of Joints in Children: An International Pilot Study to Test Multiobserver Ultrasound Reliability. Arthritis Care Res (Hoboken) 2020; 72:498-506. [DOI: 10.1002/acr.23335] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 08/01/2017] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | | | - Peter Balint
- National Institute of Rheumatology and Physiotherapy Budapest Hungary
| | | | | | - Juan Carlos Nieto
- Hospital General Universitario Gregorio Marañón and Complutense University Madrid Spain
| | | | | | | | - Maria Antonietta D'Agostino
- APHPHôspital Ambroise Paré, 92100 Boulogne‐Billancourt, INSERM U1173, UFR Simone Veil, and Versailles‐Saint‐Quentin University Saint‐Quentin en Yvelines France
| | - Esperanza Naredo
- Hospital General Universitario Gregorio Marañón and Complutense University Madrid Spain
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Cimaz R, Giani T, Caporali R. What is the real role of ultrasound in the management of juvenile idiopathic arthritis? Ann Rheum Dis 2020; 79:437-439. [PMID: 32060038 DOI: 10.1136/annrheumdis-2019-216358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/10/2020] [Accepted: 02/03/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy .,REsearch Center for Adult and Pediatric Rheumatic Diseases, Milano, Italy.,ASST G Pini, Milano, Italy
| | - Teresa Giani
- AOU Meyer, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy.,REsearch Center for Adult and Pediatric Rheumatic Diseases, Milano, Italy.,ASST G Pini, Milano, Italy
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10
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Brunner E, Ting T, Vega-Fernandez P. Musculoskeletal ultrasound in children: Current state and future directions. Eur J Rheumatol 2020; 7:S28-S37. [PMID: 35929859 PMCID: PMC7004269 DOI: 10.5152/eurjrheum.2019.19170] [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: 09/08/2019] [Accepted: 10/20/2019] [Indexed: 08/07/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic inflammatory arthritides that if inadequately treated, may be associated with chronic disability and deformity. Early diagnosis and treatment initiation is essential in the management of patients with JIA. Conventional means of evaluation of disease presence, disease activity and response to therapy including physical exam, labs and x-rays are at times limited and may be insufficient in making an accurate assessment. Musculoskeletal ultrasound (MSUS) is a well-established modality that is patient and family-friendly, non-invasive, does not require sedation and can be performed at the bedside in real-time. MSUS offers information that cannot be attained by standard outcome measures, and may help to advance both diagnosis and treatment of patients with JIA ultimately improving patient outcomes. This review explores the background of MSUS and the current evidence to support its potential role as a diagnostic, disease activity monitoring and interventional tool.
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Affiliation(s)
| | - Tracy Ting
- Department of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patricia Vega-Fernandez
- Department of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Zheng Q, Lu M. Bilateral brachial synovial cysts in systemic juvenile idiopathic arthritis: Case report and literature review. Int J Rheum Dis 2019; 22:1578-1581. [PMID: 31245900 PMCID: PMC6771648 DOI: 10.1111/1756-185x.13618] [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] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/04/2019] [Accepted: 05/09/2019] [Indexed: 11/28/2022]
Abstract
Aim To review the clinical features of brachial synovial cyst. Method A case of bilateral brachial synovial cysts is described in a child suffering from systemic juvenile idiopathic arthritis during a relapse. Magnetic resonance imaging and ultrasonography were conducted to further evaluate the nature of the cysts. The case is compared with known cases in a literature review. Results Review of the literature showed that brachial synovial cysts occur most commonly in systemic juvenile idiopathic arthritis. It is considered that uncontrolled systemic inflammation and recurrent disease activity might be the cause of synovial cysts. Conclusion Brachial synovial cyst is a rare manifestation of juvenile idiopathic arthritis. Uncontrolled systemic inflammation inducing chronic damage to joint structure may be the primary cause of synovial cyst formation.
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Affiliation(s)
- Qi Zheng
- Department of Rheumatology, Immunology and Allergy, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Meiping Lu
- Department of Rheumatology, Immunology and Allergy, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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12
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The role of Doppler Ultrasonography in evaluating disease activity in a group of juvenile idiopathic arthritis patients. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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13
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Gremese E, Fedele AL, Alivernini S, Ferraccioli G. Ultrasound assessment as predictor of disease relapse in children and adults with arthritis in clinical stable remission: new findings but still unmet needs. Ann Rheum Dis 2018; 77:1391-1393. [PMID: 29860230 PMCID: PMC6161664 DOI: 10.1136/annrheumdis-2018-212941] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/11/2018] [Accepted: 05/19/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Elisa Gremese
- Division of Rheumatology, IRCCS-Fondazione Policlinico Universitario A. Gemelli-Catholic University of the Sacred Heart, Rome, Italy
| | - Anna Laura Fedele
- Division of Rheumatology, IRCCS-Fondazione Policlinico Universitario A. Gemelli-Catholic University of the Sacred Heart, Rome, Italy
| | - Stefano Alivernini
- Division of Rheumatology, IRCCS-Fondazione Policlinico Universitario A. Gemelli-Catholic University of the Sacred Heart, Rome, Italy
| | - Gianfranco Ferraccioli
- Division of Rheumatology, IRCCS-Fondazione Policlinico Universitario A. Gemelli-Catholic University of the Sacred Heart, Rome, Italy
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Shelmerdine SC, Di Paolo PL, Tanturri de Horatio L, Malattia C, Magni-Manzoni S, Rosendahl K. Imaging of the hip in juvenile idiopathic arthritis. Pediatr Radiol 2018; 48:811-817. [PMID: 29766251 DOI: 10.1007/s00247-017-4022-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
Hip involvement is common and estimated to occur in approximately 35-63% of children with juvenile idiopathic arthritis (JIA). It is more prevalent in the aggressive systemic subtypes, with irreversible changes occurring as early as within 5 years of diagnosis. Whilst clinical parameters and joint examination can be useful for assessing disease severity, subclinical disease is known to exist and delayed treatment may herald a lifetime of disability and pain. Early recognition of JIA changes is therefore crucial in determining treatment options. Validated scoring systems in the radiologic assessment of the hip for clinical drug trials may inform treatment outcomes, although robust tools for analysis are still lacking. This review article details the modalities utilised for imaging the hip in children with JIA with particular efforts focused upon reliability and validity in their assessment of joint disease. We conclude with a short literature review on the potential future techniques being developed for hip joint imaging in JIA.
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Affiliation(s)
- Susan Cheng Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Pier Luigi Di Paolo
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Clara Malattia
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Largo Gaslini, Genoa, 5, 16147, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), University of Genova, Genoa, Italy
| | - Silvia Magni-Manzoni
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), University of Genova, Genoa, Italy.,Pediatric Rheumatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Karen Rosendahl
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway
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Zhao Y, Rascoff NE, Iyer RS, Thapa M, Reichley L, Oron AP, Wallace CA. Flares of Disease in Children with Clinically Inactive Juvenile Idiopathic Arthritis Were Not Correlated with Ultrasound Findings. J Rheumatol 2018; 45:851-857. [PMID: 29606669 DOI: 10.3899/jrheum.170681] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The validity of our current definitions for clinically inactive disease (CID) in juvenile idiopathic arthritis (JIA) based on physical examination is challenged by the development of advanced musculoskeletal imaging tools. We aimed to prospectively determine the prevalence of abnormal ultrasound (US) findings in children with CID in JIA and their clinical significance. METHODS Children aged ≥ 4 years with CID and a history of arthritis from a single tertiary center were approached over 1 year. Standard US of knees, tibiotalar joints, subtalar joints, and wrists were performed at baseline and at a followup visit. US images were scored by 2 pediatric musculoskeletal radiologists. RESULTS Forty children with CID were enrolled and followed clinically. The median duration of inactive disease was 1 year. The most common International League of Associations for Rheumatology JIA categories were extended oligoarticular JIA (30%) and rheumatoid factor-negative polyarthritis (38%). At baseline, among a total of 289 joints scanned, 24 joints (8%) had at least 1 abnormal finding in 18 (45%) of 40 subjects. When evaluated at the individual joint level against flares identified during followup exams, these baseline US findings had a sensitivity of 15% and a positive predictive value of 12%. The predictive performance of the second US was even less. CONCLUSION Our study demonstrates that nearly half of children with CID had abnormal US findings in 1 of 8 commonly affected joints. These findings did not correlate with subsequent clinical flares in up to 2 years of followup.
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Affiliation(s)
- Yongdong Zhao
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA. .,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project.
| | - Nanci E Rascoff
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Ramesh S Iyer
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Mahesh Thapa
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Lucas Reichley
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Assaf P Oron
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Carol A Wallace
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
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Nguyen JC, Lee KS, Thapa MM, Rosas HG. US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection. Radiographics 2017; 37:1181-1201. [PMID: 28696851 DOI: 10.1148/rg.2017160137] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy. © RSNA, 2017.
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Affiliation(s)
- Jie C Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Kenneth S Lee
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Mahesh M Thapa
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Humberto G Rosas
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
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Miotto e Silva VB, Mitraud SDAV, Furtado RNV, Natour J, Len CA, Terreri MTDSELRA. Patients with juvenile idiopathic arthritis in clinical remission with positive power Doppler signal in joint ultrasonography have an increased rate of clinical flare: a prospective study. Pediatr Rheumatol Online J 2017; 15:80. [PMID: 29132381 PMCID: PMC5683235 DOI: 10.1186/s12969-017-0208-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 10/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ultrasonography (US) studies carried out on joints of juvenile idiopathic arthritis (JIA) patients in clinical remission demonstrate the presence of subclinical synovitis. The significance of subclinical synovitis and the positive power Doppler (PD) signal on US in JIA in clinical remission is not well understood. The objectives of this study were to assess whether the changes detected by US in patients with JIA in clinical remission can predict disease flare and to evaluate factors associated with flare and joint damage over 30 months of follow-up. METHODS A prospective study was performed with clinical and ultrasound evaluation in 34 joints of JIA patients in clinical remission. Clinical evaluation including physical exam, functional capacity and inflammatory markers was performed at baseline and every six months thereafter, for a total period of 30 months. US evaluation included presence of synovitis, PD signal and erosion at baseline and every 12 months thereafter. Subclinical synovitis was defined when there was synovitis with or without positive PD signal in US joints of patients in clinical remission. Flare was defined as any joint presenting clinical arthritis requiring therapy modification. RESULTS We evaluated a total of 35 patients, 28 (80%) girls, 14 (40%) persistent oligoarticular subtype, 12 (34.3%) oligoarticular extended and 9 (25.7%) polyarticular and 26 (74.3%) in remission on medication. Twenty (57.1%) patients flared. The risk of flare was five times higher in patients with positive PD signal and 14 times higher in patients in remission on medication. Regarding the assessment of joints after 6 months and 12 months of US evaluation, 70/3162 (2.2%) joints and 80/2108 (3.8%) joints flared, respectively. Joints with subclinical synovitis with positive PD signal flared more after 6 and 12 months. Twenty five of 2108 (1.2%) joints showed erosion over time. Joints with subclinical synovitis with or without positive PD signal showed more erosion. CONCLUSIONS Patients in remission on medication with subclinical synovitis with positive PD signal on US have a higher risk of flare, therefore they should be monitored closely during treatment. In the same way, joints with subclinical synovitis with or without positive PD signal should be monitored due to the risk of flare and joint damage.
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Affiliation(s)
- Vanessa Bugni Miotto e Silva
- 0000 0001 0514 7202grid.411249.bPediatric Rheumatology Unit, Allergy, Immunology and Rheumatology Division, Pediatric Department, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Borges Lagoa Street, 802, Vila Clementino, São Paulo, SP Zip code 04038-001 Brazil
| | | | - Rita Nely Vilar Furtado
- 0000 0001 0514 7202grid.411249.bRheumatology Division, Department of Medicine, UNIFESP/EPM, São Paulo, Brazil
| | - Jamil Natour
- 0000 0001 0514 7202grid.411249.bRheumatology Division, Department of Medicine, UNIFESP/EPM, São Paulo, Brazil
| | - Claudio Arnaldo Len
- 0000 0001 0514 7202grid.411249.bPediatric Rheumatology Unit, Allergy, Immunology and Rheumatology Division, Pediatric Department, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Borges Lagoa Street, 802, Vila Clementino, São Paulo, SP Zip code 04038-001 Brazil
| | - Maria Teresa de Sande e Lemos Ramos Ascensão Terreri
- 0000 0001 0514 7202grid.411249.bPediatric Rheumatology Unit, Allergy, Immunology and Rheumatology Division, Pediatric Department, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Borges Lagoa Street, 802, Vila Clementino, São Paulo, SP Zip code 04038-001 Brazil
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Basra HAS, Humphries PD. Juvenile idiopathic arthritis: what is the utility of ultrasound? Br J Radiol 2017; 90:20160920. [PMID: 28291375 DOI: 10.1259/bjr.20160920] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a heterogeneous condition and an important cause of acquired disability in children. Evidence supports early treatment to prevent future complications. This relies on prompt diagnosis, achieved by a high index of clinical suspicion and supportive evidence, including the detection of joint and or tendon inflammation. Ultrasound is a readily accessible, well-tolerated, safe and accurate modality for assessing joints and the surrounding soft tissues. It can also be used to guide therapy into those joints and tendon sheaths resistant to systemic treatments. Ultrasound imaging is highly operator dependent, and the developing skeleton poses unique challenges in interpretation with sonographic findings that can mimic pathology and vice versa. Ultrasound technology has been rapidly improving and is more accessible than ever before. In this article, we review the normal appearances, highlight potential pitfalls and present the key pathological findings commonly seen in JIA.
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Affiliation(s)
- Hershernpal A S Basra
- 1 Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Paul D Humphries
- 2 Department of Radiology, Great Ormond Street Hospital for Children, University College London Hospital NHS Foundation Trust, London, UK
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Musculoskeletal Ultrasound for Diagnosis and Treatment in Juvenile Idiopathic Arthritis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Horton DB, Onel KB, Beukelman T, Ringold S. Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance. J Rheumatol 2017; 44:352-360. [PMID: 28148696 DOI: 10.3899/jrheum.161078] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the attitudes and strategies of pediatric rheumatology clinicians toward withdrawing medications for children with clinically inactive juvenile idiopathic arthritis (JIA). METHODS Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed an anonymous electronic survey on decision making and approaches for withdrawing medications for inactive nonsystemic JIA. Data were analyzed using descriptive statistics. RESULTS Of 388 clinicians in CARRA, 124 completed surveys (32%), predominantly attending pediatric rheumatologists. The most highly ranked factors in decision making for withdrawing medications were the duration of clinical inactivity, drug toxicity, duration of prior activity, patient/family preferences, joint damage, and JIA category. Diagnoses of rheumatoid factor-positive polyarthritis and persistent oligoarthritis made respondents less likely and more likely, respectively, to withdraw JIA medications. Three-quarters of respondents waited for 6-12 months of inactive disease before stopping methotrexate (MTX) or biologics, but preferences varied. There was also considerable variability in the strategies used to reduce, taper, or stop medications for clinically inactive JIA; most commonly, clinicians reported slow medication tapers lasting at least 2 months. For children receiving combination MTX-biologic therapy, 63% of respondents preferred stopping MTX first. Most clinicians reported using imaging only seldom or sometimes to guide decision making, but most were also reluctant to withdraw medications in the presence of asymptomatic imaging abnormalities suggestive of subclinical inflammation. CONCLUSION Considerable variability exists among pediatric rheumatology clinicians regarding when and how to withdraw medications for children with clinically inactive JIA. More research is needed to identify the most effective approaches to withdraw medications and predictors of outcomes.
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Affiliation(s)
- Daniel B Horton
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA. .,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine.
| | - Karen B Onel
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine
| | - Timothy Beukelman
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine
| | - Sarah Ringold
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine
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Żuber Z, Owczarek A, Sobczyk M, Migas-Majoch A, Turowska-Heydel D, Sternal A, Michalczak J, Chudek J. Establishing percentile charts for hip joint capsule and synovial cavity thickness in apparently healthy children. Pediatr Rheumatol Online J 2017; 15:8. [PMID: 28143500 PMCID: PMC5286797 DOI: 10.1186/s12969-017-0136-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The usefulness of musculoskeletal ultrasonography (MSUS) in paediatric population is limited by lack of reference values. One of such parameters is hip joint capsule thickness, postulated as an early measure for synovitis. However, the joint capsule is hardly a distinguished structure from slit synovial cavity in patients with little or no fluid collection. Therefore, in patients without effusion, it is more convenient to measure hip joint capsule thickness together with synovial cavity. The aim of the study was to establish percentile chart for hip joint capsule and synovial cavity thickness (HJC&SCT) in apparently healthy children. MATERIAL AND METHODS The analysis included 816 US of hip joint in 408 children without musculoskeletal disorders, distributed equally throughout the whole developmental period in 18 one-year subgroups. Hip joints US was performed according to standard protocol including measurement of HJC&SCT in a single rheumatology centre by three investigators. RESULTS The 3rd, 10th, 25th, 50th, 75th, 90th, and 97th HJC&SCT percentile curves were depicted in the age and height charts for the combined group of girls and boys. The median HJC&SCT values were increasing with age from 3.7 (C10 - C90: 3.3 - 4.2) mm in the first year of life up to 6.7 (5.8 - 7.3) in 16 years old, and above. In a similar way the increase was seen with height from 3.9 (3.5 - 4.7) mm in shorter than 95 cm to 6.9 (6.2 - 7.4) mm in taller than 169 cm subjects. Intra-observer and inter-observer mean precision was less than 1.8 and 12.5%, respectively. CONCLUSION The developed centile chart for hip joint capsule and synovial cavity thickness in the paediatric population is expected to improve detection of hip joint capsule disorders, including synovitis in juvenile idiopathic arthritis.
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Affiliation(s)
- Zbigniew Żuber
- Department of Older Children with subunits of Neurology and Rheumatology, St. Louis Regional Specialised Children's Hospital, Krakow, Poland.
| | - Aleksander Owczarek
- 0000 0001 2198 0923grid.411728.9Department of Statistics, School of Pharmacy in Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Małgorzata Sobczyk
- Department of Older Children with subunits of Neurology and Rheumatology, St. Louis Regional Specialised Children’s Hospital, Krakow, Poland
| | - Agata Migas-Majoch
- Department of Older Children with subunits of Neurology and Rheumatology, St. Louis Regional Specialised Children’s Hospital, Krakow, Poland
| | - Dorota Turowska-Heydel
- Department of Older Children with subunits of Neurology and Rheumatology, St. Louis Regional Specialised Children’s Hospital, Krakow, Poland
| | - Agnieszka Sternal
- Department of Older Children with subunits of Neurology and Rheumatology, St. Louis Regional Specialised Children’s Hospital, Krakow, Poland
| | - Justyna Michalczak
- Department of Older Children with subunits of Neurology and Rheumatology, St. Louis Regional Specialised Children’s Hospital, Krakow, Poland
| | - Jerzy Chudek
- 0000 0001 2198 0923grid.411728.9Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
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Abstract
BACKGROUND In the recent years, musculoskeletal ultrasound (MSUS) has been regarded as especially promising in the assessment of juvenile idiopathic arthritis (JIA), as a reliable method to precisely document and monitor the synovial inflammation process. MAIN CONTENT MSUS is particularly suited for examination of joints in children due to several advantages over other imaging modalities. Some challenges should be considered for correct interpretation of MSUS findings in children, due to the peculiar features of the growing skeleton. MSUS in JIA is considered particularly useful for its ability to detect subclinical synovitis, to improve the classification of patients in JIA subtypes, for the definition of remission, as guidance to intraarticular corticosteroid injections and for capturing early articular damage. Current evidence and applications of MSUS in JIA are documented by several authors. Recent advances and insights into further investigations on MSUS in healthy children and in JIA patients are presented and discussed in the present review. CONCLUSIONS MSUS shows great promise in the assessment and management of children with JIA. Nonetheless, anatomical knowledge of sonographic changes over time, underlying immunopathophysiology, standardization and validation of MSUS in healthy children and in patients with JIA are still under investigation. Further research and educational efforts are required for expanding this imaging modality to more clinicians in their daily practice.
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Affiliation(s)
- Silvia Magni-Manzoni
- Pediatric Rheumatology Unit, IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio 4, 00165, Rome, Italy.
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Colebatch-Bourn AN, Edwards CJ, Collado P, D'Agostino MA, Hemke R, Jousse-Joulin S, Maas M, Martini A, Naredo E, Østergaard M, Rooney M, Tzaribachev N, van Rossum MA, Vojinovic J, Conaghan PG, Malattia C. EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice. Ann Rheum Dis 2015; 74:1946-57. [PMID: 26245755 DOI: 10.1136/annrheumdis-2015-207892] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/14/2015] [Indexed: 12/12/2022]
Abstract
To develop evidence based points to consider the use of imaging in the diagnosis and management of juvenile idiopathic arthritis (JIA) in clinical practice. The task force comprised a group of paediatric rheumatologists, rheumatologists experienced in imaging, radiologists, methodologists and patients from nine countries. Eleven questions on imaging in JIA were generated using a process of discussion and consensus. Research evidence was searched systematically for each question using MEDLINE, EMBASE and Cochrane CENTRAL. Imaging modalities included were conventional radiography, ultrasound, MRI, CT, scintigraphy and positron emission tomography. The experts used the evidence obtained from the relevant studies to develop a set of points to consider. The level of agreement with each point to consider was assessed using a numerical rating scale. A total of 13 277 references were identified from the search process, from which 204 studies were included in the systematic review. Nine points to consider were produced, taking into account the heterogeneity of JIA, the lack of normative data and consequent difficulty identifying pathology. These encompassed the role of imaging in making a diagnosis of JIA, detecting and monitoring inflammation and damage, predicting outcome and response to treatment, use of guided therapies, progression and remission. Level of agreement for each proposition varied according to the research evidence and expert opinion. Nine points to consider and a related research agenda for the role of imaging in the management of JIA were developed using published evidence and expert opinion.
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Affiliation(s)
- A N Colebatch-Bourn
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK Department of Rheumatology, Yeovil District Hospital, Yeovil, UK
| | - C J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - P Collado
- Hospital Universitario Severo Ochoa, Madrid, Spain
| | - M-A D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France Inserm U1173, Laboratoire d'Excellence INFLAMEX, Université Versailles St. Quentin, Montigny-le-Bretonneux, France
| | - R Hemke
- Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | | | - M Maas
- Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - A Martini
- Institut Gaslini, Genova, Italy Department of Pediatrics, University of Genova, Genova, Italy
| | - E Naredo
- Rheumatology Department, Hospital General Universitario Gregorio Maraňón, Madrid, Spain
| | - M Østergaard
- Copenhagen Center for Arthritis Research, Center of Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - M Rooney
- Queen's University Belfast, Belfast, UK
| | - N Tzaribachev
- Pediatric Rheumatology Research Institute, Bad Bramstedt, Germany
| | - M A van Rossum
- Academic Medical Centre, Emma Children's Hospital, Amsterdam, The Netherlands Department of Rheumatology, Jan van Breemen Research Institute/Reade, Amsterdam, The Netherlands
| | - J Vojinovic
- Faculty of Medicine University of Nis, Department of Pediatric Rheumatology, Clinic Center, Niš, Serbia
| | - P G Conaghan
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds , Leeds, UK
| | - C Malattia
- Institut Gaslini, Genova, Italy Department of Pediatrics, University of Genova, Genova, Italy
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Hassan HAES, El Ganzouri AMI, Ahmed SF, Sayed SMAE. High frequency power doppler ultrasonography in oligoarticular juvenile idiopathic arthritis: Correlation with disease severity. EGYPTIAN RHEUMATOLOGIST 2015. [DOI: 10.1016/j.ejr.2014.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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