Imaging of Inflammatory Arthritis in Children

Procedures for the content, conduct and format of EULAR/PReS paediatric musculoskeletal ultrasound courses

Background

Despite the worldwide increasing request of education on paediatric musculoskeletal ultrasound (PedMSUS), content, conduct and format of PedMSUS courses have never been internationally agreed.

Objectives

To produce educational procedures for the conduct, content and format of EULAR/PReS PedMSUS courses.

Methods

After a systemic literature review and expert opinion collection, a panel of items for the development of procedures on PedMSUS courses was identified. Agreement on the items was assessed through Delphi surveys among a taskforce of 24 members, which included 18 experts in PedMSUS (8 rheumatologists, 1 radiologist, 9 paediatric rheumatologists), 1 methodologist and rheumatologist expert in MSUS, 2 patient research partners, 1 health professional in rheumatology and 2 EMEUNET/EMERGE members, from 8 different European countries. Each item was assessed through a 5-point Likert scale (0, full disagreement; 5, full agreement); agreement was reached for >75% of answers rating 4–5. All items with agreement were included in the preliminary core set of educational procedures, which underwent external assessment by a broader Consensus group (Faculty and Tutors of previous EULAR PedMSUS courses and PReS Imaging Working Party members), through Delphi survey.

Results

Two Delphi surveys produced the preliminary core set of procedures for basic, intermediate, advanced and teach-the-teachers (TTT) PedMSUS courses. A Delphi survey within the Consensus group produced agreement on the proposed procedures.

Conclusions

Shared EULAR/PReS procedures for the conduct, content and format of basic, intermediate, advanced and TTT PedMSUS courses were identified on international basis.

Ultraschalldiagnostik in der Kinderrheumatologie

Der Artikel gibt einen Überblick zum aktuellen Stand der Ultraschallbefundung in der Kinderrheumatologie und geht insbesondere auf den praktischen Einsatz und die technischen Aspekte der Gelenksonografie ein. Dabei werden auch die wissenschaftlichen Entwicklungen der letzten Jahre zusammengefasst und berücksichtigt. Neben der Gelenksonografie wird die Ultraschalltechnik in der Kinderrheumatologie zunehmend auch auf weitere Körperregionen und -organe ausgeweitet, die für die kinderrheumatologische Diagnostik relevant sind.

The new role of musculoskeletal ultrasound in the treat-to-target management of juvenile idiopathic arthritis

This article reviews the role of musculoskeletal ultrasound (MSUS) for the diagnosis, monitoring and treat-to-target management of JIA. Technological advancements in MSUS allow more precise evaluation of arthritis, tenosynovitis and enthesitis versus clinical examination alone, which may assist treatment decisions. In adult studies, serum and synovial biomarkers have correlated with MSUS findings. Within paediatric rheumatology, significant developments in the definition of normal and pathology, a necessity for the future integration of MSUS into treat-to-target management, have already been reached or are underway, which in turn could allow tighter control of disease activity and earlier identification of treatment response and failure, bringing the goal of 'precision medicine' closer. Additionally, the utility of MSUS for the evaluation of subclinical disease remains an unexamined area of interest. 'Ultrasound remission' combined with clinical assessment and immunological markers could therefore potentially improve the treat-to-target management of JIA.

Ultrasound imaging in paediatric rheumatology

The role of ultrasound imaging in the diagnosis and monitoring of paediatric rheumatic diseases with special emphasis on recent scientific work regarding the evidence base and standardization of this technique is being reviewed. An overview of the most important practical aspects for the use of musculoskeletal ultrasound in a clinical setting is also provided. Huge scientific efforts and advances in recent years illustrate the increasing importance of musculoskeletal ultrasound in pediatric rheumatology. Several studies focused on setting an evidence-based standard for the ultrasound appearance of healthy and normal joints in children of all age groups. Physiologic vascularization and ossification were two main aspects of these studies. Other publications demonstrate that ultrasound imaging is also an important and useful tool to detect pathology as synovitis, tenosynovitis or enthesitis in children and to monitor pediatric patients with rheumatic conditions. Important practical aspects include training in the use of correct ultrasound techniques, as well as knowledge and experience of normal pediatric sonoanatomy and the appearance of pathological findings on ultrasound.

Juvenile-Versus Adult-Onset Spondyloarthritis: Similar, but Different

This article provides an overview of juvenile spondyloarthritis and important differences in the classification criteria, clinical presentation, outcomes, and pathology in juvenile versus adult-onset disease. Key differences in classification criteria between children and adults with spondyloarthritis are important to understand, as they can make transition from pediatric to adult care challenging. MRI and ultrasonography are increasingly relied on for the assessment of adult-onset disease activity and change over time in the pediatric population. The unique features of the maturing axial and peripheral skeleton are described for each modality, as they are key to understand for accurate interpretation of pathology in the pediatric population.

The Role of Ultrasound in Juvenile Idiopathic Arthritis: A Narrative Review From an Imaging Perspective

Objective:

Musculoskeletal sonography (MSKS) is increasingly being used in the setting of juvenile idiopathic arthritis (JIA). The purpose of this narrative review was to describe the role of sonography in JIA and outline strategies for operators of pediatric MSKS.

Methods:

A literature review through multiple medical databases was conducted by restricting the search to medical subject headings (MeSH). Peer-reviewed English-language articles from 2007 to 2018 were included, which focused the on common sonographic findings of JIA.

Results:

Twenty-six articles were selected for inclusion in the study after a complete reading. Many studies aimed to address the validity of sonographic techniques in the assessment of JIA, but few studies discussed the specific sonographic appearances of JIA, scanning pitfalls, and appropriate imaging techniques.

Conclusion:

MSKS reveals subclinical manifestations of arthropathy, but the true value of detecting subclinical disease is not well understood. MSKS is limited in the evaluation of articular cartilage thinning and bony erosions. Responsiveness of MSKS in JIA remains to be formally assessed with higher quality studies.

Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance

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.