Physical activity for paediatric rheumatic diseases: standing up against old paradigms

The Role of Psychology in Pediatric Rheumatic Diseases

Pediatric rheumatic diseases (PRDs) are a heterogeneous group of diseases that can have a chronic unpredictable disease course that can negatively affect mood, functioning, and quality of life. Given the range of difficulties faced in managing PRDs, as well as the psychosocial issues youth with these diseases experience, pediatric psychologists can be well suited to address concerns that arise in care for youth with PRDs including adherence, cognitive assessment, pain management, functional disability, and mood. Potential ways that pediatric psychologists can address these concerns and be embedded within an interdisciplinary treatment plan for youth with PRDs are described.

Feasibility and Acceptability of Yoga for Adolescents with Juvenile Idiopathic Arthritis

BACKGROUND/OBJECTIVES

Yoga is effective for adults with arthritis but unstudied in adolescents with juvenile idiopathic arthritis (JIA).

METHODS

A pilot study assessed the feasibility and acceptability of an 8-week group yoga intervention for adolescents ages 14-18 with JIA. Each 75-min session included breathing techniques, relaxation, mindfulness, and modified yoga postures, using yoga props and a rope wall. An online video was available for home practice. The outcome measures administered at the baseline and at 8 weeks were physician global assessment with joint count, visual assessment with a joint damage assessment index, the Pediatric Quality of Life Arthritis Module 3.0 (Peds QL), and the visual analog scale for pain.

RESULTS

Thirteen out of 25 participants attended ≥1 class with a mean of 5.7 ± 2.2 classes. Common reasons for non-enrollment included distance, schedule, and lack of interest. The average distance to classes was 29.0 ± 41.7 miles. There was a trend toward improvement for joint count (p = 0.07), global assessment (p = 0.10), and the Pain and Hurt domain of the Peds QL (p = 0.13), but no other outcomes approached significance. Satisfaction data from an anonymous survey (n = 8) were high in all areas.

CONCLUSIONS

Adolescents with JIA who attended yoga reported enjoyment, pain reduction, and interest in continued practice with no adverse events. Future studies should consider stakeholder engagement to reduce barriers and larger sample sizes to test the effectiveness.

Physical fitness in adolescent patients with familial Mediterranean fever

INTRODUCTION

Familial Mediterranean fever (FMF) is the most frequent monogenic auto-inflammatory disease worldwide responsible for episodes of fever, serositis and musculoskeletal symptoms. Inflammatory attacks are responsible for sedentary behavior and FMF patients may be at increased cardiovascular risk. Cardiorespiratory Fitness (CRF) and physical capacities during adolescence are associated with cardiovascular mortality in adulthood. In this study, we aimed to describe the physical fitness of FMF adolescents.

METHODS

A monocentric retrospective study at the Versailles Hospital between January 2020 and June 2023. All FMF patients over 14-year-old who had completed a routine physical test were included. Clinical and physical data including results of the 6-minute walking test, timed unipedal stance test, Ruffier-Dickson index, 30-seconds chair-stand test and sit-and-reach test were extracted from medical records. Results were compared with previously published normative reference values and criterion-referenced standards for healthy subjects.

RESULTS

Eighteen FMF patients (12 girls, 6 boys) were included. The median age was 16 years old [14-18]. Clinical history included joint symptoms (n = 11), chest pleuritis (n = 8), and leg pain (n = 11). Estimated VO2max was below the recommended thresholds in 13 patients, which predicts cardiovascular risk. Cardiovascular adaptation was poor in 11 patients. Low VO2max was associated with CRP > 5 mg/l on test day and history of joint symptoms.

CONCLUSION

FMF patients displayed altered physical capacities compared to normative values of healthy subjects. History of musculoskeletal pain, systemic inflammation and sedentary behavior may participate in impaired physical abilities and promote cardiovascular diseases in adulthood. Specific exercise programs could benefit patients for disease control and cardiovascular risk reduction.

Level and correlates of physical activity among children and adolescents with juvenile idiopathic arthritis compared to controls: results from a German nationwide prospective observational cohort study

BACKGROUND

Physical active lifestyles are essential throughout growth and maturation and may offer potential preventive and therapeutic benefit in patients with juvenile idiopathic arthritis (JIA). Insufficient physical activity (PA), in contrast, can lead to aggravation of disease-related symptoms. This study aimed to i) examine PA levels in children and adolescents with JIA compared to general population controls and ii) investigate correlates of pronounced physical inactivity in order to identify risk groups for sedentary behaviour.

METHODS

Data from children and adolescents with JIA and population controls aged 3 to 17 years documented in the National Pediatric Rheumatologic Database (NPRD) and the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) were used. Self-reported PA was collected from parents/guardians of children up to 11 years of age or adolescents 12 years of age and older. To compare PA-related data, age- and sex-specific pairwise analyses were conducted considering NPRD/KiGGS participants' data from 2017. Correlates of physical inactivity among patients were identified using a linear regression model.

RESULTS

Data of 6,297 matched-pairs (mean age 11.2 ± 4.2 years, female 67%, patients' disease duration 4.5 ± 3.7 years, persistent oligoarthritis 43%) were available for evaluation. Almost 36% of patients aged 3-17 years (vs. 20% of controls) achieved the WHO recommended amount of PA, while PA steadily decreased with age (18% of patients aged ≥ 12 years) and varied between JIA categories. Female adolescents and patients with enthesitis-related arthritis were least likely to achieve the minimum recommended level of PA. Physical inactivity was associated with female sex, higher age at disease onset, longer disease duration, more functional disability (C-HAQ) and higher disease activity (cJADAS-10).

CONCLUSIONS

Depending on JIA category, children and adolescents with JIA were similarly or even more likely to achieve the WHO recommended minimum level of PA compared to general population controls. However, since a large proportion of young JIA patients appear to be insufficiently physically active, engagement in targeted efforts to promote PA is urgently needed.

Assessment of quality of life, school performance, and physical activity in adolescents with Familial Mediterranean fever

OBJECTIVES

The aim of this study is to evaluate differences in school performance, school attendance, quality of life, and physical activity in adolescents with Familial Mediterranean fever (FMF) compared to healthy controls.

METHODS

One hundred and twenty-nine patients with FMF and 154 healthy controls between 13 and 18 years were included in the study. Demographic, school performance (according to grade point average), school absenteeism, and type and frequency of exercise were recorded. Quality of life was evaluated with the Pediatric Quality of Life Inventory (PedsQL) 4.0.

RESULTS

The mean age of FMF patients was 15.1 ± 2.7 years, and 69 patients (53.5%) were female. School performance was significantly higher in the control group compared to FMF patients (P < 0.001). In the control group, there were significantly higher participants who engaged in professional sports (P < 0.001). Patients with FMF had significantly lower self-reported PedsQL scores in school functioning, physical, and psychosocial health domains compared to those in the control group (P = 0.001, P < 0.001, and P = 0.028, respectively).

CONCLUSIONS

FMF patients demonstrated lower school performance and quality-of-life scores compared to healthy controls. In addition to improving symptoms in chronic diseases, it is important to evaluate and improve the quality of life of patients in routine practice and to ensure psychosocial well-being.

Impaired cardiorespiratory fitness and endothelial function after SARS-CoV-2 infection in a sample of mainly immunocompromised youth

This study aimed to compare cardiopulmonary fitness and endothelial function 6 months after hospital diagnosis in a sample mainly comprising immunocompromised patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection versus noninfected controls. Youth (n = 30; age: 14 yr; 60% females) with confirmed SARS-CoV-2 seen in a tertiary hospital of Sao Paulo, Brazil, were matched by propensity score based on BMI, age, sex, and pre-existing diseases with a control group who had not been tested positive for SARS-CoV-2 infection (n = 30; age: 15 yr; 50% females). Cardiopulmonary fitness (by means of a cardiopulmonary exercise test: CPET) and brachial flow-mediated dilation (%b-FMD) were assessed 3-6 mo after diagnosis. Patients were matched by propensity score based on BMI, age, sex and pre-existing diseases, if any, with a control group who had not been tested positive for SARS-CoV-2. Compared with controls, patients with COVID-19 showed reduced ventilatory anaerobic threshold (VAT) and peak exercise time and minute ventilation/maximum voluntary ventilation (V̇e/MVV) (all P < 0.01). Brachial endothelial function variables were all adjusted for body surface area (BSA). Patients with COVID-19 had decreased %b-FMD (3.6 vs. 5.4; P = 0.03) mean and positive flow (P = 0.02 and P = 0.03, respectively) versus controls. Adjusted linear regression models exploring associations between CPET variables, %b-FMD and the potential predictors post-COVID-19 syndrome, number of symptoms, hospitalization, and COVID severity did not detect significant associations, except for total shear rate in hospitalization (coefficient: -65.07 [95%CI -119.5;-10.5], P = 0.02). Immunocompromised and previously healthy children and adolescents with COVID-19 presented with impaired exercise capacity and endothelial dysfunction when compared with their noninfected counterparts, but the mechanisms remain unknown.NEW & NOTEWORTHY COVID-19 appeared to impair recovery of exercise capacity and endothelial function in a sample mainly comprising immunocompromised patients, but the mechanisms are unknown. These findings support the need for preventive measures against COVID-19 in this vulnerable population and suggest the necessity of proper monitoring and treatment for these patients.

Lupus Nephritis in Children: Novel Perspectives

Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.

Home-Based Exercise Training in the Recovery of Multisystem Inflammatory Syndrome in Children: A Case Series Study

OBJECTIVE

To assess the potential therapeutic role of exercise on health-related quality of life, assessed by the Pediatric Outcomes Data Collection Instrument (PODCI), coronary flow reserve (CFR), cardiac function, cardiorespiratory fitness, and inflammatory and cardiac blood markers in multisystemic inflammatory syndrome in children (MIS-C) patients.

METHODS

This is a case series study of a 12-wk, home-based exercise intervention in children and adolescents after MIS-C diagnosis. From 16 MIS-C patients followed at our clinic, 6 were included (age: 7-16 years; 3 females). Three of them withdrew before the intervention and served as controls. The primary outcome was health-related quality of life, assessed PODCI. Secondary outcomes were CFR assessed by 13N-ammonia PET-CT imaging, cardiac function by echocardiography, cardiorespiratory fitness, and inflammatory and cardiac blood markers.

RESULTS

In general, patients showed poor health-related quality of life, which seemed to be improved with exercise. Additionally, exercised patients showed improvements in coronary flow reserve, cardiac function, and aerobic conditioning. Non-exercised patients exhibited a slower pattern of recovery, particularly in relation to health-related quality of life and aerobic conditioning.

CONCLUSIONS

Our results suggest that exercise may play a therapeutic role in the treatment of post-discharge MIS-C patients. As our design does not allow inferring causality, randomized controlled trials are necessary to confirm these preliminary findings.

Electronic textiles: New age of wearable technology for healthcare and fitness solutions

Sedentary lifestyles and evolving work environments have created challenges for global health and cause huge burdens on healthcare and fitness systems. Physical immobility and functional losses due to aging are two main reasons for noncommunicable disease mortality. Smart electronic textiles (e-textiles) have attracted considerable attention because of their potential uses in health monitoring, rehabilitation, and training assessment applications. Interactive textiles integrated with electronic devices and algorithms can be used to gather, process, and digitize data on human body motion in real time for purposes such as electrotherapy, improving blood circulation, and promoting wound healing. This review summarizes research advances on e-textiles designed for wearable healthcare and fitness systems. The significance of e-textiles, key applications, and future demand expectations are addressed in this review. Various health conditions and fitness problems and possible solutions involving the use of multifunctional interactive garments are discussed. A brief discussion of essential materials and basic procedures used to fabricate wearable e-textiles are included. Finally, the current challenges, possible solutions, opportunities, and future perspectives in the area of smart textiles are discussed.

Physical activity as a promising alternative for young people with juvenile idiopathic arthritis: Towards an evidence-based prescription

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in young people. Although biologics now enable most children and adolescents with JIA to enjoy clinical remission, patients present lower physical activity and spend more time in sedentary behavior than their healthy counterparts. This impairment probably results from a physical deconditioning spiral initiated by joint pain, sustained by apprehension on the part of both the child and the child's parents, and entrenched by lowered physical capacities. This in turn may exacerbate disease activity and lead to unfavorable health outcomes including increased risks of metabolic and mental comorbidities. Over the past few decades, there has been growing interest in the health benefits of increased overall physical activity as well as exercise interventions in young people with JIA. However, we are still far from evidence-based physical activity and / or exercise prescription for this population. In this review, we give an overview of the available data supporting physical activity and / or exercise as a behavioral, non-pharmacological alternative to attenuate inflammation while also improving metabolism, disease symptoms, poor sleep, synchronization of circadian rhythms, mental health, and quality of life in JIA. Finally, we discuss clinical implications, identify gaps in knowledge, and outline a future research agenda.

Construct validity of Patient-Reported Outcomes Measurement Information System Paediatric measures in juvenile idiopathic arthritis and systemic lupus erythematosus: cross-sectional evaluation

OBJECTIVES

Evaluate construct validity of Patient-Reported Outcomes Measurement Information System (PROMIS) Paediatric measures of symptoms and functioning against measures of disease activity among youth with juvenile idiopathic arthritis (JIA) or systemic lupus erythematosus (SLE).

DESIGN

Cross-sectional associations among PROMIS measures and clinical metrics of disease activity were estimated.

SETTING

Seven clinical sites of the Childhood Arthritis and Rheumatology Alliance (CARRA) in the USA.

PARTICIPANTS

Youth aged 8-17 years enrolled in the CARRA Registry.

INTERVENTION

PROMIS measures were collected and associations with clinical measures of disease activity estimated, by condition, in bivariate and multivariable analyses with adjustment for sociodemographics, insurance status, medications and disease duration.

MAIN OUTCOME MEASURES

PROMIS Paediatric measures of mobility, physical activity, fatigue, pain interference, family relationships, peer relationships, depressive symptoms, psychological stress, anxiety, and meaning and purpose, and clinical metrics of disease.

RESULTS

Among 451 youth (average age 13.8 years, 71% female), most (n=393, 87%) had a JIA diagnosis and the remainder (n=58, 13%) had SLE. Among participants with JIA, those with moderate/high compared with low/inactive disease had, on average, worse mobility (multivariable regression coefficient and 95% CIs) (-7.40; -9.30 to -5.50), fatigue (3.22; 1.02 to 5.42), pain interference (4.76; 3.04 to 6.48), peer relationships (-2.58; -4.52 to -1.64), depressive symptoms (3.00; 0.96 to 5.04), anxiety (2.48; 0.40 to 4.56) and psychological stress (2.52; 0.68 to 4.36). For SLE, youth with active versus inactive disease had on average worse mobility (-5.07; -10.15 to 0.01) but PROMIS Paediatric measures did not discriminate participants with active and inactive disease in adjusted analyses.

CONCLUSIONS

Seven PROMIS Paediatric measures discriminated between active and inactive disease in youth with JIA. Results advance the usefulness of PROMIS for understanding well-being and improving interventions for youth with JIA, but larger studies are needed to determine utility in SLE cohorts.

TRIAL REGISTRATION NUMBER

National Institute of Arthritis and Musculoskeletal and Skin Diseases (U19AR069522).

Six-Minute Walk as a Measure of Walking Capacity and Endurance in Patients With Pediatric-Onset Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Despite low levels of disability, youth with pediatric-onset multiple sclerosis (POMS) engage in less physical activity compared with peers. The contribution of walking capacity, endurance, behavior, and MS comorbidities remains relatively undefined and may provide valuable insights into the limitations toward physical activity in youth with MS. The primary objective of this study was to investigate differences in walking capacity, endurance, and real-world behaviors of daily activity between youth with POMS and controls.

METHODS

Youth diagnosed with MS prior to 18 years and aged 21 years or younger were recruited in addition to healthy controls. Participants completed questionnaires to quantify fatigue, depression, and physical activity levels and the timed 2- and 6-minute walk (6MW) as an assessment of walking capacity and endurance. Participants completed questionnaires to quantify fatigue, depression, and physical activity levels. Participants also completed the timed 2- and 6-minute walk (6MW) as an assessment of walking capacity and endurance and were sent home with a waist-worn accelerometer to assess real-world walking behavior.

RESULTS

Forty-five patients with POMS and 85 control participants were enrolled. The POMS cohort had a mean age of 16.9 ± 2.7 years, with a mean disease duration of 2.8 ± 2.6 years. A greater proportion of the POMS cohort was overweight/obese compared with controls (75% vs 33%). Participants with MS walked a significantly shorter distance in 6 minutes compared with controls (1,848 feet vs 2,134 feet, p < 0.0001) and, unlike controls, were unable to accelerate to their peak speed at the end of the 6MW. Body mass index category and MS disease significantly affected 6MW performance. Using continuous accelerometry, participants with MS spent less time in moderate-to-vigorous physical activity compared with controls (20.4 vs 35.4 min/d, p = 0.0003). The POMS cohort reported significantly higher levels of depression and fatigue but self-reported similar levels of daily physical activity as controls.

DISCUSSION

Youth with POMS exhibit slower 6MW performance and less daily engagement in moderate-to-vigorous physical activity, suggesting limitations in functional walking capacity, endurance, and daily activity behavior. Limitations in walking endurance and capacity are most prominent in those youth who are overweight/obese and living with MS.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that, compared with healthy controls, patients with POMS walk shorter distances on the 6MW test, are less able to accelerate to peak speed at the end of the test, and are less physically active.

Physical and Psychosocial Health in Pediatric Uveitis Patients

BACKGROUND

To investigate the possible associations between childhood noninfectious uveitis and cardio-respiratory fitness, physical activity, health related quality of life and fatigue.

METHODS

Cross-sectional analysis of 23 patients with noninfectious uveitis, aged 8-18 years. BMI, exercise capacity, muscle strength and physical activity were measured. Health-related quality of life and fatigue were assessed. The results were compared to standardized values for age matched healthy children.

RESULTS

Twenty-three patients were included. Children with uveitis had a higher bodyweight and body mass index. Children with uveitis had lower cardio-respiratory fitness and they were less physically active, but they experienced a normal quality of life and normal fatigue. Parents of children with uveitis reported a lower quality of life and more fatigue for their children than parents of healthy children.

CONCLUSION

Our study indicates that children with noninfectious uveitis are at risk of developing lower physical and psychosocial health.

Parent Risk Perceptions, Physical Literacy, and Fundamental Movement Skills in Children With Juvenile Idiopathic Arthritis

PURPOSE

This pilot study sought to examine the fundamental movement skills (FMS) and physical literacy (PL) of children with juvenile idiopathic arthritis (JIA) and to explore their relationship with physical activity (PA) and parent perceptions of PA-related risks.

METHODS

Twenty-five children with JIA and their parents completed questionnaires. Fundamental movement skills were assessed in the laboratory and PA through accelerometry data.

RESULTS

Children spent a median of 39.4%, 40.9%, and 18.2% of their day sedentary, in light, and in moderate to vigorous PA, respectively. Fundamental movement skills and PL scores were within the average range, although were related to which joints (upper/lower body) were affected by JIA. Parents who viewed activities such as biking and climbing as risky tended to have children with weaker locomotor skills and lower PL.

CONCLUSION

Children with JIA had age-appropriate PA, FMS, and PL; however, parent perceptions of PA-related risks are related to their child's FMS and PL.

The Role of Psychology in Pediatric Rheumatic Diseases

Pediatric rheumatic diseases (PRDs) are a heterogeneous group of diseases that can have a chronic unpredictable disease course that can negatively affect mood, functioning, and quality of life. Given the range of difficulties faced in managing PRDs, as well as the psychosocial issues youth with these diseases experience, pediatric psychologists can be well suited to address concerns that arise in care for youth with PRDs including adherence, cognitive assessment, pain management, functional disability, and mood. Potential ways that pediatric psychologists can address these concerns and be embedded within an interdisciplinary treatment plan for youth with PRDs are described.

COVID-19 quarantine in adolescents with autoimmune rheumatic diseases: mental health issues and life conditions

Objectives

To assess mental health and life conditions in adolescents with autoimmune rheumatic diseases (ARDs) and healthy controls quarantined during COVID-19 pandemic.

Method

A cross-sectional study included 155 ARD adolescents and 105 healthy controls. Online survey included self-reported strengths and difficulties questionnaire (SDQ), and a semi-structured questionnaire with demographic data, daily home and school routine, physical activities, and COVID-19 information during the pandemic.

Results

Among patients, 56% had juvenile idiopathic arthritis (JIA), 29% juvenile systemic lupus erythematosus (JSLE), and 15% juvenile dermatomyositis (JDM). No differences were found regarding sex, ethnicity, and current age between ARD patients and controls (p > 0.05). Abnormal emotional SDQ (38% vs. 35%, p = 0.653) were similar in both groups. Logistic regression analyses in ARD patients demonstrated that female (OR = 2.4; 95%CI 1.0–6.0; p = 0.044) was associated with severe emotional SDQ dysfunction, whereas sleep problems were considered as a risk factor for both worse total SDQ (OR = 2.6; 95%CI 1.2–5.5; p = 0.009) and emotional SDQ scores (OR = 4.6; 95%CI 2.2–9.7; p < 0.001). Comparisons between ARD patients with and without current prednisone use showed higher median scores of peer problems in the first group [3 (0–10) vs. 2 (0–7), p = 0.049], whereas similar median and frequencies between JIA, JSLE, and JDM (p > 0.05).

Conclusions

Approximately one third of JIA, JSLE, and JDM patients presented abnormal total and emotional scores of SDQ during COVID-19 quarantine. Sleep problems were the main factor associated with emotional difficulties in these ARD adolescents. The knowledge of mental health issues rates in adolescents with ARD supports the development of prevention strategies, like sleep hygiene counseling, as well as the references of the affected patients to specialized mental health services, as necessary.

Key Points • One third of ARD patients presented mental health issues during COVID-19 quarantine • Sleep problems were associated with emotional difficulties. • It is necessary to warn pediatric rheumatologists about the importance of sleep hygiene counseling.

Bone Health in Children with Rheumatic Disorders: Focus on Molecular Mechanisms, Diagnosis, and Management

Bone is an extremely dynamic and adaptive tissue, whose metabolism and homeostasis is influenced by many different hormonal, mechanical, nutritional, immunological and pharmacological stimuli. Genetic factors significantly affect bone health, through their influence on bone cells function, cartilage quality, calcium and vitamin D homeostasis, sex hormone metabolism and pubertal timing. In addition, optimal nutrition and physical activity contribute to bone mass acquisition in the growing age. All these factors influence the attainment of peak bone mass, a critical determinant of bone health and fracture risk in adulthood. Secondary osteoporosis is an important issue of clinical care in children with acute and chronic diseases. Systemic autoimmune disorders, like juvenile idiopathic arthritis, can affect the skeletal system, causing reduced bone mineral density and high risk of fragility fractures during childhood. In these patients, multiple factors contribute to reduce bone strength, including systemic inflammation with elevated cytokines, reduced physical activity, malabsorption and nutritional deficiency, inadequate daily calcium and vitamin D intake, use of glucocorticoids, poor growth and pubertal delay. In juvenile arthritis, osteoporosis is more prominent at the femoral neck and radius compared to the lumbar spine. Nevertheless, vertebral fractures are an important, often asymptomatic manifestation, especially in glucocorticoid-treated patients. A standardized diagnostic approach to the musculoskeletal system, including prophylaxis, therapy and follow up, is therefore mandatory in at risk children. Here we discuss the molecular mechanisms involved in skeletal homeostasis and the influence of inflammation and chronic disease on bone metabolism.

A home-based exercise program during COVID-19 pandemic: Perceptions and acceptability of juvenile systemic lupus erythematosus and juvenile idiopathic arthritis adolescents

OBJECTIVES

To investigate the perceptions and acceptability of a home-based exercise intervention in systemic lupus erythematosus (JSLE) and juvenile idiopathic arthritis (JIA) adolescent patients during the COVID-19 pandemic, and to explore the effects of the intervention on health-related quality of life (HRQoL), sleep quality, and mental health conditions parameters.

METHODS

This was a randomized controlled trial of a 12-week, home-based exercise training program conducted between October and December 2020. During this period, social distancing measures were in place in Brazil to contain the spread of COVID-19. Adolescent patients diagnosed with JSLE and JIA participated in the study. Health-related qualitative and quantitative data were collected before and after the follow-up.

RESULTS

21 JSLE patients and 30 JIA patients were analyzed. Six themes emerged from patients' feedback: 1) Suitability of the home-based format; 2) Appropriate trainer supervision, 3) Motivators and facilitators for the program; 4) Barriers to the program; 5) Health benefits; 6) Patients' suggestions to improve the program. Overall, data indicated that the intervention showed good acceptability and elicited improvements in the perceived HRQoL and fatigue in JIA and JSLE patients during the pandemic. However, further quantitative analyses with validated HRQoL, sleep quality, and mental health conditions instruments did not capture these benefits (p>0.05).

CONCLUSION

Our main findings based on in-depth qualitative assessments suggest that a home-based exercise training program was suitable and well-accepted by adolescents with JSLE and JIA during the COVID-19 pandemic. Nonetheless, adherence was not high, particularly among JIA patients, suggesting that facilitators and barriers identified in the current study should be explored to improve the quality of new home-based exercise programs implementation, particularly in a future emerging crisis.

Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects

Pediatric antiphospholipid syndrome (APS) is a rare acquired multisystem autoimmune thromboinflammatory condition characterized by thrombotic and non-thrombotic clinical manifestations. APS in children and adolescents typically presents with large-vessel thrombosis, thrombotic microangiopathy, and, rarely, obstetric morbidity. Non-thrombotic clinical manifestations are frequently seen in pediatric APS and may be present even before the vascular thrombotic events occur. We review insights into the pathogenesis of APS and discuss potential targets for therapy. The identification of multiple immunologic abnormalities in patients with APS reveals molecular targets for current or future treatment. Management strategies, especially for APS in adolescents, require screening for additional prothrombotic risk factors and consideration of counseling regarding contraceptive strategies, lifestyle recommendations, treatment adherence, and mental health issues associated with this autoimmune thrombophilia. The main goal of therapy in pediatric APS is the prevention of thrombosis. The management of acute thrombosis events in children and adolescents is the same as for primary APS, which involves isolated occurrences, and secondary APS, which is seen in association with another autoimmune disease, e.g., systemic lupus erythematosus. A pediatric hematologist should be consulted so other differential thrombophilic conditions can be eliminated. Therapy includes unfractionated heparin or low-molecular-weight heparin followed by vitamin K antagonists. Treatment of catastrophic APS involves triple therapy (anticoagulation, intravenous corticosteroid pulse therapy, and plasma exchange) and may include intravenous immunoglobulin for children and adolescents with this condition. New drugs such as eculizumab and sirolimus seem to be promising drugs for APS.

The profile of musculoskeletal pain and its associations with sleep quality and depression during the COVID-19 in Turkey

Background

The current pandemic has affected people’s health multidimensionally. This study aims to investigate musculoskeletal pain, sleep quality, depression levels, and their relationships in individuals belonging to different age groups during COVID-19 in Turkey.

Methods

A web-based self-administered survey that consisted of demographic questions, The Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), and scores of musculoskeletal pain was sent to participants. Pearson correlation analysis was used for determining the statistical relationship between variables.

Results

The study includes 1,778 participants. The highest percentage for mild, moderate, and severe pain was in the head (49.8%), back (15.5%), and head (11.5%), respectively. The PSQI-total had shown a weak correlation with pain levels in all body parts. The highest correlation for sleep quality and pain levels was between the PSQI-5 and lower back pain. There was a weak correlation between PSQI-2 and the BDI score, and a moderate correlation between the PSQI-1, PSQI-5, PSQI-7, PSQI-total, and BDI score. Pain in all body parts showed a weak correlation with depression level.

Conclusions

This study showed that musculoskeletal pain was varied in body parts with different intensities according to age groups in Turkey during the pandemic. The most common pain was in the head, back, and lower back. Headache was found correlated with the parameters of sleep quality. Pain of the head, neck, back, lower back, and shoulder were correlated with sleep latency. Sleep quality was associated with depression and musculoskeletal pain, while musculoskeletal pain was correlated with depression.

Home-based exercise program for adolescents with juvenile dermatomyositis quarantined during COVID-19 pandemic: a mixed methods study

BACKGROUND

Exercise has been suggested to prevent deterioration of health-related quality of life (HRQL) and overall health in pediatric rheumatologic diseases during the COVID-19 pandemic. Herein we describe the effects of a 12-week, home-based, exercise program on overall health and quality of life among quarantined patients with juvenile dermatomyositis (JDM).

METHOD

This prospective, quasi-experimental, mixed methods (qualitative and quantitative) study was conducted between July and December 2020, during the most restricted period of COVID-19 pandemic in Brazil. The home-based exercise program consisted of a 12-week, three-times-a-week, aerobic and strengthening (bodyweight) training program. Qualitative data were systematically evaluated. Strengths and Difficulties Questionnaire (SDQ), Pediatric Quality of Life Inventory (PedsQOL) and Pittsburgh Sleep Quality Index (PSQI) evaluate symptoms of mental health disorder, HRQL, and quality of sleep.

FINDINGS

11 patients (out of 27) met the inclusion criteria (91% female; mean ± SD age: 13.5 ± 3.2 years). Adherence to the intervention was 72.6%. Barriers to exercise involved poor internet connectivity, excessive weekly sessions, and other commitments. Even though not statistically significant, Self-report SDQ subscales Total Difficulties Score, Emotional Problems Score, and PedsQOL School Functioning Score improved after intervention (- 2.4; 95%confidence interval [CI] -5.1; 0.2, p = 0.06; - 1.0; 95%CI -2.2; 0.2, p = 0.09 and; 11.7; 95%CI -2.5; 25.8, p = 0.09, respectively). Remaining SDQ subscales were not altered. Six themes emerged from patients' and parents' comments (qualitative results). Patients engaged in exercise reported other health-related benefits including increased motivation, concentration and strength.

INTERPRETATION

A home-based exercise program was associated with qualitative perceptions of improvements in overall health and HRQL by quarantined adolescents with JDM during COVID-19 pandemic. Lessons from this trial may help developing interventions focused on tackling physical inactivity in JDM.

Home-Based Exercise Training in Childhood-Onset Takayasu Arteritis: A Multicenter, Randomized, Controlled Trial

Introduction

Childhood-onset Takayasu Arteritis (c-TA) is a rare, large-vessel vasculitis seen in children that could predisposing patients to a high risk of mortality. Exercise has the potential to improve overall health in several diseases, but evidence remains scant in c-TA. The main objective of this study was to investigate the safety and potential therapeutic effects of exercise in c-TA.

Methods

This was a 12-week, multicenter, randomized, controlled trial, to test the effects of a home-based, exercise intervention vs. standard of care in c-TA patients in remission. The primary outcomes were arterial inflammation, assessed by [¹⁸F] FDG- PET/MRI and systemic inflammatory markers. Secondary outcomes included, physical activity levels, functionality, body composition, disease-related parameters, and quality of life.

Results

Thirty-seven patients were assessed for eligibility, which represents the total number of c-TA patients being followed by the three specialized medical ambulatory services in Sao Paulo. After exclusions, fourteen c-TA patients (71.4% females) aged 12-25 years were randomly allocated into exercised (n=5) and non-exercised groups (n=9). Exercise did not exacerbate arterial inflammation. In fact, exercised patients had a reduction in the frequency of vessel segments with severe inflammation, whereas the non-exercised patients had an opposite response (P=0.007). Greater improvements in visceral fat, steps per day, functionality and physical component SF-36 were observed in the exercised patients (P ≤ 0.05).

Conclusions

Exercise is safe and may improve visceral fat, physical activity levels, functionality, and physical component SF-36 in c-TA patients. Thus, exercise arises as a novel, evidence-based intervention to improve general health in c-TA.

Clinical Trial Registration

https://www.clinicaltrials.gov/ct2/show/NCT03494062?term=NCT03494062&draw=2&rank=1, identifier NCT03494062.

Reducing fatigue in pediatric rheumatic conditions: a systematic review

BACKGROUND

Although fatigue is a prevalent distressing symptom in children and adolescents with Pediatric Rheumatic Conditions (PRCs), intervention studies designed for reducing fatigue in PRCs are limited.

AIM

To systematically review evidence regarding the efficacy of interventions intended to reduce fatigue in patients with PRCs.

METHODS

Comprehensive electronic searches were performed in PubMed/ MEDLINE, Embase, Web of Science and Cinahl. The risk of bias was assessed using the 'Revised Cochrane risk-of-bias tool for randomized trials' and 'Quality Assessment Tool for Before-After Studies With No Control Group' for respectively studies with and without a control group.

RESULTS

Ten out of 418 studies were included with a total of 240 participants (age range 5-23 years). Interventions included land-based and aquatic-based exercise therapy, prednisolone, vitamin-D and creatine supplementation, psychological therapy and a transition program into an adult rheumatology program. Fatigue was assessed with self-reported questionnaires in all included studies. Land-based exercise therapy was effective in one pre-post intervention study, whereas not effective in two randomized controlled trials. Aquatic-based exercise therapy was found more effective than land-based exercise therapy. Two placebo-controlled studies showed a significant positive effect in reducing subjective fatigue with prednisolone and vitamin-D. Creatine was not found effective. Cognitive therapy was effective in one pre-post intervention study, while one RCT did not show an effect in reducing fatigue. A transition program based on health education showed a small reducing effect, however, it was not clear if this was a significant effect. Six studies showed a high risk of bias, three studies a moderate risk, and one study had a low risk of bias.

CONCLUSIONS

Insufficient evidence is provided to substantiate the efficacy of current interventions to reduce fatigue in PRCs. The low number of studies, non-comparable interventions, risk of bias, and inconclusive outcomes of the included studies denote future research should focus on intervention studies aimed at the treatment of fatigue in children and adolescents with PRCs. Identification of possible underlying biological and psychosocial mechanisms as possible treatment targets to reduce complaints of fatigue in children and adolescents with PRCs is warranted.

An Update on the Management of Childhood-Onset Systemic Lupus Erythematosus

Childhood-onset systemic lupus erythematosus (cSLE) is a prototype of a multisystemic, inflammatory, heterogeneous autoimmune condition. This disease is characterized by simultaneous or sequential organ and system involvement, with unpredictable flare and high levels of morbidity and mortality. Racial/ethnic background, socioeconomic status, cost of medications, difficulty accessing health care, and poor adherence seem to impact lupus outcomes and treatment response. In this article, the management of cSLE patients is updated. Regarding pathogenesis, a number of potential targets for drugs have been studied. However, most treatments in pediatric patients are off-label drugs with recommendations based on inadequately powered studies, therapeutic consensus guidelines, or case series. Management practices for cSLE patients include evaluations of disease activity and cumulative damage scores, routine non-live vaccinations, physical activity, and addressing mental health issues. Antimalarials and glucocorticoids are still the most common drugs used to treat cSLE, and hydroxychloroquine is recommended for nearly all cSLE patients. Disease-modifying antirheumatic drugs (DMARDs) should be standardized for each patient, based on disease flare and cSLE severity. Mycophenolate mofetil or intravenous cyclophosphamide is suggested as induction therapy for lupus nephritis classes III and IV. Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin) appear to be another good option for cSLE patients with lupus nephritis. Regarding B-cell-targeting biologic agents, rituximab may be used for refractory lupus nephritis patients in combination with another DMARD, and belimumab was recently approved by the US Food and Drug Administration for cSLE treatment in children aged > 5 years. New therapies targeting CD20, such as atacicept and telitacicept, seem to be promising drugs for SLE patients. Anti-interferon therapies (sifalimumab and anifrolumab) have shown beneficial results in phase II randomized control trials in adult SLE patients, as have some Janus kinase inhibitors, and these could be alternative treatments for pediatric patients with severe interferon-mediated inflammatory disease in the future. In addition, strict control of proteinuria and blood pressure is required in cSLE, especially with angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use.

Physical activity and exercise in patients with pediatric rheumatic disease: A systematic search and review

Childhood rheumatic diseases are a group of diseases that can affect many organs and systems, resulting in pain, joint stiffness, muscle atrophy and weakness. Physical inactivity has been reported in many childhood rheumatic diseases. There are many studies in the literature comparing the effectiveness of exercise programs in children with juvenile idiopathic arthritis. Exercise and physical activity are considered major parts of the treatment of children with rheumatic disease. The aim of this review is to systematically present studies on physical activity and exercise programs in children with rheumatism from the last 5 years. An internet-based search of three databases-PubMed, PEDro and Medline- was conducted to find relevant studies. Two reviewers individually identified studies on the basis of their title, abstract or full text-as necessary-to determine their eligibility. Differences of opinion between the two examiners were resolved by discussion. Scientific studies of children with different rheumatic diagnoses have shown that physical activity and exercise have a significant effect on reducing the symptoms of the disease. However, the duration, frequency, method and evaluation of the exercises are still being discussed in the literature.

Wearable Technologies for Children with Chronic Illnesses: An Exploratory Approach

OBJECTIVE

To determine the utility of wearable technologies in physical activity assessment in three paediatric diseases, namely, Niemann-Pick C (NP-C), Juvenile Idiopathic Arthritis (JIA) and Duchenne Muscular Dystrophy (DMD).

DESIGN

Exploratory study SETTING AND PATIENTS: Thirty children were recruited across three UK hospitals (Royal Manchester's Children Hospital, Great Ormond Street Children's Hospital, and the Great North Children's Hospital). Ten were diagnosed with NP-C, eight with DMD and twelve with JIA.

INTERVENTION

All participants completed the 6-min walk test (6MWT) at enrolment. Patients were provided with disease-specific smartphone apps paired with a wearable device via Bluetooth. Ambulation was recorded in 30-min epochs measuring average daily maximum (ADM), average daily steps (ADS) and average daily steps per 30-min epoch (ASE).

RESULTS

Median 6MWT results were 450 m, 325 m and 434.5 m for the NP-C, DMD and JIA cohorts, respectively. Wearable data capture was feasible in all three disease cohorts, although complete data capture was not sustained. A statistically significant between-cohort difference was identified for ADM, ADS and ASE. Statistically significant differences were found between DMD/JIA for ADM; NP-C/DMD for ADS and DMD/JIA for ASE.

DISCUSSION

Wearable sensor technologies have the potential to provide additional information for our understanding of ambulation in chronic paediatric disease. The wearable devices were easy to use and popular with patients although key features need to be addressed to appropriately meet study objectives. As the technology continues to evolve at a rapid pace, opportunities to implement child friendly solutions are already available.

Poor physical activity levels and cardiorespiratory fitness among patients with childhood-onset takayasu arteritis in remission: a cross-sectional, multicenter study

BACKGROUND

It is currently unknown whether patients with childhood-onset Takayasu disease (c-TA) are prone to physical inactivity and poor aerobic capacity. In this study, we assessed physical activity levels and cardiorespiratory fitness along with health-related quality of life (HRQL) and various traditional and non-traditional risk factors in patients with c-TA vs. healthy controls.

METHODS

c-TA patients with non-active disease (n = 17) and age- and sex-matched healthy controls (n = 17) were enrolled in the study. We assessed physical activity levels, aerobic capacity, body composition, systemic inflammation, cardiometabolic markers, disease-related parameters, and HRQL.

RESULTS

c-TA patients showed greater time spent in sedentary behavior (P = 0.010), and lower moderate-to-vigorous physical activity (P > 0.001) and lower step counts per day (P > 0.001). VO2peak (P < 0.001) and chronotropic response (P = 0.016) were significantly lower in patients with c-TA and they had worse HRQL in physical domain (P < 0.001), lower bone mineral content and density, and higher insulin levels vs. healthy controls (all P ≤ 0.05).

CONCLUSIONS

c-TA patients exhibited reduced physical activity levels and aerobic capacity, worse cardiometabolic risk factors and HRQL parameter compared with healthy peers. Physical inactivity and aerobic deconditioning emerge as potentially novel risk factors for c-TA. The role of physical activity interventions in preventing poor outcomes and improving HRQL in c-TA remains to be explored.

Juvenile Dermatomyositis: New Clues to Diagnosis and Therapy

PURPOSE OF REVIEW

To identify clues to disease activity and discuss therapy options.

RECENT FINDINGS

The diagnostic evaluation includes documenting symmetrical proximal muscle damage by exam and MRI, as well as elevated muscle enzymes-aldolase, creatine phosphokinase, LDH, and SGOT-which often normalize with a longer duration of untreated disease. Ultrasound identifies persistent, occult muscle inflammation. The myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) are associated with specific disease course variations. Anti-NXP-2 is found in younger children and is associated with calcinosis; anti-TIF-1γ+ juvenile dermatomyositis has a longer disease course. The diagnostic rash-involving the eyelids, hands, knees, face, and upper chest-is the most persistent symptom and is associated with microvascular compromise, reflected by loss of nailfold (periungual) end row capillaries. This loss is associated with decreased bioavailability of oral prednisone; the bioavailability of other orally administered medications should also be considered. At diagnosis, at least 3 days of intravenous methyl prednisolone may help control the HLA-restricted and type 1/2 interferon-driven inflammatory process. The requirement for avoidance of ultraviolet light exposure mandates vitamin D supplementation.

SUMMARY

This often chronic illness targets the cardiovascular system; mortality has decreased from 30 to 1-2% with corticosteroids. New serological biomarkers indicate occult inflammation: ↑CXCL-10 predicts a longer disease course. Some biologic therapies appear promising.

Gaps on rheumatologists' knowledge of physical activity

To assess the rheumatologists' knowledge and willingness to prescribe physical activity, we conducted a nationwide survey. All adult and paediatric rheumatologist members of the Brazilian Rheumatology Society were invited to fulfil a questionnaire on their knowledge and willingness to promote physical activity. Four hundred twenty-eight rheumatologists participated in the survey, representing approximately 25% of the society's members. Forty-five percent of the rheumatologists reported having had training to prescribe physical activity, and 68% believe that physical activity is a part of patients' treatment. Most reported assessing physical activity levels (86%) and recommending physical activity (98%) always or most of the time. However, 48% do not know the minimum physical activity recommendations for health maintenance, nor do they know how much vigorous activity should be done in replacement of moderate activity. In addition, only 20% are aware of physical activity recommendation for paediatric patients, whereas 31% know that very light-intensity physical activity promotes health-related beneficial effects. Year of graduation, having been trained on physical activity prescription, and regularly recommending physical activity to patients did not associate with the overall score of correct answers (OR: 1.00 [0.99, 1.02], p = 0.391; OR: 0.99 [0.69, 1.44], p = 983; OR: 0.90 [0.61, 1.32], p = 0.576; respectively). Rheumatologists are highly willing to promote physical activity, but major gaps in their knowledge were identified. Given the widespread recognition of physical activity as a key element on the management of rheumatic patients, these data hint to the need of incorporating physical activity in the rheumatologist' training. Key Points • This survey showed that rheumatologists are highly prone to promote physical activity. • However, rheumatologists have major gaps in knowledge of physical activity. • Adding physical activity to rheumatologist's training programs is key to improve physical activity promotion.

Muscle function and architecture in children with juvenile idiopathic arthritis

AIM

To assess muscle function and functional abilities in children with juvenile idiopathic arthritis (JIA).

METHODS

Fourteen children with JIA and 14 healthy controls matched for age and sex were included. Muscle characteristics, both structural (thickness, cross-sectional area (CSA) and fascicle angle) and qualitative (intermuscular adipose tissue; IMAT), were assessed in thigh muscles using ultrasound and peripheral quantitative computed tomography (pQCT). Muscle function and functional abilities were determined from the assessment of maximal voluntary isometric contraction (MVIC) knee extensors force and vertical jump performance.

RESULTS

No significant difference in MVIC force was observed between the two groups. However, squat jump height was significantly reduced in children with JIA (18.3 ± 5.4 vs 24.3 ± 7.9 cm, P < .05). No differences in structural parameters were observed, but IMAT/CSA (0.22 ± 0.02 vs 0.25 ± 0.03; P = .01) was significantly lower in children with JIA than in healthy children.

CONCLUSION

Knee extensor muscle architecture and force were comparable between children with and without JIA, but functional abilities (vertical jump performance) were poorer in JIA. The lower IMAT area in JIA could result from a lower physical activity level compared with healthy children.

Changes in Eating Habits and Sedentary Behavior During the COVID-19 Pandemic in Adolescents With Chronic Conditions

Introduction: Among healthy adolescents, school closures and home confinement were shown to increase unhealthier eating habits and sedentary behavior. It remains unknown to which extent the pandemic has impacted the lifestyle of adolescents with chronic conditions. Thus, the aim of this study is to report on the impact of the COVID-19 outbreak on eating habits and sedentary behavior among adolescents with multiple chronic conditions (n = 347) from a tertiary, referral hospital vs. healthy peers. Methods: This observational study was conducted in São Paulo (Brazil) between July and October 2020, period in which a set of social distancing measures to contain the pandemic. Results: The main findings of this study were that adolescents with chronic conditions and health peers showed important changes in eating habits (e.g., more often cooking and eating in front of television than before quarantine). Also, 86.8% of adolescents with chronic conditions and 91.6% of healthy adolescents reported increasing screen time during pandemic. No major differences were observed between patients and controls. Conclusions: Adolescents with chronic conditions and healthy peers exposed to pandemic showed substantial changes in lifestyle, stressing the need for specific care to mitigate poor eating habits and excessive sedentary behavior for patients and healthy adolescents.

The effect of test modality on dynamic exercise biomarkers in children, adolescents, and young adults

Cardiopulmonary exercise testing (CPET) modalities, treadmill (TM), and cycle ergometer (CE), influence maximal gas exchange and heart rate (HR) responses. Little is known regarding CPET modality effect on submaximal biomarkers during childhood and adolescence. Ninety‐four healthy participants (7–34 y.o., 53% female) performed TM and CE CPET to address two major gaps: (1) the effect of modality on submaximal CPET biomarkers, and (2) estimation of work rate in TM CPET. Breath‐by‐breath gas exchange enabled calculation of linear regression slopes such as V˙O₂/ΔHR and ΔV˙E/ΔV˙CO₂. Lean body mass (LBM) was measured with dual X‐ray absorptiometry. We tested a novel TM CPET estimate of work rate based on TM velocity², incline, and body mass (VIM). Like the linear relationship between V˙O₂ and work rate in CE CPET, V˙O₂ increased linearly with TM VIM. TM ΔV˙O₂/ΔHR was highly correlated with CE (r = 0.92), and each increased substantially with LBM (P < 0.0001 for TM and CE). ΔV˙O₂/ΔHR was to a small (~8.7%) but significant extent larger in TM (1.6 mL/min/beat, P = 0.04). In contrast, TM and CE ΔV˙E/ΔV˙CO₂ decreased significantly with LBM, supporting earlier observations from CE CPET. For both CE and TM, males had significantly higher ΔV˙O₂/ΔHR but lower ΔV˙E/ΔV˙CO₂ than females. Novel TM CPET biomarkers such as ΔVIM/ΔHR and ∆V˙O₂/ΔVIM paralleled effects of LBM observed in CE CPET. TM and CE CPET submaximal biomarkers are not interchangeable, but similarly reflect maturation during critical periods. CPET analysis that utilizes data actually measured (rather than estimated) may improve the clinical value of TM and CE CPET.

Combating physical inactivity during the COVID-19 pandemic

Physical inactivity is common during periods of self-isolation, but for patients with rheumatic diseases, there are crucial benefits to be gained from maintaining an active lifestyle throughout the COVID-19 pandemic. Patients should be provided with support to maintain physical activity and avoid prolonged periods of time spent sitting.

Lower genital tract infections in young female juvenile idiopathic arthritis patients

BACKGROUND

To evaluate human papillomavirus (HPV), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in juvenile idiopathic arthritis (JIA) patients.

METHODS

After exclusion, 33 female adolescent and young JIA patients (ILAR criteria) and 28 healthy controls were selected for this study. Demographic data, gynecological, sexual function, cervical cytology and histological abnormalities were evaluated. JIA clinical/laboratorial parameters and treatment were also assessed. HPV-DNA, CT-DNA and NG-DNA testing in cervical specimens were performed by Hybrid Capture 2 assays.

RESULTS

The mean current age was similar in JIA patients and controls (23.3 ± 6.24 vs. 26.1 ± 6.03 years, p = 0.09). The frequencies of sexual intercourse (76% vs. 89%, p = 0.201) and abnormal cervical cytology (24% vs. 11%, p = 0.201) were similar in JIA compared to controls. The higher frequency of HPV infection in JIA patients than controls (30% vs. 11%, p = 0.155) did not reach statistical significance. CT (0% vs. 7%, p = 0.207) and NG infections (0% vs. 4%, p = 0.459) were also alike in both groups. Further evaluation of JIA patients with abnormal and normal cervical cytology showed that the former group had a higher frequency of HPV infection (87% vs. 12%, p = 0.0002) with a low frequency of HPV vaccination (0% vs. 8%, p = 1.0). No differences were evidenced between these two JIA groups regarding demographic data, sexual function and clinical/laboratorial parameters. The frequencies of methotrexate (p = 0.206) and biological agent use (p = 0.238) were similar in both JIA groups.

CONCLUSIONS

To our knowledge, this was the first study to assess lower genital infections in JIA patients allowing the identification of HPV as main cause of cervical dysplasia. Methotrexate and biological agents do not seem to increase risk of lower genital tract infections in JIA patients.

Physical activity and sedentary levels in children with juvenile idiopathic arthritis and inflammatory bowel disease. A systematic review and meta-analysis

BACKGROUND

Physical activity (PA) is essential for children throughout their growth and maturation. It improves physiological and psychological health and limits the risk of developing metabolic disorders. However, some chronic physiological and metabolic diseases may lead to decreased PA. The diversity of outcomes in the literature offers no consensus for physical activity and sedentary levels in children with juvenile idiopathic arthritis (JIA) or inflammatory bowel disease (IBD).

METHODS

A literature review and a meta-analysis were carried out with original studies from a Medline database search. Only high-quality studies (STROBE checklist) written in English comparing PA level or sedentary behavior (SB) between children with the disorders and their healthy peers were considered. The aim was to examine PA and SB in children with JIA or IBD compared to their healthy peers.

RESULTS

The literature review and meta-analysis identified decreased PA and increased time spent in SB in these populations, which may exacerbate both their lower physical fitness and the symptoms of their health disorders.

CONCLUSION

Results nevertheless show discrepancies due to the different materials and methods used and the variables measured. Further studies are needed to establish a gold standard method for assessing PA level in these populations.

TNF blockade contributes to restore lipid oxidation during exercise in children with juvenile idiopathic arthritis

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) have impaired physical abilities. TNF-α plays a crucial role in this pathogenesis, but it is also involved in the use of lipids and muscle health. Objective of this study was to explore substrate oxidation and impact of TNF blockade on energy metabolism in children with JIA as compared to healthy children.

METHODS

Fifteen non-TNF-blockaded and 15 TNF-blockaded children with JIA and 15 healthy controls were matched by sex, age, and Tanner stage. Participants completed a submaximal incremental exercise test on ergocycle to determine fat and carbohydrate oxidation rates by indirect calorimetry.

RESULTS

The maximal fat oxidation rate during exercise was lower in JIA children untreated by TNF blockade (134.3 ± 45.2 mg.min- 1) when compared to the controls (225.3 ± 92.9 mg.min- 1, p = 0.007); but was higher in JIA children under TNF blockade (163.2 ± 59.0 mg.min- 1, p = 0.31) when compared to JIA children untreated by TNF blockade. At the same relative exercise intensities, there was no difference in carbohydrate oxidation rate between three groups.

CONCLUSIONS

Lipid metabolism during exercise was found to be impaired in children with JIA. However, TNF treatment seems to improve the fat oxidation rate in this population.

TRIAL REGISTRATION

In ClinicalTrials.gov, reference number NCT02977416 , registered on 30 November 2016.

Participation in school and physical education in juvenile idiopathic arthritis in a Nordic long-term cohort study

BACKGROUND

The aim of the study was to describe school attendance and participation in physical education in school among children with juvenile idiopathic arthritis (JIA).

METHODS

Consecutive cases of JIA from defined geographical areas of Finland, Sweden and Norway with disease onset in 1997 to 2000 were followed for 8 years in a multi-center cohort study, aimed to be as close to population-based as possible. Clinical characteristics and information on school attendance and participation in physical education (PE) were registered.

RESULTS

Participation in school and in PE was lowest initially and increased during the disease course. Eight years after disease onset 228/274 (83.2%) of the children reported no school absence due to JIA, while 16.8% reported absence during the last 2 months due to JIA. Full participation in PE was reported by 194/242 (80.2%), partly by 16.9%, and none by 2.9%. Lowest participation in PE was found among children with ERA and the undifferentiated categories. Absence in school and PE was associated with higher disease activity measures at the 8-year visit. School absence > 1 day at baseline predicted use of disease-modifying anti-rheumatic drugs, including biologics (DMARDs) (OR 1.2 (1.1-1.5)), and non-remission off medication (OR 1.4 (1.1-1.7) 8 years after disease onset.

CONCLUSION

School absence at baseline predicted adverse long-term outcome. In children and adolescents with JIA participation in school activities is mostly high after 8 years of disease. For the minority with low participation, special attention is warranted to promote their full potential of social interaction and improve long-term outcome.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of ≥ 7 Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study

BACKGROUND

Moderate to severe depressive symptoms occur in up to one-third of patients at 1 year following ICU discharge, negatively affecting patient outcomes. This study evaluated patient and caregiver factors associated with the development of these symptoms.

METHODS

This study used the Rehabilitation and Recovery in Patients after Critical Illness and Their Family Caregivers (RECOVER) Program (Phase 1) cohort of 391 patients from 10 medical/surgical university-affiliated ICUs across Canada. We determined the association between patient depressive symptoms (captured by using the Beck Depression Inventory II [BDI-II]), patient characteristics (age, sex, socioeconomic status, Charlson score, and ICU length of stay [LOS]), functional independence measure (FIM) motor subscale score, and caregiver characteristics (Caregiver Assistance Scale and Center for Epidemiologic Studies-Depression Scale) by using linear mixed models at time points 3, 6, and 12 months.

RESULTS

BDI-II data were available for 246 patients. Median age at ICU admission was 56 years (interquartile range, 45-65 years), 143 (58%) were male, and median ICU LOS was 19 days (interquartile range, 13-32 days). During the 12-month follow-up, 67 of 246 (27.2%) patients had a BDI-II score ≥ 20, indicating moderate to severe depressive symptoms. Mixed models showed worse depressive symptoms in patients with lower FIM motor subscale scores (1.1 BDI-II points per 10 FIM points), lower income status (by 3.7 BDI-II points; P = .007), and incomplete secondary education (by 3.8 BDI-II points; P = .009); a curvilinear relation with age (P = .001) was also reported, with highest BDI-II at ages 45 to 50 years. No associations were found between patient BDI-II and comorbidities (P = .92), sex (P = .25), ICU LOS (P = .51), or caregiver variables (Caregiver Assistance Scale [P = .28] and Center for Epidemiologic Studies Depression Scale [P = .74]).

CONCLUSIONS

Increased functional dependence, lower income, and lower education are associated with increased severity of post-ICU depressive symptoms, whereas age has a curvilinear relation with symptom severity. Knowledge of risk factors may inform surveillance and targeted mental health follow-up. Early mobilization and rehabilitation aiming to improve function may serve to modify mood disorders.

Feasibility and safety of a 6-month exercise program to increase bone and muscle strength in children with juvenile idiopathic arthritis

BACKGROUND

Arthritis in childhood can be associated with muscle weakness around affected joints, low bone mass and low bone strength. Exercise is recognized as an important part of management of children with juvenile idiopathic arthritis (JIA) but the exercise prescription to best promote bone and muscle health is unknown. We therefore aimed to: 1. assess feasibility and safety of a 6-month home- and group-based exercise program for children with JIA; 2. estimate the effect of program participation on bone mass and strength, muscle function and clinical outcomes and 3. determine if any positive changes in bone and muscle outcomes are maintained 6 months later.

METHODS

We recruited 24 children with JIA who were part of the Linking Exercise, Physical Activity and Pathophysiology in Childhood Arthritis (LEAP) study to participate in a 6-month home-based exercise program involving jumping and handgrip exercises, resistance training and one group exercise session per month. We assessed lumbar spine bone mass (dual energy X-ray absorptiometry), distal tibia and radius bone microarchitecture and strength (high-resolution peripheral quantitative computed tomography), muscle function (jumping mechanography, dynamometry) and clinical outcomes (joint assessment, function, health-related quality of life) at baseline, 6- and 12-months. Adherence was assessed using weekly activity logs.

RESULTS

Thirteen children completed the 6-month intervention. Participants reported 9 adverse events and post-exercise pain was rare (0.4%). Fatigue improved, but there were no other sustained improvements in muscle, bone or clinical outcomes. Adherence to the exercise program was low (47%) and decreased over time.

CONCLUSION

Children with JIA safely participated in a home-based exercise program designed to enhance muscle and bone strength. Fatigue improved, which may in turn facilitate physical activity participation. Prescribed exercise posed adherence challenges and efforts are needed to address facilitators and barriers to participation in and adherence to exercise programs among children with JIA.

TRIAL REGISTRATION

Data of the children with JIA are from the LEAP study (Canadian Institutes of Health Research (CIHR; GRANT# 107535 ). http://www.leapjia.com/.

Ovarian reserve in young juvenile idiopathic arthritis patients

OBJECTIVES

Juvenile idiopathic arthritis (JIA) occurs during reproductive age, however, there are no systematic data regarding ovarian function in this disease.

METHODS

Twenty-eight post-pubertal JIA patients and age-matched 28 healthy controls were studied. Complete ovarian function was assessed during the early follicular phase of the menstrual cycle including anti-Müllerian hormone (AMH), estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and antral follicle count (AFC) by ovarian ultrasound, and anti-corpus lutheum antibodies (anti-CoL). Demographic data, menstrual abnormalities, disease parameters and treatment were also evaluated.

RESULTS

The mean current age (22.6 ± 6.59 vs. 22.5 ± 6.59 years, p = .952) was similar in JIA patients and healthy controls with a higher median menarche age [13(8-16) vs. 12(8-14) years, p = .029]. A lower median AMH levels [2.65(0.47-9.08) vs. 4.83(0.74-17.24) ng/mL, p = .029] with a higher LH [8.44 ± 4.14 vs. 6.03 ± 2.80 IU/L, p = .014] and estradiol levels [52.3(25.8-227.4) vs. 38.9(26.2-133.6) pg/mL, p = .008] were observed in JIA compared to control group. Anti-CoL and AFC were similar in both groups (p > .05). Further analysis of JIA patients revealed that current age, disease duration, number of active/limited joints, ESR, CRP, patient/physician VAS, JADAS 71, DAS 28, CHAQ, HAQ, patient/parents PedsQL, PF-SF 36, cumulative glucocorticoid and cumulative methotrexate doses were not correlated with AMH, FSH, estradiol levels or AFC (p > .05).

CONCLUSION

The present study was the first to suggest diminished ovarian reserve, not associated to hypothalamic pituitary gonadal axis, in JIA patients during reproductive age. The impact of this dysfunction in future fertility of these patients needs to be evaluated in prospective studies.

Patient's experiences with the care for juvenile idiopathic arthritis across Europe

BACKGROUND

To assess the views of juvenile idiopathic arthritis (JIA) patients and their parents on the care and treatment they receive in referral pediatric rheumatology centers throughout Europe.

METHODS

In a collaboration between physicians and patient associations, a questionnaire was developed, covering various domains of JIA care, including demographics, diagnosis, referrals to various health care professionals, access to pain and fatigue management and support groups, information they received about the disease and awareness of and participation in research. The questionnaire was translated and distributed by parent associations and pediatric rheumatologists in 25 countries, 22 of which were European. After completion the replies were entered on the PRINTO website. Replies could either be entered directly by parents on the website or on paper. In these cases, the replies were scanned and emailed by local hospital staff to Utrecht where they were entered by I.R. in the database.

RESULTS

The survey was completed by 622 parents in 23 countries. The majority (66.7%) of patients were female, with median age 10-11 years at the completion of the questionnaire. Frequencies of self-reported JIA categories corresponded to literature. Some patients had never been referred to the ophthalmologist (22.8%) or physiotherapist (31.7%). Low rates of referral or access to fatigue (3.5%) or pain management teams (10.0%), age appropriate disease education (11.3%), special rehabilitation (13.7%) and support groups (20.1%) were observed. Many patients indicated they did not have contact details for urgent advice (35.9%) and did not receive information about immunizations (43.2%), research (55.6%) existence of transition of care clinics (89,2%) or financial support (89.7%). While on immunosuppressive drugs, about one half of patients did not receive information about immunizations, travelling, possible infections or how to deal with chickenpox or shingles.

CONCLUSIONS

Low rates of referral to health care professionals may be due to children whose illness is well managed and who do not need additional support or information. Improvements are needed, especially in the areas of supportive care and information patients receive. It is also important to improve doctor patient communication between visits. Physicians can be instrumental in the setting up of support groups and increasing patients' awareness of existing support. Suggestions are given to convey crucial pieces of information structurally and repeatedly to ensure, among other things, compliance.

The brain and immune system prompt energy shortage in chronic inflammation and ageing

Sequelae frequently seen in patients with chronic inflammatory diseases, such as fatigue, depressed mood, sleep alterations, loss of appetite, muscle wasting, cachectic obesity, bone loss and hypertension, can be the result of energy shortages caused by an overactive immune system. These sequelae can also be found in patients with chronic inflammatory diseases that are in remission and in ageing individuals, despite the immune system being less active in these situations. This Perspectives article proposes a new way of understanding situations of chronic inflammation (such as rheumatic diseases) and ageing based on the principles of evolutionary medicine, energy regulation and neuroendocrine-immune crosstalk. A conceptual framework is provided to enable physicians and scientists to better understand the signs and symptoms of chronic inflammatory diseases and long-term disease consequences resulting from physical and mental inactivity.