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Borocco C, Anselmi F, Rossi-Semerano L. Contribution of Ultrasound in Current Practice for Managing Juvenile Idiopathic Arthritis. J Clin Med 2022; 12:91. [PMID: 36614888 PMCID: PMC9821589 DOI: 10.3390/jcm12010091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
The interest and application of musculoskeletal ultrasound (MSUS) in juvenile idiopathic arthritis (JIA) are increasing. Numerous studies have shown that MSUS is more sensitive than clinical examination for detecting subclinical synovitis. MSUS is a well-accepted tool, easily accessible and non-irradiating. Therefore, it is a useful technique throughout JIA management. In the diagnostic work-up, MSUS allows for better characterizing the inflammatory involvement. It helps to define the disease extension, improving the classification of patients into JIA subtypes. Moreover, it is an essential tool for guiding intra-articular and peritendinous procedures. Finally, during the follow-up, in detecting subclinical disease activity, MSUS can be helpful in therapeutic decision-making. Because of several peculiarities related to the growing skeleton, the MSUS standards defined for adults do not apply to children. During the last decade, many teams have made large efforts to define normal and pathological US features in children in different age groups, which should be considered during the US examination. This review describes the specificities of MSUS in children, its applications in clinical practice, and its integration into the new JIA treat-to-target therapeutic approach.
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Affiliation(s)
- Charlotte Borocco
- Department of Paediatric Rheumatology, National Reference Centre for Auto-Inflammatory Diseases and Amyloidosis of Inflammatory Origin (CEREMAIA), Bicêtre Hospital (AP-HP), 94270 Le Kremlin-Bicêtre, France
| | - Federica Anselmi
- Department of Paediatric Rheumatology, National Reference Centre for Auto-Inflammatory Diseases and Amyloidosis of Inflammatory Origin (CEREMAIA), Bicêtre Hospital (AP-HP), 94270 Le Kremlin-Bicêtre, France
- Unit of Paediatric Rheumatology, Department of Translational Medicine, Section of Paediatrics, University of Naples Federico II, 80138 Naples, Italy
| | - Linda Rossi-Semerano
- Department of Paediatric Rheumatology, National Reference Centre for Auto-Inflammatory Diseases and Amyloidosis of Inflammatory Origin (CEREMAIA), Bicêtre Hospital (AP-HP), 94270 Le Kremlin-Bicêtre, France
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Moura RA, Fonseca JE. B Cells on the Stage of Inflammation in Juvenile Idiopathic Arthritis: Leading or Supporting Actors in Disease Pathogenesis? Front Med (Lausanne) 2022; 9:851532. [PMID: 35449805 PMCID: PMC9017649 DOI: 10.3389/fmed.2022.851532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a term that collectively refers to a group of chronic childhood arthritides, which together constitute the most common rheumatic condition in children. The International League of Associations for Rheumatology (ILAR) criteria define seven categories of JIA: oligoarticular, polyarticular rheumatoid factor (RF) negative (RF-), polyarticular RF positive (RF+), systemic, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated arthritis. The ILAR classification includes persistent and extended oligoarthritis as subcategories of oligoarticular JIA, but not as distinct categories. JIA is characterized by a chronic inflammatory process affecting the synovia that begins before the age of 16 and persists at least 6 weeks. If not treated, JIA can cause significant disability and loss of quality of life. Treatment of JIA is adjusted according to the severity of the disease as combinations of non-steroidal anti-inflammatory drugs (NSAIDs), synthetic and/ or biological disease modifying anti-rheumatic drugs (DMARDs). Although the disease etiology is unknown, disturbances in innate and adaptive immune responses have been implicated in JIA development. B cells may have important roles in JIA pathogenesis through autoantibody production, antigen presentation, cytokine release and/ or T cell activation. The study of B cells has not been extensively explored in JIA, but evidence from the literature suggests that B cells might have indeed a relevant role in JIA pathophysiology. The detection of autoantibodies such as antinuclear antibodies (ANA), RF and anti-citrullinated protein antibodies (ACPA) in JIA patients supports a breakdown in B cell tolerance. Furthermore, alterations in B cell subpopulations have been documented in peripheral blood and synovial fluid from JIA patients. In fact, altered B cell homeostasis, B cell differentiation and B cell hyperactivity have been described in JIA. Of note, B cell depletion therapy with rituximab has been shown to be an effective and well-tolerated treatment in children with JIA, which further supports B cell intervention in disease development.
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Affiliation(s)
- Rita A Moura
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal
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Feldt J, Schicht M, Welss J, Gelse K, Sesselmann S, Tsokos M, Socher E, Garreis F, Müller T, Paulsen F. Production and Secretion of Gelsolin by Both Human Macrophage- and Fibroblast-like Synoviocytes and GSN Modulation in the Synovial Fluid of Patients with Various Forms of Arthritis. Biomedicines 2022; 10:biomedicines10030723. [PMID: 35327525 PMCID: PMC8945596 DOI: 10.3390/biomedicines10030723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 12/04/2022] Open
Abstract
Gelsolin (GSN) is an actin-binding protein involved in cell formation, metabolism and wound closure processes. Since this protein is known to play a role in arthritis, here we investigate how the synovial membrane with its specific synoviocytes contributes to the expression of GSN and how the amount of GSN expressed is modulated by different types of arthritis. Synovial membranes from adult healthy subjects and patients with rheumatoid arthritis (RA) and osteoarthritis (OA) are analyzed by immunofluorescence, Western blot and ELISA. Macrophage-like synoviocytes (MLS) and fibroblast-like synoviocytes (FLS) were isolated, cultured and analyzed for their potential to produce and secrete GSN. In addition, the GSN concentrations in the synovial fluid of various forms of arthritis are determined by ELISA. GSN is produced by the healthy and arthritic synovial membranes. Both forms of synoviocytes (MLS and FLS) release GSN. The results show that there is a significant reduction in GSN in the synovial fluid in adult patients with OA. This reduction is also detectable in adult patients with RA but is not as evident. In juvenile arthritis, there is a slight increase in GSN concentration in the synovial fluid. This study shows that primary MLS and FLS express GSN and that these cells, in addition to articular chondrocytes, contribute to GSN levels in synovial fluid. Furthermore, GSN concentrations are modulated in different types of arthritis. Further studies are needed to fully understand how GSN is involved in joint homeostasis.
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Affiliation(s)
- Jessica Feldt
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Universitätsstr. 19, 91054 Erlangen, Germany; (J.F.); (J.W.); (E.S.); (F.G.)
| | - Martin Schicht
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Universitätsstr. 19, 91054 Erlangen, Germany; (J.F.); (J.W.); (E.S.); (F.G.)
- Correspondence: (M.S.); (F.P.)
| | - Jessica Welss
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Universitätsstr. 19, 91054 Erlangen, Germany; (J.F.); (J.W.); (E.S.); (F.G.)
| | - Kolja Gelse
- Department of Trauma Surgery and Orthopaedic Surgery, Hospital Traunstein, 83278 Traunstein, Germany;
| | - Stefan Sesselmann
- Institute for Medical Engineering, University of Applied Sciences Amberg-Weiden, 92224 Amberg, Germany;
| | - Michael Tsokos
- Institute of Legal Medicine and Forensic Sciences, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Eileen Socher
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Universitätsstr. 19, 91054 Erlangen, Germany; (J.F.); (J.W.); (E.S.); (F.G.)
| | - Fabian Garreis
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Universitätsstr. 19, 91054 Erlangen, Germany; (J.F.); (J.W.); (E.S.); (F.G.)
| | - Thomas Müller
- Department of Child and Adolescent Medicine, Pediatrics I, Pediatric Rheumatology, Martin Luther University Halle-Wittenberg (MLU), 06108 Halle (Saale), Germany;
| | - Friedrich Paulsen
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Universitätsstr. 19, 91054 Erlangen, Germany; (J.F.); (J.W.); (E.S.); (F.G.)
- Correspondence: (M.S.); (F.P.)
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Winsz-Szczotka K, Kuźnik-Trocha K, Lachór-Motyka I, Lemski W, Olczyk K. Concerted Actions by PIICP, CTXII, and TNF-α in Patients with Juvenile Idiopathic Arthritis. Biomolecules 2021; 11:biom11050648. [PMID: 33924892 PMCID: PMC8146247 DOI: 10.3390/biom11050648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022] Open
Abstract
Joint destruction in juvenile idiopathic arthritis (JIA), initiated in the early, preclinical stage of the disease, is diagnosed on the basis of clinical evaluation and radiographic imaging. The determination of circulating cartilage-matrix turnover markers can facilitate the diagnosis and application of better and earlier treatment strategies for JIA. We have shown that 96 JIA patients have elevated levels of procollagen II C-terminal propeptide (PIICP), reflecting the extent of joint cartilage biosynthesis, and C-telopeptide of type II collagen (CTXII), a biomarker of the resorption of this tissue. Patients who did not respond to treatment had particularly high levels of these markers. JIA treatment resulted in the normalization of these markers in remissive patients, but not in those with active JIA. We showed correlations between examined variables and inflammatory process indicators, i.e., C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and tumor necrosis factor-α (TNF-α). The TNF-α of patients responding to treatment correlated with PIICP, especially in the patients before treatment (r = 0.898, p < 0.001). Significant changes in serum PIICP during JIA therapy suggest its potential diagnostic utility in the monitoring of disease activity and the possibility of its use in assessing treatment towards remission. Understanding changes in type II collagen metabolism over the course of the discussed arthritis may allow the implementation of both new diagnostic tools and new therapeutic strategies in children with JIA.
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Affiliation(s)
- Katarzyna Winsz-Szczotka
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, ul. Jedności 8, 41-200 Sosnowiec, Poland; (K.K.-T.); (W.L.); (K.O.)
- Correspondence: ; Tel.: +48-323-64-1152
| | - Kornelia Kuźnik-Trocha
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, ul. Jedności 8, 41-200 Sosnowiec, Poland; (K.K.-T.); (W.L.); (K.O.)
| | - Iwona Lachór-Motyka
- Department of Rheumatology, The John Paul II Pediatric Center in Sosnowiec, ul. Gabrieli Zapolskiej 3, 41-218 Sosnowiec, Poland;
| | - Wojciech Lemski
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, ul. Jedności 8, 41-200 Sosnowiec, Poland; (K.K.-T.); (W.L.); (K.O.)
| | - Krystyna Olczyk
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, ul. Jedności 8, 41-200 Sosnowiec, Poland; (K.K.-T.); (W.L.); (K.O.)
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Yang X, Li L, Tang X, Xiang B, Wen T. Can intraoperative ultrasound visualize the closed reduction and elastic intramedullary nail fixation processes of double forearm fractures in children? Medicine (Baltimore) 2021; 100:e24324. [PMID: 33761632 PMCID: PMC9282027 DOI: 10.1097/md.0000000000024324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 12/21/2020] [Indexed: 02/05/2023] Open
Abstract
To evaluate the feasibility of utilizing ultrasonography to monitor the fracture reduction and elastic intramedullary nail fixation processes in treating children with double forearm fractures. A retrospective analysis of 30 children with double forearm fractures treated at our hospital between January 2016 and July 2018. The children were aged 3 to 10 years. All patients were treated with closed reduction and internal fixation with elastic intramedullary nails using intraoperative ultrasound monitoring and intermittent radiographic imaging. The closed reduction and fixation were successful in all patients. The operation times ranged from 16 to 30 minutes, averaging 21 minutes. No neurovascular injuries occurred during closed reduction and nail insertion. Moreover, closed reduction was successful in the first attempt in 86.7% of patients. All patient outcomes were optimal, lacking serious complications during follow-ups. Intraoperative ultrasound monitoring can clearly show the shape and changes in fracture ends, distal growth plates, and surrounding soft tissues, and fracture reduction and passage of elastic nail processes at fracture ends during closed reduction; therefore, visualizing closed reductions can be achieved. The combination of intraoperative ultrasound and radiographic imaging can ensure operative effects and significantly reduce radiation exposure for both doctors and patients. An adequately powered prospective randomized trial is required to confirm our findings.
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Affiliation(s)
| | - Lang Li
- Department of Pediatric Surgery
| | | | | | - Tianfu Wen
- Department of Hepatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Hinkle A, Dickason CQ, Jinguji T, Shenoi S, Thapa M, Saper MG, Bompadre V, Schmale GA. Prevalence and Severity of Juvenile Osteochondritis Dissecans in Patients With Juvenile Idiopathic Arthritis. Orthop J Sports Med 2021; 9:2325967120984139. [PMID: 33718500 PMCID: PMC7917878 DOI: 10.1177/2325967120984139] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic
arthritides presenting in patients aged ≤16 years, with a prevalence of 16
to 150 per 100,000. Juvenile osteochondritis dissecans (OCD) is an
idiopathic disease of articular cartilage and subchondral bone, has an onset
age of 10 to 16 years, and often affects the knee, with a prevalence of 2 to
18 per 100,000. Currently, there are few studies that have evaluated the
relationship between JIA and OCD. Hypothesis: OCD is more prevalent in children with JIA, and when diagnosed in such
patients, OCD often presents at an advanced state. Study Design: Case series; Level of evidence, 4. Methods: The medical records of patients with diagnoses of both JIA and OCD treated
between January 2008 and March 2019 at a single children’s hospital were
retrospectively reviewed. Associations between timing of diagnoses, number
and types of corticosteroid treatments, category of arthritis, timing of
diagnoses, and lesion stability were examined with Spearman correlation
coefficients. Results: A total of 2021 patients with JIA were identified, 20 of whom (19 female, 1
male) had OCD of the knee and/or talus for a prevalence of 1 in 100 or 1000
in 100,000, or approximately 50 to 500 times that of the general population.
These 20 patients had a total of 28 OCD lesions: 43% (9 femur, 3 talus) were
radiographically stable over time, 50% (10 femur, 2 patella, 2 talus) were
unstable at initial diagnosis, and 7% (2 femur) were initially stable but
progressed to unstable lesions despite drilling. Twelve patients (60%)
underwent surgery: 4 (20%) with stable femoral lesions for persistent
symptoms despite prolonged nonoperative treatment and 8 (40%) for treatment
of their unstable lesions (femoral and patellar). Within our study design,
we could identify no significant associations between lesion stability and
timing of diagnoses, number of joint injections, or limb deformities, nor
were there associations between timing of JIA and OCD diagnoses and category
of arthritis. Conclusion: In our population of patients with JIA, OCD lesions were found to be 50 to
500 times more prevalent when compared with published rates in the general
population and often presented at an advanced state, with instability or
delayed healing requiring surgery for stabilization or resolution of
symptoms.
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Affiliation(s)
- Andrew Hinkle
- Tulane School of Medicine, New Orleans, Louisiana, USA
| | - Celeste Quitiquit Dickason
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Thomas Jinguji
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Susan Shenoi
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Mahesh Thapa
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael G Saper
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
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Association of Circulating COMP and YKL-40 as Markers of Metabolic Changes of Cartilage with Adipocytokines in Juvenile Idiopathic Arthritis. Metabolites 2020; 10:metabo10020061. [PMID: 32050571 PMCID: PMC7073573 DOI: 10.3390/metabo10020061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/01/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022] Open
Abstract
The aim of this study was to evaluate the association of circulating cartilage oligomeric matrix protein (COMP) and human cartilage glycoprotein-39 (YKL-40) as markers of metabolic changes of cartilage, with leptin, adiponectin, and resistin in juvenile idiopathic arthritis (JIA) patients before and after treatment. A significant decrease of COMP and an increase of YKL-4 were found in blood of untreated patients. JIA treatment leading to clinical improvement resulted in normalization of COMP levels only. Concentrations of both markers in treated patients, while showing no clinical improvement, differed from those in controls and patients with remission. The leptin level decreased (p < 0.05) in untreated patients; however, concentrations of adiponectin and resistin increased (p < 0.05) as compared to controls. JIA treatment resulted in normalization of adipocytokine levels in remissive patients but not those with active JIA. Untreated patients showed a correlation between COMP and leptin, adiponectin, and body mass index (BMI) and between YKL-40 and leptin, adiponectin, BMI, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). In inactive JIA, a correlation between YKL-40 and leptin was shown. Treated patients with an active JIA demonstrated a correlation between COMP and adiponectin and between YKL-40 and leptin, adiponectin, BMI, CRP, and ESR. The results of this work indicate that leptin and adiponectin but not resistin may be involved in the development and progression of joint dysfunction in JIA. Additionally, we suggest that YKL-40 may be a useful biomarker of disease activity and may be used to assess treatment towards remission, as compared to COMP.
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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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Current status and recent advances on the use of ultrasonography in pediatric rheumatic diseases. World J Pediatr 2020; 16:52-59. [PMID: 31515696 DOI: 10.1007/s12519-019-00312-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ultrasonography has become a useful tool in the clinical rheumatology settings in the last two decades, but its use has only recently been explored by pediatric rheumatologists. The aim of this article is to review the literature on the current status and recent advances on the use of ultrasound in pediatric rheumatic diseases. DATA SOURCES We have retrieved and reviewed the relevant articles from MEDLINE/PubMed databases published so far, on the applications of ultrasound in juvenile idiopathic arthritis (JIA), systemic lupus erythematosus, dermatomyositis, enthesitis, Sjogren's syndrome, and other rheumatic diseases. In addition, articles on novel ultrasound imaging technology of potential use in pediatric rheumatology are also reviewed. RESULTS In JIA, ultrasound can be used to detect subclinical synovitis, to improve the classification of patients in JIA subtypes, to capture early articular damage, to monitor treatment response, and to guide intraarticular injections. Ultrasound is also considered useful in other rheumatic disorders for the evaluation of musculoskeletal symptoms, assessment of parotid gland pathology, and measurement of skin thickness and pathology. Novel ultrasound techniques developed to augment the functionality of ultrasonography may also be applicable in pediatric rheumatic disorders. CONCLUSIONS Ultrasound shows great promise in the assessment and management of children with rheumatologic disorders. However, standardization and validation of ultrasound in healthy children and in patients with rheumatic diseases are still needed.
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