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Malcová H, Dallos T, Bouchalova K, Brejchová I, Brichová M, Bušányová B, Fabianová J, Fráňová J, Furdová A, Jarošová K, Kobrová K, Kostolná B, Košková E, Lokaj M, Macků M, Melocíková J, Michaličková M, Minxová L, Moravčíková D, Němcová D, Pískovský T, Říhová E, Schüller M, Skalická E, Svozílková P, Tomčíková D, Vargová V, Vrtíková E, Doležalová P, Heissigerová J. Recommendations for the Management of Uveitis Associated With Juvenile Idiopathic Arthritis: The Czech and Slovak adaptation of SHARE Initiative. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2020; 76:1-15. [PMID: 33086847 DOI: 10.31348/2020/7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and uveitis is its most important extra-articular manifestation. Evidence-based recommendations are available only to a limited extent and therefore JIA associated uveitis management is mostly based on physicians experience. Consequently, treatment practices differ widely, both nationally and internationally. Therefore, an effort to optimize and publish recommendations for the care of children and young adults with rheumatic diseases was launched in 2012 as part of the international project SHARE (Single Hub and Access Point for Pediatric Rheumatology in Europe) to facilitate clinical practice for paediatricians and (paediatric) rheumatologists. The aim of this work was to translate published international SHARE recommendations for the diagnosis and treatment of JIA associated uveitis and to adapt them for use in the Czech and Slovak Republics. International recommendations were developed according to the standard methodology of the European League against Rheumatism (EULAR) by a group of nine experienced paediatric rheumatologists and three experts in ophthalmology. It was based on a systematic literature review and evaluated in the form of an online survey and subsequently discussed using a nominal group technique. Recommendations were accepted if > 80% agreement was reached (including all three ophthalmologists). A total of 22 SHARE recommendations were accepted: 3 on diagnosis, 5 on disease activity assessment, 12 on treatment and 2 on future recommendations. Translation of the original text was updated and modified with data specific to the czech and slovak health care systems and supplemented with a proposal for a protocol of ophthalmological dispensarization of paediatric JIA patients and a treatment algorithm for JIA associated uveitis. Conclusion: The aim of the SHARE initiative is to improve and standardize care for paediatric patients with rheumatic diseases across Europe. Therefore, recommendations for the diagnosis and treatment of JIA-associated uveitis have been formulated based on the evidence and agreement of leading European experts in this field.
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Constantin T, Foeldvari I, Anton J, de Boer J, Czitrom-Guillaume S, Edelsten C, Gepstein R, Heiligenhaus A, Pilkington CA, Simonini G, Uziel Y, Vastert SJ, Wulffraat NM, Haasnoot AM, Walscheid K, Pálinkás A, Pattani R, Györgyi Z, Kozma R, Boom V, Ponyi A, Ravelli A, Ramanan AV. Consensus-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis: the SHARE initiative. Ann Rheum Dis 2018; 77:1107-1117. [PMID: 29592918 PMCID: PMC6059050 DOI: 10.1136/annrheumdis-2018-213131] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In 2012, a European initiative called Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) was launched to optimise and disseminate diagnostic and management regimens in Europe for children and young adults with rheumatic diseases. Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and uveitis is possibly its most devastating extra-articular manifestation. Evidence-based guidelines are sparse and management is mostly based on physicians' experience. Consequently, treatment practices differ widely, within and between nations. OBJECTIVES To provide recommendations for the diagnosis and treatment of JIA-associated uveitis. METHODS Recommendations were developed by an evidence-informed consensus process using the European League Against Rheumatism standard operating procedures. A committee was constituted, consisting of nine experienced paediatric rheumatologists and three experts in ophthalmology from Europe. Recommendations derived from a validated systematic literature review were evaluated by an Expert Committee and subsequently discussed at two consensus meetings using nominal group techniques. Recommendations were accepted if >80% agreement was reached (including all three ophthalmologists). RESULTS In total, 22 recommendations were accepted (with >80% agreement among experts): 3 on diagnosis, 5 on disease activity measurements, 12 on treatment and 2 on future recommendations. CONCLUSIONS The SHARE initiative aims to identify best practices for treatment of patients suffering from JIA-associated uveitis. Within this remit, recommendations for the diagnosis and treatment of JIA-associated uveitis have been formulated by an evidence-informed consensus process to suggest a standard of care for JIA-associated uveitis patients throughout Europe.
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Affiliation(s)
- Tamas Constantin
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Ivan Foeldvari
- Klinikum Eilbek, Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Jordi Anton
- Department of Pediatric Rheumatology, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Joke de Boer
- Department of Ophthalmology, University Hospital Utrecht, Utrecht, The Netherlands
| | | | - Clive Edelsten
- Department of Ophthalmology, Great Ormond Street Hospital, London, UK
| | - Raz Gepstein
- Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel
| | - Arnd Heiligenhaus
- Department of Ophthalmology, Uveitis-Center, and Ophtha Lab, at St. Franziskus Hospital, Muenster, Germany
- University of Duisburg-Essen, Duisburg, Germany
| | | | - Gabriele Simonini
- Department of Paediatrics, Rheumatology Unit, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Yosef Uziel
- Department of Paediatrics, Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sebastian J Vastert
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Anne-Mieke Haasnoot
- Department of Ophthalmology, University Hospital Utrecht, Utrecht, The Netherlands
| | - Karoline Walscheid
- Department of Ophthalmology, Uveitis-Center, and Ophtha Lab, at St. Franziskus Hospital, Muenster, Germany
| | | | - Reshma Pattani
- Department of Ophthalmology, Great Ormond Street Hospital, London, UK
| | - Zoltán Györgyi
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Richárd Kozma
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Victor Boom
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Andrea Ponyi
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
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Abstract
In children, laboratory evaluations can assist in the screening of patients for inflammatory disorders, confirm diagnoses, allow for monitoring of disease activity and response to therapy, and suggest prognoses and risk of morbidities associated with rheumatic diseases. This review provides an overview of the usefulness and interpretation of both the commonly ordered tests ordered by the general pediatrician as well as those frequently used in the pediatric rheumatology clinic for diagnosis and disease monitoring. Studies discussed include the complete blood count, acute phase reactants, autoantibodies, serum complement, urinalysis, streptococcal antibody tests, and commonly used genetic studies.
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Affiliation(s)
- Jay Mehta
- Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY 10467, USA.
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Kotaniemi K, Savolainen A, Karma A, Aho K. Recent advances in uveitis of juvenile idiopathic arthritis. Surv Ophthalmol 2003; 48:489-502. [PMID: 14499817 DOI: 10.1016/s0039-6257(03)00084-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chronic scarring-type uveitis is a frequent extra-articular manifestation of juvenile idiopathic arthritis. It occurs in about 20% of children with this disease, commencing typically within a few years from its onset. The risk of uveitis is greatest in antinuclear antibody-positive girls with early onset oligoarthritis. The classic clinical picture is chronic bilateral anterior uveitis, usually asymptomatic until substantial damage to intraocular structures occurs. In view of the asymptomatic nature of the condition, routine screening of juvenile idiopathic arthritis patients 2-4 times a year is crucial to prevent complications. The treatment consists of topical corticosteroids and mydriatics, in severe cases with immunosuppressive agents, and surgical management of complications. Although the prognosis of uveitis is improving, there are cases refractory to standard regimens. Patients in whom uveitis commences prior to the onset of arthritis present a special problem.
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Affiliation(s)
- N K Waheed
- Massachusetts Eye and Ear Infirmary, Boston 02114, USA
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Egeskjold EM. Autoantibodies as diagnostic tool in juvenile connective tissue diseases. Indian J Pediatr 1989; 56:335-42. [PMID: 2807468 DOI: 10.1007/bf02722296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
Patients with juvenile chronic arthritis (JCA) may be subdivided into a minority, who carry IgM rheumatoid factor and have erosive polyarthritis resembling adult rheumatoid arthritis, and the majority (90%), who are seronegative by conventional means. Between 30 and 60% of patients with JCA have positive antinuclear antibodies (ANAs) according to the choice of substrate for indirect immunofluorescence. The importance of ANAs is the frequent development of associated asymptomatic chronic iridocyclitis, which may impair vision causing worse handicap than the arthritis, which remains predominantly pauciarticular in two thirds of these young children. ANA positive patients rarely possess antibodies to deoxyribonucleic acid (DNA) or extractable nuclear antigens (ENA), and current studies suggest that several different nuclear antigens, including histones, may be involved.
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Affiliation(s)
- A M Leak
- Clinical Research Centre, Division of Rheumatology, Harrow, Middlesex
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Abstract
Chronic nongranulomatous uveitis associated with JRA, a distinctive clinical entity occurring almost exclusively in the pediatric age group, represents an important cause of visual impairment in children. Despite continuing clarification of the clinical manifestations of this disorder, the etiology of uveitis associated with JRA remains unknown and the pathophysiology is still poorly understood. Further study of uveitis-associated JRA, by the application of improved immunologic theories and techniques, should aid in developing more effective therapeutic and preventive strategies.
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Abstract
The immunological alterations that have been reported in juvenile chronic arthritis are reviewed. Their role in patient management and classification as well as their possible etiopathogenetic relevance are discussed.
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Affiliation(s)
- A Martini
- Department of Pediatrics, University of Pavia, Italy
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Abstract
This study of children with chronic arthritis confirms that patients at greatest risk for chronic iridocyclitis have a young age of onset and positive antinuclear antibodies (ANA). Children who are ANA negative have a low risk of iridocyclitis. When it occurs it is at a significantly older age. No child developing juvenile chronic arthritis over 9, even with positive ANA, had chronic iritis. There was remarkable variation in ANA titres; these correlated with erythrocyte sedimentation rate, active arthritis, and iridocyclitis. Maximum ANA titres were often seen very early in the disease but at this time were usually not associated with a poor prognosis. Histocompatibility antigens A2 and DRw8 were significantly increased, suggesting primary associations in pauciarticular arthritis with ANA. HLA-DR5 was associated with mild forms of arthritis and with absence of, or only mild, iritis. HLA-B15/w62 was associated with severe forms of eye involvement.
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Abstract
Fifty-six children with JCA have attended the Rheumatology Clinic at the Royal Hospital for Sick Children, Glasgow, over the past five years. Eleven have monoarthritis, 21 pauciarthritis and 24 polyarthritis. Seven children with pauciarthritis and one with monoarthritis developed ocular complications. Of these six were girls. In six children the arthritis preceded the uveitis. In one child arthritis and uveitis presented at the same time and in another the uveitis preceded the arthritis by one year. All were treated with steroids (7 topically, 1 systemically) and topical mydriatic agents. After an initial response the uveitis persisted as a low-grade inflammation gradually leading to secondary complications and increasing loss of vision. Only two patients enjoy normal vision at present. The importance of routine slit-lamp microscopy in all children with JCA is stressed, especially in those with pauciarthritis and antinuclear antibodies.
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Egeskjold EM, Johansen A, Høyeraal HM, Permin H, Johnsen V, Høier-Madsen M. Complexed autoantibodies in patients with juvenile connective tissue diseases, isolated by rate-zonal ultracentrifugation. ACTA PATHOLOGICA, MICROBIOLOGICA, ET IMMUNOLOGICA SCANDINAVICA. SECTION C, IMMUNOLOGY 1985; 93:71-7. [PMID: 4013750 DOI: 10.1111/j.1699-0463.1985.tb02925.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Selected sera from one patient with systemic lupus erythematosus, two with mixed connective tissue disease, one with dermatomyositis, one with progressive systemic sclerosis and one with juvenile rheumatoid arthritis were investigated for autoantibodies after fractionation by computerized rate-zonal ultracentrifugation. Anti-Smith antibodies sedimented in an area from 6-11 S and anti-ribonucleoprotein from 6-13 S. IgG anti-IgG and IgG antinuclear antibodies (ANA) were present in free or complexed form in the 6-13 S area. IgM ANA occurred as 7 S IgM in patients with systemic lupus erythematosus and mixed connective tissue disease, whereas IgM ANA sedimented in the 19 S area in patients with dermatomyositis and progressive systemic sclerosis. Complexes containing IgG anti-IgG and ANA, positioned in the 6-13 S area are likely to play a significant role in the pathogenesis of systemic lupus erythematosus and mixed connective tissue disease.
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Osborn TG, Patel NJ, Moore TI, Zuckner J. Use of the HEp-2 cell substrate in the detection of antinuclear antibodies in juvenile rheumatoid arthritis. ARTHRITIS AND RHEUMATISM 1984; 27:1286-9. [PMID: 6333875 DOI: 10.1002/art.1780271111] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Presence and titer of antinuclear antibodies (ANA) were determined in 217 juvenile rheumatoid arthritis (JRA) patients, by indirect immunofluorescence using HEp-2 cells as substrate. Positive ANA titers (greater than or equal to 1:40) were present in 131 (60%) of the JRA patients. All 3 JRA onset types demonstrated increased percentages of ANA positivity compared with healthy children. Sixty-seven percent of the patients in the polyarticular onset group had positive titers; titers were positive in 62% of the pauciarticular onset group and in 32% of the systemic onset group. ANA were also found in 45% of control patients with other connective tissue diseases. In JRA patients, the speckled pattern occurred most commonly (72%). Fourteen patients (8 with pauciarticular onset and 6 with polyarticular onset) had iridocyclitis; all of them had high titers (greater than or equal to 1:80) of ANA. The use of HEp-2 cells provided a sensitive substrate for detecting ANA in JRA. It proved to be of value in differentiating JRA patients from healthy controls, but not from patients with other connective tissue diseases.
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