Juvenile idiopathic arthritis-associated uveitis: a nationwide population-based study in Taiwan

The inequity of global healthcare in pediatric rheumatology

In pediatric rheumatology, global health inequity relates to the uneven distribution of healthcare resources, accessibility, and health outcomes among children with rheumatic conditions across various countries, regions, and socioeconomic groups. This inequity can manifest in various ways. This review article provides an overview of common rheumatic diseases, such as juvenile idiopathic arthritis and systemic lupus erythematosus, which significantly contribute to and are affected by disparities in global healthcare. Subsequently, we delve into the inequalities in accessing patient care, encompassing issues related to diagnosis and treatment. Additionally, we address challenges in educational advancement and identify research gaps within the field of pediatric rheumatology. We also reveal successful global collaborations, such as a Global Task Force for Pediatric Musculoskeletal Health and special working groups among international organizations, aimed at bridging the disparities gap. Through these efforts, we try to enhance understanding, cooperation, and resource allocation to ensure equal access to quality care worldwide for children with rheumatic conditions. Futhermore, we present a case study from Thailand, highlighting their successful initiatives in developing pediatric rheumatology within their healthcare system.

Taiwan ocular inflammation society consensus recommendations for the management of juvenile idiopathic arthritis-associated uveitis

We presented the development of a consensus guideline for managing juvenile idiopathic arthritis-associated uveitis (JIAU) in Taiwan, considering regional differences in manifestation and epidemiology. The Taiwan Ocular Inflammation Society (TOIS) committee formulated this guideline using a modified Delphi approach with two panel meetings. Recommendations were based on a comprehensive evidence-based literature review and expert clinical experiences, and were graded according to the Oxford Centre for Evidence-Based Medicine's "Levels of Evidence" guideline (March 2009). The TOIS consensus guideline consists of 10 recommendations in four categories: screening and diagnosis, treatment, complications, and monitoring, covering a total of 27 items. These recommendations received over 75% agreement from the panelists. Early diagnosis and a coordinated referral system between ophthalmologists and pediatric rheumatologists are crucial to prevent irreversible visual impairment in children with JIAU. However, achieving a balance between disease activity and medication use remains a key challenge in JIAU management, necessitating further clinical studies.

Pediatric Rheumatological Diseases in a Tertiary Care Hospital of Central India: A Retrospective Clinico-Epidemiological Profile

Introduction: Infectious diseases account for the major health problem in developing countries like India. Though non-infectious diseases like rheumatological disorders are not very common, the burden of these disorders as a group is high in society due to the huge population size. The rheumatological disorders have varied presentations which may mimic other infectious pathologies leading to a significant time lag in the diagnosis. There is inadequate data on the exact burden of these diseases. The spectrum of rheumatological disorders in developing countries is different as compared to the Western world. Hence this study was carried out with the aim of studying the clinical, epidemiological, and laboratory profile of rheumatological disorders in the pediatric age group in a tertiary care hospital. Methods: It was a retrospective study. Data of patients admitted with the diagnosis of rheumatological disorder in the age group of one month to 15 years during the period from June 2018 to December 2022 were reviewed. Results: A total of 35 patients were identified with 20 being female. The mean age of the patients was 8.42± 3.95 years. The most common disease was juvenile idiopathic arthritis (JIA)- 10(28.57%) with an equal proportion of polyarticular JIA and systemic-onset JIA, followed by systemic lupus erythematosus (SLE) nine (25.71%) and Kawasaki Disease (KD)- eight (22.85%). The commonest presenting complaint was fever followed by a rash, whereas the most common findings were pallor and rash. Anemia was present in 25 (71.42%). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were high in 20 (57.14%) and 22 (62.85%), respectively. Antinuclear antibodies (ANA) were positive in 10 (28.57%) and rheumatoid factor (RA) factor in only one (2.85%) case. Conclusions: The most common rheumatological disorder identified was JIA. Fever and rash were the common presenting complaints. Pallor was the commonest sign whereas anemia was the commonest hematological abnormality.

Epidemiology, Treatment, and Outcomes of Juvenile Idiopathic Arthritis-Associated Uveitis: A Multi-Institutional Study in Taiwan

PURPOSE

To assess the epidemiology, treatment, and outcomes of juvenile idiopathic arthritis (JIA)-associated uveitis (JIA-U) in Taiwan.

METHODS

Retrospective, multicenter database.

RESULTS

Totally, 44 (6.1%) of the 722 JIA patients had uveitis. The mean ages of JIA and JIA-U diagnosis were 10.7 and 11.1 years, respectively. JIA-U patients had more antinuclear antibody presence. Among JIA-U patients, 25 (56.8%) were male, 11 (25.0%) experienced any ocular complication, and 8 (18.2%) received ocular surgery. Inactivity lasting ≥6 months was achieved in 17 (38.6%) patients; however, 11 (25.0%) of those experienced reactivation with a mean of 624.7 days after achieving inactivity. Female had more ocular complications and surgeries.

CONCLUSION

Late age at JIA-U diagnosis and male predominance were distinctive in Taiwan. For patients with inactivity lasting ≥ 6 months was achieved, they still required close follow-up due to the high reactivation rate within 2 years. Female had poorer ocular outcomes.

Juvenile idiopathic arthritis in an adult Filipino female: A case report

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is a family of arthritic conditions that occurs in childhood. If untreated, the disease may result in poor quality of life and complications, such as long-term joint damage, that may affect patients their entire lives.

METHODS

A case of a 23-year-old Filipino female presenting with persistent joint pain in both knees, ankles, wrists, and multiple fingers and toes since childhood was investigated. Bilateral eye pain and redness with associated headache, nausea, and vomiting, prompted consultation at the emergency room. Physical examination revealed deformity, erythema and swelling of multiple joints. Ophthalmologic exam revealed poor visual acuity of both eyes (20/100, both eyes). C-reactive protein was elevated, and rheumatoid factor (RF) was negative. The patient underwent glaucoma drainage device (Ahmed valve) insertion on both eyes and was treated on an out-patient basis with adalimumab, methotrexate, prednisone, folic acid, and prednisolone acetate eye drops.

CONCLUSION

JIA is a complicated disease which begins early in life and affects patients even in adulthood. These patients may suffer from arthritis with permanent joint deformities and uveitis, among other disabilities that make daily tasks impossible, impacting patients both mentally and socially.

Impact of Kawasaki disease on juvenile idiopathic arthritis in real-world patients: A population-based cohort study

Objectives

Recent research has demonstrated the commonality of several biological markers between Kawasaki disease (KD) and juvenile idiopathic arthritis (JIA), including interleukin-1β and -6. Therefore, in this cohort study, we assessed whether KD increases the risk of JIA.

Methods

This study enrolled 7009 patients with and 56 072 individuals without KD in the period 2010-2018 from Taiwan's National Health Insurance Research Database. On the basis of sex, age, and comorbidities, we executed propensity score matching at the ratio 1:8. The adjusted hazard ratio (aHR) for JIA was determined through multiple Cox regression. Stratified analysis and sensitivity tests were also employed.

Results

When adjusting for age, sex, and comorbidities, the JIA risk was noted to be 2.02-fold greater in children with KD than it was in those without (aHR: 2.02, 95% confidence interval: 1.12-3.67, p = 0.0205). The sensitivity test and subgroup analysis obtained consistent findings in the different sex and comorbidity subgroups.

Conclusion

Children's risk of JIA is higher if they have KD. Pediatricians should consider the possibility of JIA in this population. More investigations are necessary to identify the pathological mechanisms that link JIA and KD.

Psychological Effects and Quality of Life in Parents and Children with Jia-Associated Uveitis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease common in children and young adults. Uveitis is the most frequent serious extra-articular JIA manifestation and can lead to severe ocular complications, vision loss, and permanent blindness. This study aims to evaluate the psychological condition and the quality of life of children affected by JIA associated with uveitis (JIA-U) and the repercussion of this condition on parents. Thirty children and adolescents with active uveitis (Uveitis group) and comorbid joint symptoms of JIA were referred to the Unit of Ophthalmology, Giovanni XXIII Hospital of Bari, and 30 age-matched healthy controls (Healthy group) were enrolled with their parents. Four questionnaires were administered: Child Behaviour Checklist (CBCL), Parent Stress Index in Short Form (PSI), Pediatric Quality of Life Inventory (PedsQL), and Coping Inventory for Stressful Situations (CISS). The data were collected from February 2021 to December 2021. No significant differences between the two groups in CBCL, PSI, or CISS tests were shown (p > 0.05). Conversely, significant differences between the two groups were observed in the PedsQL (p < 0.05). This study shows how several ocular complications, recurrent eye examinations, and the rigor of long-term treatment may negatively influence health-related quality of life in children with JIA-U.

Patients with juvenile idiopathic arthritis are at increased risk for obstructive sleep apnoea: a population-based cohort study

BACKGROUND AND OBJECTIVES

Juvenile idiopathic arthritis (JIA), an autoimmune disease, has been proposed to be comorbid with obstructive sleep apnoea (OSA). We aimed at testing the hypothesis that patients with JIA may presented with high risk of OSA in a cohort study.

SUBJECTS AND METHODS

This is a cohort study including patients with JIA from 1999 to 2013 identified from a longitudinal health registry. A matched non-JIA control group was also included. The primary outcome variable was presence of OSA. A Cox proportional hazard model was developed to estimate the risk of OSA in patients with JIA. A cumulative probability model was adopted to assess the time-dependent effect of JIA on OSA development, implying a causal link of the association.

RESULTS

A total of 2791 patients with JIA were included, and 11 164 individuals without JIA were selected as matched controls. A total of 95 included subjects had OSA: 31 in the JIA group and 64 in the control group. Patients with JIA were more likely to have OSA compared with controls (adjusted hazard ratio, aHR = 1.922, 95% confidence interval [CI] = 1.244-2.970). The incidence of developing OSA was particularly high among patients with JIA-associated deformity that presented at age 18-30 years (aHR = 1.993, 95% CI = 1.277-3.113) and males (aHR = 1.786, 95% CI = 1.097-2.906). The risk of developing OSA increased over 60 months (aHR = 2.523, 95% CI = 1.322-4.815) of follow-up after the JIA diagnosis.

CONCLUSIONS

Patients with JIA have a significantly increased risk of developing OSA compared with matched individuals without JIA.

Children hospitalized for juvenile arthritis in the United States

Juvenile arthritis (JA) is an autoimmune condition affecting children. We used the 2017 National Inpatient Sample (NIS) to evaluate the impact of JA in the United States. The admission data were converted to weighted form and patients between the ages of 0 and 18 (inclusive) were used in our study. 560 weighted cases were found in 2017. It was more common in females than males (340 females, 220 males), Whites (235 cases), and Medicaid covered 61.6% of all patients with JA (345 cases). The total hospital charges were $25,147,389 while the mean length of stay (LOS) was 4.55 days. The highest number of cases was reported in April 2017.

Intravitreal Dexamethasone Implants for Refractory Macular Edema in Eyes with Noninfectious Uveitis

Macular edema (ME) is a common cause of visual loss among eyes with uveitis, and its management can be challenging. Steroids are an effective treatment for ME, and intravitreal dexamethasone (DEX) implants provide sustained steroid release. The purpose of this study is to evaluate intravitreal DEX implant on refractory ME in eyes with noninfectious uveitis. A retrospective study including 52 eyes of 37 patients with refractory uveitic ME was conducted from January 2011 through August 2017 at Linkou Chang Gung Memorial Hospital in Taiwan. Patients’ demographic characteristics were collected. In addition, clinical information, including corrected visual acuity (VA), intraocular pressure (IOP), and central retinal thickness (CRT) on optical coherence tomography, was recorded and analyzed. During the study period, affected eyes received a total of 110 intravitreal DEX implants (range, one to six in each eye). After the first DEX implant injection in all eyes, VA significantly improved at one and two months. CRT significantly decreased one month after a single DEX implant, and the effect lasted for six months and waned over time. Patients receiving multiple DEX implants still showed significant decreases in CRT one month after the first implant. Increases in IOP were noted one month after the DEX implant, but the IOP could be medically controlled. Intravitreal DEX implants can effectively treat refractory uveitic ME, improving both VA and CRT with an acceptable safety profile. Further studies are necessary to evaluate the effect of multiple implants and long-term outcomes.

Epidemiology of pediatric uveitis and associated systemic diseases

BACKGROUND

The early detection of uveitis associated with systemic inflammatory disease in children is important for proper treatment and prognosis. However, the diagnosis may be delayed because of difficulties in childhood examinations and early minor systemic symptoms. The objective of our study was to identify the pattern of childhood uveitis and investigate the frequency and clinical features of rheumatic diseases in pediatric patients with uveitis.

METHODS

This retrospective observational study reviewed the medical records of children (age ≤ 18 years) with uveitis at a Korean tertiary hospital between January 2005 and December 2018. Data collected included the age at onset of uveitis, sex, anatomic location of ocular inflammation, comorbid disease (including systemic inflammatory disease), ocular complications, relevant laboratory data, and treatment. Fisher's exact test was used to compare categorical variables and the Mann-Whitney U test was used to compare continuous variables. A p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 155 pediatric patients with uveitis were included in this study. The median age at diagnosis was 13.0 years (interquartile range, 9.5-16.0 years). The male-to-female ratio was 1.09. The process was unilateral in 51.6% of children. Anterior uveitis, panuveitis, intermediate uveitis, and posterior uveitis represented 51.6, 26.5, 6.5, and 1.9% of the cases, respectively. Idiopathic uveitis (65.2%) was the most frequent type of uveitis. Systemic rheumatic disease associations were responsible for 28.4% of the cases, among which juvenile idiopathic arthritis (JIA) was the most frequent cause (14.8%). Human leukocyte antigen (HLA)-B27 and antinuclear antibody (ANA) positive rates were significantly higher in patients with JIA than in those with idiopathic uveitis (p = 0.006 and p = 0.007, respectively).

CONCLUSIONS

Approximately one-third of children with uveitis in Korea have a systemic rheumatic disease, of which JIA accounts for the majority of cases. HLA-B27 and ANA can serve as risk factors for JIA-associated uveitis.

Association Between Air Pollution and the Risk of Uveitis: A Nationwide, Population-Based Cohort Study

Previous studies have revealed an association between ocular surface disorders and air pollution, few studies have focused on the risk of uveitis. We aimed to investigate whether air pollution increases the risk of uveitis. We used the Taiwan Longitudinal Health Insurance Database (LHID) and the Taiwan Air Quality Monitoring Database (TAQMD) to conduct a retrospective cohort study. Air pollutant concentrations, including those of carbon dioxide (CO₂), were grouped into four levels according to quartiles. The outcome was the incidence of uveitis, as defined in the International Classification of Diseases, Ninth Revision. We used univariable and multivariable Cox proportional hazard regression models to calculate the adjusted hazard ratios (aHRs) and determine the potential risk factors of uveitis. Overall, 175,489 subjects were linked to their nearby air quality monitoring stations. We found that for carbon monoxide, the aHRs of uveitis risk for the Q3 and Q4 levels were 1.41 (95% confidence interval (CI) = 1.23–1.61) and 2.19 (95% CI = 1.93–2.47), respectively, in comparison with those for the Q1 level. For nitric oxide, the aHRs for the Q3 and Q4 levels were 1.46 (95% CI = 1.27–1.67) and 2.05 (95% CI = 1.81–2.32), respectively. For nitrogen oxide (NOx), the aHRs for the Q2, Q3, and Q4 levels were 1.27 (95% CI = 1.11–1.44), 1.34 (95% CI = 1.16–1.53), and 1.85 (95% CI = 1.63–2.09), respectively. For total hydrocarbon (THC), the aHRs for the Q2, Q3, and Q4 levels were 1.42 (95% CI = 1.15–1.75), 3.80 (95% CI = 3.16–4.57), and 5.02 (95% CI = 4.19–6.02), respectively. For methane (CH4), the aHRs for the Q3 and Q4 levels were 1.94 (95% CI = 1.60–2.34) and 7.14 (95% CI = 6.01–8.48), respectively. In conclusion, air pollution was significantly associated with incidental uveitis, especially at high THC and CH₄ levels. Furthermore, the uveitis risk appeared to increase with increasing NOx and THC levels.

The importance of transition from pediatric to adult rheumatology care in juvenile idiopathic arthritis

Introduction: Juvenile idiopathic arthritis (JIA) is the most common rheumatic inflammatory condition in childhood. The long-term morbidity, mortality, and quality of life have improved with the earlier use of disease-modifying drugs (DMARDs) and the availability of biology disease-modifying drugs (bDMARDs). Despite the improvement of treatment, around 50% of the patients reach adulthood with articular and/or extra articular disease activity. A careful planned transition from pediatric to adult care is necessary to reduce the loss of follow-up that is associated with stopping medications, flares, and disability due to untreated arthritis or uveitis.Areas covered: This narrative review provides an overview of the importance of transition in JIA Articles were selected from Pubmed searches.Expert opinion: JIA patients, family, and healthcare workers have to be trained to provide an effective transition plan, based on local and national policies. Important aspects such as expectations, maturation, disease characteristics, disease activity, adherence, disability, and psychological aspects among others have to be considered and addressed during the transition phase to improve self-esteem, self-assurance, and quality of life.

Improving musculoskeletal health for children and young people - A 'call to action'

This chapter describes the musculoskeletal (MSK) context in children and young people as an important contributor to the global non-communicable disease burden. Through selected MSK conditions, we describe the impact on patients, families and communities and highlight the challenges that need to be addressed. We focus on opportunities for better working together and describe exemplar initiatives to raise awareness, workforce capacity building, models of care and research agendas to have a greater global context.

Laser Flare Photometry: A Useful Tool for Monitoring Patients with Juvenile Idiopathic Arthritis-associated Uveitis

PURPOSE

We evaluated laser flare photometry (LFP) values in patients with juvenile idiopathic arthritis (JIA)-associated uveitis.

METHODS

Retrospective study. A decrease of the LFP value between baseline visit and 1 month after anti-inflammatory treatment intensification allowed us to define two groups of patients: group 1 (decreased LFP value ≥50%) and group 2 (<50%). We evaluated the prevalence of vision-threatening complications in both groups.

RESULTS

Fifty-four patients (87 eyes) were followed for 9.9 ± 5 years. Group 1 eyes (n = 54) had significantly fewer ocular complications than group 2 eyes (n = 33) at both 5 years visit (p = .03) and final visit (p = .047). At the final visit, group 2 eyes had significantly more band keratopathy, trabeculectomy, cataract surgery, glaucoma and papille edema. Group 1 eyes kept a better visual acuity (p < .0001).

CONCLUSION

The decrease of LFP values ≥50% of the initial value 1 month after treatment intensification is a good early prognostic factor.

Pediatric Uveitis and Scleritis in a Multi-Ethnic Asian Population

PURPOSE

To describe the demographics and clinical characteristics of pediatric uveitis and scleritis at a tertiary eye care center.

METHODS

Clinical records of children with either uveitis or scleritis that presented between January 1989 and January 2016 were reviewed retrospectively.

RESULTS

Seventy-three patients were identified. Fifty-four had uveitis and 19 had scleritis. Posterior uveitis was the most common (27.8%), followed by intermediate uveitis (25.9%), panuveitis (25.9%) and anterior uveitis. Majority were noninfectious uveitis (37.0%), and 29.6% were idiopathic. Common associations were sarcoidosis (14.8%), HLA-B27 haplotype (9.3%) and toxoplasmosis (7.4%). Posterior scleritis was more common (94.7%) than anterior scleritis and majority were idiopathic (68.4%). Delayed patient presentation and presenting visual acuity worse than 0.3 LogMAR were associated with poor visual outcome (p = .03; OR = 0.17; 95% CI, 0.03-0.84 and p = .007; OR = 0.09; 95% CI, 0.02-0.52 respectively).

CONCLUSION

Majority had noninfectious etiologies. Uveitis associated with juvenile idiopathic arthritis was rare.

Importance of pediatric rheumatologists and transitional care for juvenile idiopathic arthritis-associated uveitis: a retrospective series of 9 cases

BACKGROUND

Juvenile idiopathic arthritis-associated uveitis (JIA-U) is a serious condition associated with the risk of blindness. However, pediatric rheumatologists rarely encounter cases of blindness, because most patients reach adulthood during the course of follow-up before blindness occurs. Here, we report the progress of 9 patients with JIA-U, including 2 patients who became blind after the transition period. We aimed to highlight the importance of the role of pediatric rheumatologists and transitional care in preventing blindness associated with JIA-U.

CASE PRESENTATION

We conducted a retrospective analysis of the case records of 9 JIA-U patients (1 male, 8 female; median age 16.8 years, range 5.5-19.8 years). All patients presented with oligo-juvenile idiopathic arthritis (oligo-JIA) (one presented with extended oligo-JIA); the median age of uveitis onset was 5.0 years (range 3.0-13.0 years), and the onset of uveitis preceded the onset of arthritis in 2 patients. The median disease duration was 12.5 years (range 3.5-24.7 years); 4 patients had anti-nuclear antibody (ANA) positivity (≧1:160) (all with a homogeneous and speckled-pattern subtype). All patients were negative for rheumatoid factor. Eight patients received methotrexate, 7 patients received one or more biologic drugs (etanercept, infliximab, adalimumab, and golimumab), and 6 patients required ophthalmic surgery at an early age (≦ 18 years). Two patients developed blindness after the transition period. Medical examination by pediatric rheumatologists and use of biologics had been delayed in both patients. One patient developed depression after transition and interrupted her own treatment.

CONCLUSIONS

The reason for blindness in the 2 patients was thought to be the delay in the commencement of treatment and failure to provide transitional care. Inflammation is difficult to control in JIA-U even with appropriate treatment. Pediatric rheumatologists must be informed about the risk of JIA-U blindness, especially after transition. To ensure a good prognosis, the specialized treatment with the involvement of pediatric rheumatologists is necessary early on, and consideration for transitional medicine is essential. Therefore, this report reaffirms the importance of planned transitional care that has been advocated for globally.

Pregnancy outcomes and perinatal complications of Asian mothers with juvenile idiopathic arthritis - a case-control registry study

BACKGROUNDS

In order to provide juvenile idiopathic arthritis (JIA) patients with better pre-conceptional and prenatal counselling, we investigated the obstetrical and neonatal outcomes among women with Asian descent.

METHODS

Through the linkage of Taiwan National Health Insurance database and National Birth Registry, we established a population-based birth cohort in Taiwan between 2004 and 2014. In a case control study design, first children born to mothers with JIA are identified and matched with 5 non-JIA controls by maternal age and birth year. Conditional logistic regression was used to calculate odds ratios for maternal and neonatal outcomes crude and with adjustment.

RESULTS

Of the 2,100,143 newborn, 778 (0.037%) were born to JIA mothers. Among them, 549 first-born children were included in this research. Our result suggested that babies born to mothers with JIA were more likely to have low birth body weight, with an adjusted OR of 1.35(95% CI: 1.02 to 1.79) when compared to babies born to mothers without. No differences were observed in other perinatal complications between women with and without JIA including stillbirth, prematurity, or small for gestational age. The rate of adverse obstetrical outcomes such as caesarean delivery, preeclampsia, gestational diabetes, postpartum hemorrhage and mortality were also similar between the two.

CONCLUSIONS

Adverse obstetrical and neonatal outcomes were limited among Asian mothers with JIA. Intensive care may not be necessary for JIA mothers and their newborns.

Recommendations for the Management of Uveitis Associated With Juvenile Idiopathic Arthritis: The Czech and Slovak adaptation of SHARE Initiative

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 &gt; 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.

Effect of Uveitis on the Development of Keratopathy: A Population-Based Cohort Study

Purpose

The purpose of this study was to evaluate the effect of uveitis on the development of various keratopathies via the use of the National Health Insurance Research Database (NHIRD) in Taiwan.

Methods

Approximately 1 million patients were randomly sampled from the registry of the NHIRD. Patients diagnosed with uveitis by ophthalmologists were enrolled in the study group after exclusion. Each individual in the study group was age and sex matched to four non-uveitis individuals who serve as the control group. In addition to keratopathy, other possible risk factors and medications were included in the multivariate model, and the effects of different subtypes of uveitis for developing keratopathies were also analyzed.

Results

A total of 4773 uveitis patients (2662 male and 2111 female) and 19,092 non-uveitis patients (10,648 male and 8444 female) were enrolled. There were 406 events of keratopathy in the study group, and another 764 events occurred in the control group. A higher incidence rate was found in the study group after adjustment (adjusted hazard ratio [aHR]: 1.772), with a greater cumulative probability (P < 0.0001). For the subgroup analysis, anterior uveitis (aHR = 1.765) and panuveitis (aHR = 3.386) increased the risk of developing keratopathies. Moreover, male sex was associated with a higher aHR than female sex for developing keratopathies in the study group.

Conclusions

The presence of uveitis significantly elevates the risk for developing keratopathy.

Clinical features and characteristics of uveitis associated with juvenile idiopathic arthritis in Japan: first report of the pediatric rheumatology association of Japan (PRAJ)

BACKGROUND

Although there are many reports on Juvenile Idiopathic arthritis-associated uveitis (JIA-U) from various countries, especially from Europe and North America, there are few reports from Asia. Our aim was to investigate the epidemiology, characteristics and predictors of JIA-U in Japan.

METHODS

Data were retrospectively collected on 726 patients with JIA from medical records as of April 2016 at 15 medical centers specialized in pediatric rheumatic diseases. Of these, patients with uveitis were further investigated for the specific characteristics of this manifestation.

RESULTS

The prevalence of uveitis was 6.1% in the 726 JIA patients examined. Incidence of uveitis was significantly higher in patients with an earlier arthritis onset (2.6-vs.-5.8 years, P < 0.0001), oligoarthritis (16.1%-vs.-1.6%, P < 0.001), or anti-nuclear antibodies. On the contrary, it was significantly less common in patients with rheumatoid factor or anti-cyclic citrullinated peptide antibodies. A history of using methotrexate (MTX), infliximab or adalimumab was also associated with uveitis occurrence. The median age at uveitis diagnosis was 5 years, and the median time from arthritis onset to uveitis diagnosis was 2 years. The occurrence of anterior and bilateral uveitis was 79.3 and 53.7%, respectively. There were no symptoms at uveitis diagnosis in 58.5% of cases. Complications arising between the time of uveitis diagnosis and the last observation increased from 31.7 to 56.1%; in particular, cataract was increased 3-fold. While no patients lost their vision, 61.9% did not recover normal vision (≥ 1.0), and in many cases active uveitis persisted, especially in males. In addition to steroid eye drops (97.6%) and MTX (15.4%), biological agents were used for treating the uveitis in 41.5% of patients.

CONCLUSIONS

The epidemiology, characteristics and predictors of JIA-U in Japan are described here for the first time. Although the prevalence of JIA-U in Japan is lower than in predominantly Caucasian cohorts, as reported from North America and Europe, the epidemiology, characteristics and predictors were found to be similar.

Common Infections and Target Organs Associated with Chronic Granulomatous Disease in Iran

Recurrent severe bacterial and fungal infections are characteristic features of the rare genetic immunodeficiency disorder chronic granulomatous disease (CGD). The disease usually manifests within the first years of life with an incidence of 1 in approximately 200,000 live births. The incidence is higher in Iran and Morocco where it reaches 1.5 per 100,000 live births. Mutations have been described in the 5 subunits of NADPH oxidase, mostly in gp91phox and p47phox, with fewer mutations reported in p67phox, p22phox, and p40phox. These mutations cause loss of superoxide production in phagocytic cells. CYBB, the gene encoding the large gp91phox subunit of the transmembrane component cytochrome b558 of the NADPH oxidase complex, is localized on the X-chromosome. Genetic defects in CYBB are responsible for the disease in the majority of male CGD patients. CGD is associated with the development of granulomatous reactions in the skin, lungs, bones, and lymph nodes, and chronic infections may be seen in the liver, gastrointestinal tract, brain, and eyes. There is usually a history of repeated infections, including inflammation of the lymph glands, skin infections, and pneumonia. There may also be a persistent runny nose, inflammation of the skin, and inflammation of the mucous membranes of the mouth. Gastrointestinal problems can also occur, including diarrhea, abdominal pain, and perianal abscesses. Infection of the bones, brain abscesses, obstruction of the genitourinary tract and/or gastrointestinal tract due to the formation of granulomatous tissue, and delayed growth are also symptomatic of CGD. The prevention of infectious complications in patients with CGD involves targeted prophylaxis against opportunistic microorganisms such as Staphylococcus aureus, Klebsiella spp., Salmonella spp. and Aspergillus spp. In this review, we provide an update on organ involvement and the association with specific isolated microorganisms in CGD patients.

Adult outcome of juvenile idiopathic arthritis: A nationwide population-based retrospective cohort study in Taiwan

OBJECTIVE

To clarify the development of juvenile idiopathic arthritis (JIA) to adult-onset autoimmune diseases in a population-based study in Taiwan.

METHODS

We analyzed data of 107 433 children born between 1990 and 1997 from the National Taiwan Health Insurance Database. There were 262 JIA patients and 107 171 individuals without JIA who were selected and followed up until December 2013 to investigate their outcomes of adult-onset autoimmune diseases after reaching 16 years of age. The adjusted hazard ratios (aHRs) including 95% confidence intervals (95% CI) of adult-onset autoimmune diseases were calculated using the Cox proportional regression model among different age groups.

RESULTS

The incidence rate for patients with a history of JIA was 83.56 per 10⁵ person-months for rheumatoid arthritis (RA), 16.61 for systemic lupus erythematosus (SLE), 58.39 for ankylosing spondylitis (AS), and 33.26 for psoriatic diseases. The aHRs were 29.60 for any autoimmune disease, 129.52 for RA, 10.01 for SLE, 49.62 for AS, and 8.20 for psoriatic diseases. Compared with non-JIA individuals, the aHRs of adult-onset autoimmune diseases were 34.87 (95% CI: 4.85-250.62) at the onset age of 3-5 years, 12.01 (95% CI: 2.99-48.26) at the age of 6-10 years, and 45.80 (95% CI: 29.69-70.64) at the age of 11-15 years.

CONCLUSION

Children with JIA were at an increased risk of developing RA, AS, psoriatic disease, and SLE in adulthood.

Consensus-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis: the SHARE initiative

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.

Comparison of uveitis in the course of juvenile idiopathic arthritis with isolated uveitis in children - own experiences

Objectives

Uveitis and juvenile idiopathic arthritis (JIA) relatively often coexist. Inflammatory changes in the anterior segment of the eye are the most common extra-articular symptom in children with JIA, and JIA is, in turn, the main systemic cause of anterior uveitis in children. The aim of our study was to compare the course of anterior uveitis accompanying JIA and isolated uveitis.

Material and methods

We analyzed 25 children with JIA and uveitis (group I) and 28 children with isolated uveitis (group II). The study population was retrospectively selected from the patients treated in our center in the years 1998–2016 through a search of the hospital database. All data were presented as descriptive statistics.

Results

In group I there was a higher percentage of girls than in group II (64% vs. 50%) and uveitis occurred at a significantly younger age (8.7 years vs. 11.6). Patients from group I more often presented with immunological abnormalities (positive antinuclear antibodies or HLA-B27 antigen). The majority of children from group I developed uveitis prior to (44%) or simultaneously with (20%) arthritis. In patients who first presented with uveitis, arthritis appeared on average after 28 months (median 12 months). In children in whom arthritis developed first, uveitis appeared on average after 51 months (median 36 months). In some patients the time interval between the involvement of these two organs was as long as 9–10 years. Four children from group I and three from group II were qualified for biological treatment.

Conclusions

The results of our analysis indicate the need for constant cooperation between the pediatric rheumatologist and the ophthalmologist. Although the risk of uveitis in JIA decreases with the disease duration, in some cases this complication can develop after many years. Children with present antinuclear antibodies, at younger age and of female gender should be subject to particularly close observation.

Clinico-epidemiological Profile of Pediatric Rheumatology Disorders in Eastern India

Background

Data on rheumatological disorders in children from developing countries like India are scarce. Hence, this study aimed to understand the clinical and epidemiological profile of rheumatological disorders in children as this can help organize comprehensive evidence-based health care services.

Methodology

A retrospective hospital-based study was designed in pediatric rheumatology clinic of the All India Institute of Medical Sciences, Patna, India, from January 2015 to December 2016. Clinical and laboratory findings and response to therapy of all children with rheumatological disorders were evaluated.

Results

A total of 60 children with various rheumatological disorders were included in the study. Juvenile idiopathic arthritis (JIA) was the most common pediatric rheumatology disorder observed, and polyarticular JIA was the predominate subtype observed in our patients. The mean age of disease onset was 9.1 ± 3.6 years (age range: 1-16 years). Methotrexate was the most common disease modifying antirheumatic drug used. None of the children received newer biological agents due to financial constraints. The use of alternative medicine was observed in 10% of cases.

Conclusion

The clinical and epidemiological profile of children with rheumatological disorders in our patient group was different from the European countries and Western world. There is a need for introspecting the lack of using biological agents and its potential impact in managing JIA in our patient group.

Treatment response to etanercept in methotrexate refractory juvenile idiopathic arthritis: an analysis of predictors and long-term outcomes

The aim of the study is to evaluate the long-term outcomes, predictors, and the role of inflammatory cytokines in methotrexate (MTx) refractory juvenile idiopathic arthritis (JIA) patients. This is a retrospective cohort study. MTx refractory JIA patients who received etanercept as their first biological agent in National Taiwan University Hospital (NTUH) were enrolled. Patients were classified into remission group, non-remission group, relapsing group, and non-relapsing group according to the criteria of disease remission and disease flares defined by Wallace et al. We compared the differences in the baseline data, therapeutic responses, time to etanercept tapering, and inflammatory cytokine (IL-12p70, TNF-α, IL-10, IL-6, and IL-1β) levels between these groups. Among the 58 patients, 30 (52%) reached remission. Seventeen of the 30 patients had episodes of disease flares. We found that more patients in the remission group achieved ACR pediatric 70 response at the fourth month after etanercept treatment (p < 0.002). When comparing the relapsing group and non-relapsing group, we found that patients were more likely to have disease flares if it took longer to achieve remission (p = 0.0008). Besides, etanercept was tapered earlier in the non-relapsing group (p = 0.0006). There was no significant difference in levels of inflammatory cytokine between groups. No parameter before treatment could be used as a single predictor of long-term outcomes. However, ACR pediatric 70 response at the fourth month after etanercept treatment might predict disease remission. Besides, patients who achieved remission more rapidly were less likely to have disease flares.

Epidemiology and risk of juvenile idiopathic arthritis among children with allergic diseases: a nationwide population-based study

BACKGROUND

Epidemiological research reveals that the incidence of allergic diseases and that of autoimmune diseases have been increasing in parallel, raising an interest in a potential link between the two disorders. However, the relationship between Th2-mediated allergic disease and Th1-mediated juvenile idiopathic arthritis (JIA) remains unclear. This population-based case-control study was aimed at investigating the development of childhood-onset allergic diseases and the subsequent risks of JIA.

METHODS

We included 329 children with JIA diagnosed between 2000 and 2008, and 1316 age- and sex-matched controls. The odds ratios of developing JIA were calculated to determine an association with preexisting allergic diseases.

RESULTS

The incidence rate of JIA in Taiwan between 2000 and 2008 was 1.33 cases per 100,000 children/year according to the International League of Associations for Rheumatology (ILAR) criteria. The children with a single allergic disease had an increased risk of JIA, with adjusted odds ratios of developing JIA of 1.44 for allergic conjunctivitis (95 % confidence interval [CI], 1.07-1.95), 1.50 for allergic rhinitis (1.15-1.96), and 1.44 for asthma (1.00-2.10). The adjusted odds ratios increased with the number of concurrent allergic diseases from 1.50 (95 % CI, 1.12-2.01) for those with only one allergic disease to 1.72 (1.24-2.38) for those with at least two allergic diseases. The adjusted odds ratios of those with at least two allergic diseases increased to 1.84 (95 % CI, 1.19-2.86) for boys and 2.54 (1.42-4.54) for those older than 12 years. The children who made two or more medical visits for associated allergic diseases per year had an increased risk of JIA.

CONCLUSION

Children with onset of allergic diseases were at increased risk of developing JIA. The increased risk was associated with the cumulative effect of concurrent allergic diseases and frequency of seeking medical care. Further study to investigate the role of Th2-mediated allergic diseases that contribute to the development of Th1-mediated JIA is warranted.

Birth Outcomes in Women with a History of Juvenile Idiopathic Arthritis

OBJECTIVE

To determine whether children born to women who had juvenile idiopathic arthritis (JIA) had more adverse birth outcomes than children born to mothers who never had JIA.

METHODS

Our cohort study used data from physician billing and hospitalizations covering the province of Quebec, Canada. We identified all women with JIA with a first-time birth between January 1, 1983, and December 31, 2010, and assembled a control cohort of first-time mothers without JIA from the same administrative data, matching 4:1 for date of first birth, maternal age, and area of residence. We compared outcomes (stillbirth, prematurity, small for gestational age, and major congenital anomalies) in the JIA versus non-JIA groups using logistic regression.

RESULTS

Mean age at delivery was 24.7 years in the JIA group (n = 1681) and 25.0 years for the non-JIA group (n = 6724). Women who had JIA were at higher risk for a premature baby [adjusted relative risk (RR) 1.20, 95% CI 1.01-1.42], a baby small for gestational age (adjusted RR 1.19, 95% CI 1.04-1.37), and a child with a congenital malformation (adjusted RR 6.51, 95% CI 5.05-8.39). Neural tube defects were higher in the JIA offspring: 1.61% (95% CI 1.11-2.33) versus 0.03% (95% CI 0.01-0.11) in the non-JIA group, as were congenital heart defects: 1.07% (95% CI 0.68-1.69) versus 0.58% (95% CI 0.42-0.79).

CONCLUSION

Most women with JIA will deliver a normal baby, even though they are at higher risk for having a child with adverse birth outcomes. Research is needed to understand pathophysiologic mechanisms and to investigate the effects of medications during childhood and youth on future birth outcomes.

Comparison between Outcomes of Vitrectomy in Granulomatous and Nongranulomatous Uveitis

Purpose: The aim of this study was to compare the outcomes of vitrectomy in granulomatous uveitis and nongranulomatous uveitis insufficiently managed by immunosuppressive therapy. Methods: Thirty-eight eyes with granulomatous uveitis and 17 eyes with nongranulomatous uveitis that underwent vitrectomy for ocular complications between July 2006 and August 2012 were reviewed retrospectively. Visual acuity and ocular inflammation scores before and 6 months after surgery were compared. Patients treated with vitrectomy alone and those in whom vitrectomy was combined with phacoemulsification were analyzed separately. Results: The mean visual acuity improved significantly both in granulomatous and nongranulomatous uveitis. In granulomatous uveitis, the mean inflammation scores decreased significantly both in the anterior segment and in the posterior segment. In nongranulomatous uveitis, the mean inflammation score in the posterior segment decreased significantly, although it did not change in the anterior segment. Conclusion: Vitrectomy was effective for treating ocular complications both in granulomatous uveitis and nongranulomatous uveitis, with favorable outcomes of improved visual acuity and decreased uveitis activity.

Population-based cohort study on the risk of malignancy in East Asian children with juvenile idiopathic arthritis

BACKGROUND

To investigate the association and magnitude of risk between JIA, its associated treatment and cancer development in Taiwanese children.

METHODS

Nationwide population-based 1:4 age- and gender-matched retrospective cohort study was designed using the National Health Insurance Research Database of Taiwan. A cohort of 2,892 children <16 years old with JIA was formed as well as a non-JIA cohort of 11,568 in year 2003 to 2005. They were followed up till a diagnosis of malignancy or up to 8 years until 2010. Relative risk (RR), incidence rate ratio (IRR), and adjusted hazard ratio (aHR) of developing malignancy were calculated.

RESULTS

The female to male ratio was 0.79:1. There were 3 cases of incident cancer in the "MTX use, biologics-naïve" group, only 1 in the anti-TNF biologics-containing group and 29 in the "both MTX- and biologics-naïve" group, in comparison, there were 50 cases of cancer in the non-JIA comparator group. During a 16114.16 patient-years follow-up, the RR and IRR for developing a malignancy in both methotrexate- and anti-tumor necrosis factor (TNF) biologics-naïve JIA children were 2.75 (95% confidence interval, 1.75 - 4.32) and 3.21 (2.01 - 5.05), respectively. For leukemia, the IRR was 7.38 (2.50 - 22.75); lymphoma, 8.30 (1.23 - 69.79); and soft tissue sarcoma, 11.07 (0.84 - 326.4). The IRR of other cancers was 2.08 (1.11 - 3.71). The aHR on cancer risk was 3.14 (1.98 - 4.98) in methotrexate- and biologics-naïve group. There were no statistically significant increased risk in JIA patients treated with methotrexate and/or anti-TNF biologics.

CONCLUSIONS

Compared with children without JIA, children with JIA have 3-fold increase of risk on malignancy in East Asia. Seemingly neither methotrexate nor anti-TNF biologics increases the risk further.