Treatment of juvenile rheumatoid arthritis

Unveiling the Rare Complication: Statin-Induced Immune-Mediated Necrotizing Myopathy

BACKGROUND Statin-induced necrotizing autoimmune myopathy is an exceptionally rare yet severe complication of statin therapy that may develop in individuals at any time during their exposure to statins. The development of proximal muscle weakness, muscle pain, and elevated creatine kinase (CK) levels in patients while taking statins should prompt clinical consideration of statin-induced myopathy. The pathophysiology arises from the production of auto-antibodies, which target the 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA reductase) enzyme, leading to the aggressive breakdown of myofibrils. CASE REPORT Here, we present a case of a 59-year-old woman with a medical history of dyslipidemia who developed anti-HMG-CoA reductase antibodies after taking atorvastatin. She came to the emergency department with complaints of severe proximal muscle weakness. The laboratory workup showed an elevated CK level up to 12 000 IU/L. Despite discontinuing atorvastatin, the patient's elevated CK levels persisted. The patient underwent a muscle biopsy, demonstrating myofibril necrosis. Serological analysis showed anti-HMG-CoA reductase antibodies in the patient's serum, which led to the diagnosis of immune-mediated necrotizing myopathy due to statins. The patient's statin therapy was promptly discontinued, and she was treated with a high dose of IV corticosteroids. After the patient's discharge, brief discontinuation of the corticosteroids resulted in CK elevation and a return of symptoms. This led to the second re-admission and restarting of corticosteroids until stabilization and discharge. CONCLUSIONS This case represents an important reminder for clinicians to recognize the possibility of statin-induced immune-mediated necrotizing myopathy in patients presenting with proximal muscle weakness while taking a statin, notwithstanding the rarity of this condition.

Juvenile idiopathic arthritis in Jordan: single center experience

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a heterogeneous group of disorders, including all forms of arthritis, which develops in children who are less than 16 years old. This study aimed to evaluate the clinical and laboratory features of JIA in a single center in Jordan.

METHODS

A retrospective analysis of the electronic medical records of Pediatric patients diagnosed with JIA based on the International League of Associations for Rheumatology (ILAR) criteria during the period from 2015 to 2019 at the Pediatric Rheumatology Clinic in the Queen Rania Children's Hospital. All patients were below the age of 14 years at the time of diagnosis and followed for at least 6 months. Collected data consisted of age, gender, age at initial presentation and diagnosis, JIA subtype, laboratory data, treatment options, and outcome.

RESULTS

A total of 210 patients were included in this cohort (94 males and 116 females) with the mean age at diagnosis and mean age at onset of 5.33 ± 3.40 years and 5.08 ± 3.40 years (range: 7 months - 14 years), respectively. Oligoarticular JIA was the commonest subtype (54.7%), followed by systemic arthritis (17.1%) and polyarticular arthritis (12.3%). ANA was positive in 70 patients (33.6%). Uveitis occurred in 30 (14.2%) patients.

CONCLUSION

To the best of our knowledge, this study on this cohort is the first report on JIA in Jordan, in comparison with other regionally and internationally published reports. Oligoarticular JIA was found to be the most common subtype. For detailed knowledge on JIA characteristics and patterns, a population-based, rather than a single center study, should be conducted in Jordan.

Characterizing pain flares in adolescent inflammatory and non-inflammatory musculoskeletal disorders: A qualitative study using an interpretative phenomenological approach

BACKGROUND

Adolescents with musculoskeletal disorders experience acute exacerbations in pain, colloquially called "pain flares" in adult literature. This study aimed to explore adolescents' lived experience of pain flares, including what pain flares are, why they occur, how they are managed and what lasting effects they have on adolescents.

METHODS

A sample of 10 adolescents diagnosed with juvenile idiopathic arthritis or chronic idiopathic pain syndrome were recruited from a tertiary hospital in the UK. Data were collected using semi-structured interviews and visual aids, and analysed using interpretative phenomenological analysis.

RESULTS

Four broad themes were identified which describe as a journey of change from participants: (a) daily life with pain, where adolescents report a level of pain that is "normal" for them which they can tolerate and continue their daily routines around; (b) pre-flare period, where adolescents begin to notice pain increasing beyond normal levels and employ preventative strategies to reduce the risk of symptoms developing into a flare; (c) flare period, where adolescents describe the symptoms, frequency, duration, impact and their attempts to manage flares; to their (d) post-flare period, where symptoms begin to return to baseline levels and adolescents take actions to regain the level of normality experienced in daily life.

CONCLUSION

This study has identified a number of components of the pain flare experience. Findings show that pain flares are more than an increase in pain intensity; they are multi-layered and require other features to change. These findings help to differentiate pain flares from typical fluctuations in pain.

Developing and Evaluating JIApp: Acceptability and Usability of a Smartphone App System to Improve Self-Management in Young People With Juvenile Idiopathic Arthritis

BACKGROUND

Flare-ups in juvenile idiopathic arthritis (JIA) are characterized by joint pain and swelling and often accompanied with fatigue, negative emotions, and reduced participation in activities. To minimize the impact of JIA on the physical and psychosocial development and well-being of young people (YP), it is essential to regularly monitor disease activity and side effects, as well as to support self-management such as adherence to treatment plans and engagement in general health-promoting behaviors. Smartphone technology has the potential to engage YP with their health care through convenient self-monitoring and easy access to information. In addition, having a more accurate summary of self-reported fluctuations in symptoms, behaviors, and psychosocial problems can help both YP and health care professionals (HCPs) better understand the patient's condition, identify barriers to self-management, and assess treatment effectiveness and additional health care needs. No comprehensive smartphone app has yet been developed in collaboration with YP with JIA, their parents, and HCPs involved in their care.

OBJECTIVES

The objective of this study was to design, develop, and evaluate the acceptability and usability of JIApp, a self-management smartphone app system for YP with JIA and HCPs.

METHODS

We used a qualitative, user-centered design approach involving YP, parents, and HCPs from the rheumatology team. The study was conducted in three phases: (1) phase I focused on developing consensus on the features, content, and design of the app; (2) phase II was used for further refining and evaluating the app prototype; and (3) phase III focused on usability testing of the app. The interview transcripts were analyzed using qualitative content analysis.

RESULTS

A total of 29 YP (aged 10-23, median age 17) with JIA, 7 parents, and 21 HCPs were interviewed. Major themes identified as the ones that helped inform app development in phase I were: (1) remote monitoring of symptoms, well-being, and activities; (2) treatment adherence; and (3) education and support. During phase II, three more themes emerged that informed further refinement of the app prototype. These included (4) adapting a reward system to motivate end users for using the app; (5) design of the app interface; and (6) clinical practice integration. The usability testing during phase III demonstrated high rates of overall satisfaction and further affirmed the content validity of the app.

CONCLUSIONS

We present the development and evaluation of a smartphone app to encourage self-management and engagement with health care for YP with JIA. The app was found to have high levels of acceptability and usability among YP and HCPs and has the potential to improve health care and outcomes for this age group. Future feasibility testing in a prospective study will firmly establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with arthritis.

Cervical fracture from chronic steroid usage presenting as a stroke: A case report

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This case highlights the important fact that stroke mimics can require the same urgency in care and diagnosis as strokes themselves.

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Such a case demonstrates that clinicians should carefully examine imaging of the cervical spine in cases of hemiparesis, even in cases where there is no recent history of trauma.

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The case of several cervical spine fractures resulting from a simple head tilt perhaps implicates that the bone mineral density of patients on long-term steroid use should be monitored starting at an early age and that a certain threshold of bone density should be impermissible.

Introduction

Misdiagnosis of Brown-Séquard-like presentations can delay treatment; potentially endangering the positive outcomes a patient might otherwise have had. Stroke mimics can be perceived as signaling the end of urgent investigation and care once stroke is ruled out; however, stroke mimics themselves can require prompt care. Herein, we discuss an extremely rare case where stroke was ruled out, resulting in a lapse in care that lead to an exacerbated hemiparesis over the following week.

Presentation of case

We present a patient with an occult cervical spine fracture with extension of the neck, caused by reduced bone density from a chronic steroid regimen. Nine days after the initial onset of her neurological symptoms, the patient presented to the ED with the complaint of left sided weakness and right-sided sensory loss. She was determined to have a left- sided Brown Séquard syndrome, which resolved following anterior cervical discectomy and fusion at C4-C6 and a laminectomy from C4-C6.

Discussion

This case indicated that patients with dangerously low bone density should be weaned off chronic steroid therapy to prevent the onset of osteoporotic symptoms early in adulthood. Furthermore, this case emphasizes the importance of continued investigation of symptoms if a stroke is ruled out and the need for more diligent monitoring of bone density of chronic steroid users.

Conclusion

Stroke mimics can require the same urgency in care and diagnosis as strokes themselves.