1
|
Ključevšek D, Potočnik Tumpaj V, Gazikalović A. The role of radiography in diagnosing, monitoring and prognosing juvenile idiopathic arthritis. Pediatr Radiol 2024; 54:481-489. [PMID: 37640799 DOI: 10.1007/s00247-023-05742-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023]
Abstract
The current role of conventional radiography in the diagnosis, monitoring and prognosis of juvenile idiopathic arthritis (JIA) is reviewed, as its role has changed with the increasing use of ultrasound and magnetic resonance imaging, as well as with the introduction of biological drugs. Conventional radiography does not play an important role in the diagnosis of JIA, as this is based on history, clinical examination and laboratory findings. The main role of conventional radiography is in the detection and monitoring of growth disorders and chronic structural and morphological changes of the affected joints and bones, in addition to helping with the differential diagnosis of conditions that mimic JIA. Radiographic changes of the joints depend on the age of the child, the type and duration of arthritis and the specific joints affected. There are no standard protocols for arthritis monitoring and most indications for imaging are based on individual case-by-case decisions. The development of degenerative joint changes is considered a poor predictive factor, but there are no clear studies that more precisely define the predictive value of radiographic changes. Conventional radiography remains an important imaging modality in narrowing the differential diagnosis and in evaluating growth disorders and the developing destructive joint changes.
Collapse
Affiliation(s)
- Damjana Ključevšek
- Department of Radiology, University Children's Hospital Ljubljana, University Medical Center Ljubljana, Bohoričeva 20, 1000, Ljubljana, Slovenia.
- Department of Radiology, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | - Vesna Potočnik Tumpaj
- Department of Radiology, General hospital of Slovenj Gradec, Slovenj Gradec, Slovenia
| | - Ana Gazikalović
- Department of Radiology, University Children's Hospital Ljubljana, University Medical Center Ljubljana, Bohoričeva 20, 1000, Ljubljana, Slovenia
| |
Collapse
|
2
|
Tarsia M, Zajc Avramovič M, Gazikalović A, Ključevšek D, Avčin T. A clinical perspective on imaging in juvenile idiopathic arthritis. Pediatr Radiol 2024; 54:490-504. [PMID: 38015293 PMCID: PMC10984900 DOI: 10.1007/s00247-023-05815-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity, and predict disease course and outcome in children with juvenile idiopathic arthritis (JIA). Over the past few decades, great efforts have been made to improve the quality of diagnostic imaging and to reach a consensus on which methods and scoring systems to use. However, there are still some critical issues, and the diagnosis, course, and management of JIA are closely related to clinical assessment. This review discusses the main indications for conventional radiography (XR), musculoskeletal ultrasound (US), and magnetic resonance imaging (MRI), while trying to maintain a clinical perspective. The diagnostic-therapeutic timing at which one or the other method should be used, depending on the disease/patient phenotype, will be assessed, considering the main advantages and disadvantages of each imaging modality according to the currently available literature. Some brief clinical case scenarios on the most frequently and severely involved joints in JIA are also presented.
Collapse
Affiliation(s)
- Maria Tarsia
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Mojca Zajc Avramovič
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva 20 SI-1525, 1000, Ljubljana, Slovenia
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ana Gazikalović
- Department of Radiology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva ulica 20, 1000, Ljubljana, Slovenia
| | - Damjana Ključevšek
- Department of Radiology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva ulica 20, 1000, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva 20 SI-1525, 1000, Ljubljana, Slovenia.
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| |
Collapse
|
3
|
Ferjani HL, Dhia SB, Nessib DB, Dghaies A, Kaffel D, Maatallah K, Hamdi W. The childhood arthritis radiographic score of the hip: the proposal cut-off value using cluster analysis. Clin Rheumatol 2024; 43:465-472. [PMID: 37635192 DOI: 10.1007/s10067-023-06749-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease that affects children. It is crucial to detect and treat hip involvement in JIA early to prevent functional impairment and reduced quality of life. The Childhood Arthritis Radiographic Score of the Hip (CARSH) is a validated radiographic scoring system used to assess hip involvement in JIA. In this study, we aimed to determine cut-off values for CARSH scores using cluster analysis. METHODS The study was conducted as a cross-sectional analysis and included JIA patients with hip involvement who underwent a pelvic radiograph. The same pelvic radiograph was interpreted by two experienced pediatric rheumatologists at baseline and after 3 weeks by both readers for reliability. The CARSH scores were calculated for each hip four times (twice by each reader). For the 50 hips, a total of 200 interpretations of the CARSH score were obtained. Model-based clustering was employed to identify distinct groups of CARSH score interpretations and characterize the phenotype of each cluster. RESULTS Twenty-five children with hip involvement were included. The mean age was 13.9 ± 4.6 years. JIA subtypes were as follows: ERA in 64%, oligoarthritis in 16%, psoriatic arthritis in 12%, polyarthritis RF + in 4%, and RF - in 4% of patients. For the 200 hip interpretations, three clusters based on the level of the CARSH were identified by model-based clustering. Cluster 1 consisted of 17 CARSH score interpretations with a median score of 7 ± 3 (ranging from 1 to 15). This group primarily comprised patients with enthesitis-related arthritis (ERA) and psoriatic arthritis. Patients in cluster 1 were generally older, experienced longer diagnostic delays, and had a longer disease duration compared to the other clusters. Cluster 2 exhibited a moderate CARSH score, with an average score of 4 ± 3 (1 to 15). Patients in this group had significantly higher body weight compared to the other clusters. Cluster 3 represented the group with the least severe hip involvement, characterized by CARSH scores of 2 ± 1 (ranging from 0 to 9). This cluster had a higher proportion of male patients and higher C-reactive protein (CRP) levels than the other clusters. Regarding the individual items of the CARSH score, cluster 1 showed higher percentages of hip radiograph abnormalities such as joint space narrowing, erosions, growth abnormalities, and subchondral cysts. Cluster 2 was characterized by a high rate of acetabular sclerosis, with little to no abnormalities in other CARSH score items. Cluster 3 was the only group that exhibited hip subluxation, with minimal abnormalities in the other score items. In conclusion, this study identified three distinct groups of CARSH scores, representing varying levels of severity in hip involvement in JIA. These findings provide valuable insights for clinicians in assessing and managing JIA patients with hip involvement, enabling tailored treatment strategies based on the severity of the condition. Key Points • While a Childhood Arthritis Radiographic Score of the Hip (CARSH) is a valid and reliable tool in hip-related juvenile idiopathic arthritis, its use is limited in daily practice due to the lack of available cut-off values. • The cluster analysis defined three clusters based on the CARSH levels. • Cluster 1 exhibited the highest score with more damage and disability. Cluster 2 involved a moderate score and more overweight patients. Cluster 3 included the least level of the score but with an active disease parameter.
Collapse
Affiliation(s)
- Hanene Lassoued Ferjani
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
- Research Unit UR17SP04, Ksar Saïd, 20102010, Tunis, Tunisia.
| | - Siwar Ben Dhia
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia
| | - Dorra Ben Nessib
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, Ksar Saïd, 20102010, Tunis, Tunisia
| | - Abir Dghaies
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia
| | - Dhia Kaffel
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, Ksar Saïd, 20102010, Tunis, Tunisia
| | - Kaouther Maatallah
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, Ksar Saïd, 20102010, Tunis, Tunisia
| | - Wafa Hamdi
- Pediatric and Adult Rheumatology Department, Kassab Institute of Orthopedics, Ksar Saïd, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, Ksar Saïd, 20102010, Tunis, Tunisia
| |
Collapse
|
4
|
Balay-Dustrude E, Shenoi S. Current Validated Clinical and Patient Reported Disease Outcome Measures in Juvenile Idiopathic Arthritis. Open Access Rheumatol 2023; 15:189-206. [PMID: 37841510 PMCID: PMC10574249 DOI: 10.2147/oarrr.s261773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a common chronic illness in childhood and comprises seven categories based on the International League of Associations for Rheumatology (ILAR) criteria. Accurate assessment and measurement of the clinical, functional, and quality of life outcomes of patients with JIA are paramount for understanding the disease course and formulating effective treatment strategies. Interest in the development and use of outcome measurements specifically focused on rheumatologic conditions has greatly expanded over the last two decades, adding to and improving upon the established disease measures. Furthermore, many of these measures have been validated using the widely accepted Outcome Measures in Rheumatology (OMERACT) core principles of instrument validation, allowing researchers and clinicians to gain confidence in these tools. This review summarizes the current validated disease outcome measures in JIA, including clinical, imaging, patient-reported, and functional outcome measurement tools, and highlights ongoing work that continues to refine and improve upon the available tools. The clinical disease outcome measures discussed in this review include physician global assessment (PhGA), American College of Rheumatology (ACR, Wallace) criteria for clinical inactive disease and clinical remission, juvenile arthritis disease activity scores (JADAS), juvenile spondyloarthritis disease activity index (JSPaDA), juvenile arthritis damage index (JADAI), and the ACR pediatric response scores. The imaging outcome measures discussed include the Dijkstra composite scores, childhood arthritis radiographic score of the hip (CARSH), and Poznanski Score. The patient-reported disease outcome measures discussed include patient global assessment (PtGA), patient-reported outcome measurement information system for JIA (PROMIS), juvenile arthritis parent/child centered disease assessment index (JAPAI, JACAI), juvenile arthritis multidimensional assessment report (JAMAR), and the Pediatric quality of life inventory rheumatology module (PedsQL). The functional outcome tools discussed include the Childhood Health Assessment Questionnaire (CHAQ), juvenile arthritis functionality scale and index (JAFS and JASI), and Juvenile Arthritis Functional Assessment Report and Scale (JAFAS and JAFAR).
Collapse
Affiliation(s)
- Erin Balay-Dustrude
- Department of Pediatrics, Division of Rheumatology, University of Washington, Seattle, WA, USA
- Department of Pediatric Rheumatology, Seattle Children’s Hospital and Research Center, Seattle, WA, USA
| | - Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, University of Washington, Seattle, WA, USA
- Department of Pediatric Rheumatology, Seattle Children’s Hospital and Research Center, Seattle, WA, USA
| |
Collapse
|
5
|
Mazzoni M, Pistorio A, Magnaguagno F, Viola S, Urru A, Magnano GM, Ravelli A, Malattia C. Predictive Value of Magnetic Resonance Imaging in Patients With Juvenile Idiopathic Arthritis in Clinical Remission. Arthritis Care Res (Hoboken) 2023; 75:198-205. [PMID: 34286915 PMCID: PMC10087925 DOI: 10.1002/acr.24757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/14/2020] [Accepted: 07/15/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To define the prevalence of subclinical synovitis on magnetic resonance imaging (MRI) in a large cohort of patients with juvenile idiopathic arthritis (JIA) in clinical remission and to evaluate its predictive value in terms of disease flare and joint deterioration. METHODS Ninety patients with clinically inactive JIA who underwent a contrast-enhanced (CE)-MRI of a previously affected joint were retrospectively included. Each joint was evaluated for synovitis, tenosynovitis, and bone marrow edema. Baseline and follow-up radiographs were assessed to evaluate structural damage progression. RESULTS CE-MRI was acquired in 45 wrists, 30 hips, 13 ankles, and 2 knees. Subclinical synovitis was detected in 59 (65.5%) of 90 patients and bone marrow edema in 42 (46.7%) of 90 patients. Fifty-seven of 90 (63.3%) patients experienced a disease flare during follow-up. Forty-four of 59 (74.6%) patients with subclinical synovitis experienced a disease flare versus 13 (41.9%) of 31 patients with no residual synovitis on MRI (P = 0.002). The presence of subclinical synovitis was the best predictor of disease flare on multivariable regression analysis (hazard ratio [HR] 2.45, P = 0.003). Baseline and follow-up radiographs were available for 54 patients, and 17 (31.5%) of 54 patients experienced radiographic damage progression. The presence of bone marrow edema (HR 4.40, P = 0.045) and being >17 years old (HR 3.51, P = 0.04) were strong predictors of joint damage progression in the multivariable analysis. CONCLUSION MRI-detected subclinical inflammation was present in a large proportion of patients with JIA despite clinical remission. Subclinical synovitis and bone marrow edema have been shown to play a role in predicting the risk of disease relapse and joint deterioration, with potential implications for patients' management of the disease.
Collapse
Affiliation(s)
- Marta Mazzoni
- Università degli Studi di Genova, Dipartimento di Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Genova, Italy
| | - Angela Pistorio
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Francesca Magnaguagno
- IRCCS Istituto Giannina Gaslini, UOC di Radiologia, Istituto Giannina Gaslini, Genova, Italy
| | - Stefania Viola
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Genova, Italy
| | - Alessia Urru
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, Genova, Italy
| | - Gian Michele Magnano
- IRCCS Istituto Giannina Gaslini, UOC di Radiologia, Istituto Giannina Gaslini, Genova, Italy
| | - Angelo Ravelli
- Università degli Studi di Genova, Dipartimento di Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Clara Malattia
- Università degli Studi di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Genova, Italy and Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
6
|
Lassoued Ferjani H, Maatallah K, Miri S, Triki W, Nessib DB, Kaffel D, Hamdi W. Enthesitis-related arthritis: monitoring and specific tools. J Pediatr (Rio J) 2022; 98:223-229. [PMID: 34597529 PMCID: PMC9432174 DOI: 10.1016/j.jped.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES In this article, the authors aimed to review the different tools used in the monitoring of enthesitis-related arthritis. SOURCES The authors performed a literature review on PubMed, Google Scholar, and Scopus databases. The dataset included the original research and the reviews including patients with enthesitis-related arthritis or juvenile spondylarthritis up to October 2020. SUMMARY OF FINDING Enthesitis-related arthritis is a category of juvenile idiopathic arthritis. It is characterized by the presence of enthesitis, peripheral arthritis, as well as axial involvement. The only validated tool for disease activity measurement in juvenile idiopathic arthritis is the Disease Activity Score: It has proven its reliability and sensitivity. Nevertheless, due to an absence of validated evaluation tools, the extent of functional impairment, as well as the children and parents' perception of the disease, could not be objectively perceived. Despite the great progress in the field of imaging modalities, the role they play in the evaluation of disease activity is still controversial. This is partially due to the lack of validated scoring systems. CONCLUSIONS Further work is still required to standardize the monitoring strategy and validate the outcome measures in enthesitis-related arthritis.
Collapse
Affiliation(s)
- Hanène Lassoued Ferjani
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia.
| | - Kaouther Maatallah
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Sirine Miri
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia
| | - Wafa Triki
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Dorra Ben Nessib
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Dhia Kaffel
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| | - Wafa Hamdi
- Kassab Orthopedics Institute, Rheumatology Department, Ksar Saïd, Tunisia; University Tunis el Manar, Faculty of Medicine, Tunis, Tunisia; Research Unit UR17SP04, 2010, Ksar Said, 2010 Tunis, Tunisia
| |
Collapse
|
7
|
Naveen R, Mohindra N, Jain N, Majumder S, Aggarwal A. In response to comment on “Hip involvement in children with enthesitis-related arthritis (ERA) is associated with poor outcomes in adulthood” by Ferjani H L et al. Clin Rheumatol 2022; 41:953-954. [DOI: 10.1007/s10067-021-06021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022]
|
8
|
Comment on “Hip involvement in children with enthesitis-related arthritis (ERA) is associated with poor outcomes in adulthood”. Clin Rheumatol 2022; 41:951-952. [DOI: 10.1007/s10067-021-06013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/03/2022]
|
9
|
Weiss PF, Chauvin NA. Imaging in the diagnosis and management of axial spondyloarthritis in children. Best Pract Res Clin Rheumatol 2020; 34:101596. [DOI: 10.1016/j.berh.2020.101596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
10
|
Hemke R, Herregods N, Jaremko JL, Åström G, Avenarius D, Becce F, Bielecki DK, Boesen M, Dalili D, Giraudo C, Hermann KG, Humphries P, Isaac A, Jurik AG, Klauser AS, Kvist O, Laloo F, Maas M, Mester A, Oei E, Offiah AC, Omoumi P, Papakonstantinou O, Plagou A, Shelmerdine S, Simoni P, Sudoł-Szopińska I, Tanturri de Horatio L, Teh J, Jans L, Rosendahl K. Imaging assessment of children presenting with suspected or known juvenile idiopathic arthritis: ESSR-ESPR points to consider. Eur Radiol 2020; 30:5237-5249. [PMID: 32399709 PMCID: PMC7476913 DOI: 10.1007/s00330-020-06807-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/08/2020] [Accepted: 03/12/2020] [Indexed: 12/17/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common paediatric rheumatic disease. It represents a group of heterogenous inflammatory disorders with unknown origin and is a diagnosis of exclusion in which imaging plays an important role. JIA is defined as arthritis of one or more joints that begins before the age of 16 years, persists for more than 6 weeks and is of unknown aetiology and pathophysiology. The clinical goal is early suppression of inflammation to prevent irreversible joint damage which has shifted the emphasis from detecting established joint damage to proactively detecting inflammatory change. This drives the need for imaging techniques that are more sensitive than conventional radiography in the evaluation of inflammatory processes as well as early osteochondral change. Physical examination has limited reliability, even if performed by an experienced clinician, emphasising the importance of imaging to aid in clinical decision-making. On behalf of the European Society of Musculoskeletal Radiology (ESSR) arthritis subcommittee and the European Society of Paediatric Radiology (ESPR) musculoskeletal imaging taskforce, based on literature review and/or expert opinion, we discuss paediatric-specific imaging characteristics of the most commonly involved, in literature best documented and clinically important joints in JIA, namely the temporomandibular joints (TMJs), spine, sacroiliac (SI) joints, wrists, hips and knees, followed by a clinically applicable point to consider for each joint. We will also touch upon controversies in the current literature that remain to be resolved with ongoing research. KEY POINTS: • Juvenile idiopathic arthritis (JIA) is the most common chronic paediatric rheumatic disease and, in JIA imaging, is increasingly important to aid in clinical decision-making. • Conventional radiographs have a lower sensitivity and specificity for detection of disease activity and early destructive change, as compared to MRI or ultrasound. Nonetheless, radiography remains important, particularly in narrowing the differential diagnosis and evaluating growth disturbances. • Mainly in peripheral joints, ultrasound can be helpful for assessment of inflammation and guiding joint injections. In JIA, MRI is the most validated technique. MRI should be considered as the modality of choice to assess the axial skeleton or where the clinical presentation overlaps with JIA.
Collapse
Affiliation(s)
- Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Nele Herregods
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Gunnar Åström
- Department of Radiology, Uppsala University, Uppsala, Sweden
| | - Derk Avenarius
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Dennis K Bielecki
- Department of Diagnostic Imaging, Kings College Hospital, London, UK
| | - Mikael Boesen
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Danoob Dalili
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Chiara Giraudo
- Radiology Institute, Department of Medicine - DIMED, Padova University, Padua, Italy
| | - Kay-Geert Hermann
- Department of Radiology, University Hospital Charité, Berlin, Germany
| | - Paul Humphries
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Amanda Isaac
- Department of Radiology, Guy's & St Thomas Hospitals, London, UK
| | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Andrea S Klauser
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ola Kvist
- Department of Paediatric Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Frederiek Laloo
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Adam Mester
- Department of Radiology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Edwin Oei
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
| | - Amaka C Offiah
- Academic Unit of Child Health, University of Sheffield, Western Bank, Sheffield, UK
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | - Paolo Simoni
- Department of Radiology, Reine Fabiola Children's University Hospital of Bruxelles, University of Bruxelles, Brussels, Belgium
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation and Department of Medical Imaging, Medical University of Warsaw, Warsaw, Poland
| | | | - James Teh
- Department of Radiology, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Lennart Jans
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - Karen Rosendahl
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| |
Collapse
|
11
|
No radiographic wrist damage after treatment to target in recent-onset juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2019; 17:62. [PMID: 31484539 PMCID: PMC6727344 DOI: 10.1186/s12969-019-0362-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/09/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To evaluate radiographic progression of patients with new-onset juvenile idiopathic arthritis (JIA) in response to an early, tightly-controlled, treatment-to-target. METHODS Patients with JIA participating in the BeSt-for-Kids-study, randomized to 3 treatment strategy arms, were eligible if at least 1 conventional wrist-radiograph was available. Bone damage as reflected by carpal length was assessed using the Poznanski-score. The BoneXpert-method was used to determine the Bone Age (BA, > 5 years) and bone mineral density (BMD) of the wrist. These scores were evaluated over time and compared between the treatment arms and mean JADAS10-score using linear mixed models corrected for age and symptom duration. RESULTS In 60 patients, 252 radiographs were analysed. Baseline age and symptom duration were different between the arms. No difference in comparison to the healthy reference population was found at baseline for the Poznanski-score (IQR varying from - 0,82; 0.68), nor for BA (varying from - 0.88 to 0.74). Baseline BMD was statistically significantly lower in arm 3 (initial treatment with etanercept and methotrexate) (- 1.48; - 0.68) compared to arm 1 (- 0.84; - 0.04) and arm 2 (- 0.93; 0.15). After treatment to target inactive disease, the Poznanski-scores and the BA remained clinically unchanged, while the BMD in arm 3 improved (p < 0.05 vs arm 1). CONCLUSIONS Recent-onset JIA patients, treated-to-target aimed at inactive disease, showed no signs of radiographic wrist damage (Poznanski-score, BA or BMD) either at baseline or at follow-up, irrespective of treatment arm. A lower BMD at baseline in arm 3, initially treated with methotrexate and etanercept, improved significantly after treatment. TRIAL REGISTRATION NTR, NL1504 (NTR1574). Registered 01-06-2009.
Collapse
|
12
|
Malattia C, Rinaldi M, Martini A. The role of imaging in juvenile idiopathic arthritis. Expert Rev Clin Immunol 2018; 14:681-694. [PMID: 29972659 DOI: 10.1080/1744666x.2018.1496019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The prognosis of juvenile idiopathic arthritis (JIA) has changed dramatically due to the availability of novel drugs. Prompt diagnosis and treatment are essential to prevent permanent joint damage. As a result, methods to improve JIA diagnosis and prognosis are of high priority to tailor treatment strategies and maximize their efficacy. Musculoskeletal ultrasound and magnetic resonance imaging are more sensitive than clinical examination and radiography in the detection of joint involvement and might play a substantial role to optimize the management of JIA. Areas covered: This review compiles an inventory of potential uses of imaging studies in the modern practice of pediatric rheumatology, together with a critical analysis of the major challenges that are still to be addressed. Imaging appearance of normal growth-related changes of the musculoskeletal system will be discussed. Expert commentary: Knowledge of the evolving patterns of skeletal maturity is paramount to define pathological findings and avoid misinterpretations. Establishing a novel radiological algorithm for a rational use of imaging in JIA is of high priority to allow a speedier integration of imaging into the clinical workflow and decision-making process.
Collapse
Affiliation(s)
- Clara Malattia
- a Clinica Pediatrica e Reumatologia , Istituto Giannina Gaslini , Genova , Italy.,b Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili , Università degli studi di Genova , Italy
| | - Mariangela Rinaldi
- a Clinica Pediatrica e Reumatologia , Istituto Giannina Gaslini , Genova , Italy
| | - Alberto Martini
- c Direzione Scientifica Istituto Giannina Gaslini , Genova Italy
| |
Collapse
|
13
|
Malattia C, Tzaribachev N, van den Berg JM, Magni-Manzoni S. Juvenile idiopathic arthritis - the role of imaging from a rheumatologist's perspective. Pediatr Radiol 2018; 48:785-791. [PMID: 29766250 DOI: 10.1007/s00247-017-4014-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 10/11/2017] [Indexed: 10/17/2022]
Abstract
Alongside recent advances in treatment strategies for juvenile idiopathic arthritis (JIA), paediatric rheumatologists have taken increasing interest in the use of imaging. Magnetic resonance imaging (MRI) and musculoskeletal ultrasound, by providing more detailed information on disease activity than clinical examination and conventional radiography (CR), have become helpful diagnostic and managerial tools. The growing skeleton, however, with changing appearances over time, is still challenging in the establishment of valid scoring systems for pathological changes. Defining child- and age-specific reference standards is therefore a highly prioritized issue. The aim of this article is to raise awareness among radiologists of the substantial role that imaging can play to optimize the management of JIA patients and to describe the state-of-the-art validation process of imaging as an outcome measure. A closer collaboration between radiologists and pediatric rheumatologists is crucial to define a scheduled workflow for imaging in JIA.
Collapse
Affiliation(s)
- Clara Malattia
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Largo Gaslini, 5, 16147, Genoa, Italy.
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), University of Genova, Genoa, Italy.
| | | | - J Merlijn van den Berg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital AMC University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
14
|
Shelmerdine SC, Di Paolo PL, Tanturri de Horatio L, Malattia C, Magni-Manzoni S, Rosendahl K. Imaging of the hip in juvenile idiopathic arthritis. Pediatr Radiol 2018; 48:811-817. [PMID: 29766251 DOI: 10.1007/s00247-017-4022-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
Hip involvement is common and estimated to occur in approximately 35-63% of children with juvenile idiopathic arthritis (JIA). It is more prevalent in the aggressive systemic subtypes, with irreversible changes occurring as early as within 5 years of diagnosis. Whilst clinical parameters and joint examination can be useful for assessing disease severity, subclinical disease is known to exist and delayed treatment may herald a lifetime of disability and pain. Early recognition of JIA changes is therefore crucial in determining treatment options. Validated scoring systems in the radiologic assessment of the hip for clinical drug trials may inform treatment outcomes, although robust tools for analysis are still lacking. This review article details the modalities utilised for imaging the hip in children with JIA with particular efforts focused upon reliability and validity in their assessment of joint disease. We conclude with a short literature review on the potential future techniques being developed for hip joint imaging in JIA.
Collapse
Affiliation(s)
- Susan Cheng Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Pier Luigi Di Paolo
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Clara Malattia
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Largo Gaslini, Genoa, 5, 16147, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), University of Genova, Genoa, Italy
| | - Silvia Magni-Manzoni
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), University of Genova, Genoa, Italy.,Pediatric Rheumatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Karen Rosendahl
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway
| |
Collapse
|
15
|
A novel radiographic scoring system for growth abnormalities and structural change in children with juvenile idiopathic arthritis of the hip. Pediatr Radiol 2018; 48:1086-1095. [PMID: 29717335 PMCID: PMC6061460 DOI: 10.1007/s00247-018-4136-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/02/2018] [Accepted: 04/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Approximately 20-50% of children with juvenile idiopathic arthritis (JIA) have hip involvement within 6 years of diagnosis. Scoring systems for hip-related radiographic changes are lacking. OBJECTIVE To examine precision of potential radiographic variables and to suggest a scoring system. MATERIALS AND METHODS We reviewed a set of 75 pelvic radiographs from 75 children with JIA hip involvement across two European centres. We assessed findings of (1) destructive change and (2) growth abnormality, according to a pre-defined scoring system. All radiographs were scored independently by two sets of radiologists. One set scored the radiographs a second time. We used kappa statistics to rate inter- and intra-observer variability. RESULTS Assessment of erosions of the femoral head, femoral neck and the acetabulum showed moderate to good agreement for the same reader (kappa of 0.5-0.8). The inter-reader agreement was, however, low (kappa of 0.1-0.3). There was moderate to high agreement for the assessment of femoral head flattening (kappa of 0.6-0.7 for the same reader, 0.3-0.7 between readers). Joint space narrowing showed moderate to high agreement both within and between observers (kappa of 0.4-0.8). Femoral neck length and width measurements, the centrum-collum-diaphysis angle, and trochanteric-femoral head lengths were relatively precise, with 95% limits of agreement within 10-15% of the observer average. CONCLUSION Several radiographic variables of destructive and growth abnormalities in children with hip JIA have reasonable reproducibility. We suggest that future studies on clinical validity focus on assessing only reproducible radiographic variables.
Collapse
|
16
|
Ultrasound imaging of synovial inflammation in juvenile idiopathic arthritis. Pediatr Radiol 2017; 47:1160-1170. [PMID: 28779188 DOI: 10.1007/s00247-017-3934-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/05/2017] [Accepted: 06/23/2017] [Indexed: 01/17/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic entity of childhood. The hallmark feature of all subtypes is joint inflammation. Imaging is used to evaluate the extent and severity of inflammation, degree of joint damage and response to treatment, which in turn impacts patient management. Ultrasound has become a useful adjunct to clinical examination because it shows promise in evaluating clinical and subclinical inflammation (synovitis, enthesitis) as well as cartilage and bone erosive changes. However more collaborative research is needed to help define the normal appearance of the growing skeleton, clarify the significance of subclinical findings and develop useful definitions, imaging protocols and scoring systems of disease.
Collapse
|
17
|
|
18
|
Collado P, Malattia C. Imaging in paediatric rheumatology: Is it time for imaging? Best Pract Res Clin Rheumatol 2016; 30:720-735. [PMID: 27931964 DOI: 10.1016/j.berh.2016.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/13/2016] [Accepted: 08/04/2016] [Indexed: 11/13/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is a heterogeneous group of arthritides characterized by chronic synovial inflammation that can lead to structural damage. The main objective of JIA therapies is to induce disease control to avoid disability in childhood. The advances in therapeutic effectiveness have created a need to search for imaging tools that describe more precisely disease activity in children with JIA. Musculoskeletal ultrasound and magnetic resonance imaging have demonstrated to be more sensitive than clinical examination in early detection of synovitis. These modalities can detect both inflammatory and destructive changes. The unique characteristics of the growing skeleton and a scarce validation of imaging in children result in important challenges in evaluating paediatric population. This review describes indications and limitations of these imaging techniques and suggests some advices for a rational use in the management of JIA in clinical practice.
Collapse
Affiliation(s)
- Paz Collado
- Rheumatology/Paediatric Rheumatology Unit, Hospital Universitario Severo Ochoa, C/Corazón de María 55, 2ºA, 28002 Madrid, Spain.
| | - Clara Malattia
- Pediatria 2-Reumatologia, Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genova, Italy; University of Genova, Italy
| |
Collapse
|
19
|
Oliveira-Ramos F, Eusébio M, M Martins F, Mourão AF, Furtado C, Campanilho-Marques R, Cordeiro I, Ferreira J, Cerqueira M, Figueira R, Brito I, Canhão H, Santos MJ, Melo-Gomes JA, Fonseca JE. Juvenile idiopathic arthritis in adulthood: fulfilment of classification criteria for adult rheumatic diseases, long-term outcomes and predictors of inactive disease, functional status and damage. RMD Open 2016; 2:e000304. [PMID: 27752356 PMCID: PMC5051503 DOI: 10.1136/rmdopen-2016-000304] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/04/2016] [Accepted: 07/05/2016] [Indexed: 11/17/2022] Open
Abstract
Objectives To determine how adult juvenile idiopathic arthritis (JIA) patients fulfil classification criteria for adult rheumatic diseases, evaluate their outcomes and determine clinical predictors of inactive disease, functional status and damage. Methods Patients with JIA registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) older than 18 years and with more than 5 years of disease duration were included. Data regarding sociodemographic features, fulfilment of adult classification criteria, Health Assessment Questionnaire, Juvenile Arthritis Damage Index—articular (JADI-A) and Juvenile Arthritis Damage Index—extra-articular (JADI-E) damage index and disease activity were analysed. Results 426 patients were included. Most of patients with systemic JIA fulfilled criteria for Adult Still's disease. 95.6% of the patients with rheumatoid factor (RF)-positive polyarthritis and 57.1% of the patients with RF-negative polyarthritis matched criteria for rheumatoid arthritis (RA). 38.9% of the patients with extended oligoarthritis were classified as RA while 34.8% of the patients with persistent oligoarthritis were classified as spondyloarthritis. Patients with enthesitis-related arthritis fulfilled criteria for spondyloarthritis in 94.7%. Patients with psoriatic arthritis maintained this classification. Patients with inactive disease had lower disease duration, lower diagnosis delay and corticosteroids exposure. Longer disease duration was associated with higher HAQ, JADI-A and JADI-E. Higher JADI-A was also associated with biological treatment and retirement due to JIA disability and higher JADI-E with corticosteroids exposure. Younger age at disease onset was predictive of higher HAQ, JADI-A and JADI-E and decreased the chance of inactive disease. Conclusions Most of the included patients fulfilled classification criteria for adult rheumatic diseases, maintain active disease and have functional impairment. Younger age at disease onset was predictive of higher disability and decreased the chance of inactive disease.
Collapse
Affiliation(s)
- Filipa Oliveira-Ramos
- Rheumatology Department, Santa Maria Hospital-CHLN, Lisbon Academic Medical Center, Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | | | - Ana Filipa Mourão
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Rheumatology Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Carolina Furtado
- Rheumatology Department , Hospital do Divino Espírito Santo , Ponta Delgada , Portugal
| | - Raquel Campanilho-Marques
- Rheumatology Department, Santa Maria Hospital-CHLN, Lisbon Academic Medical Center, Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Inês Cordeiro
- Rheumatology Department , Hospital Garcia de Orta , Almada , Portugal
| | - Joana Ferreira
- Rheumatology Department , Centro Universitário Hospitalar de Coimbra , Coimbra , Portugal
| | - Marcos Cerqueira
- Rheumatology Department , ULSAM-Hospital Conde de Bertiandos , Ponte de Lima , Portugal
| | - Ricardo Figueira
- Rheumatology Department , Hospital Dr Nélio Mendonça , Funchal , Portugal
| | - Iva Brito
- Rheumatology Department , Hospital de São João and Faculdade de Medicina da Universidade do Porto , Porto , Portugal
| | - Helena Canhão
- Rheumatology Department, Santa Maria Hospital-CHLN, Lisbon Academic Medical Center, Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Maria José Santos
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - João Eurico Fonseca
- Rheumatology Department, Santa Maria Hospital-CHLN, Lisbon Academic Medical Center, Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| |
Collapse
|
20
|
Colebatch-Bourn AN, Edwards CJ, Collado P, D'Agostino MA, Hemke R, Jousse-Joulin S, Maas M, Martini A, Naredo E, Østergaard M, Rooney M, Tzaribachev N, van Rossum MA, Vojinovic J, Conaghan PG, Malattia C. EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice. Ann Rheum Dis 2015; 74:1946-57. [PMID: 26245755 DOI: 10.1136/annrheumdis-2015-207892] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/14/2015] [Indexed: 12/12/2022]
Abstract
To develop evidence based points to consider the use of imaging in the diagnosis and management of juvenile idiopathic arthritis (JIA) in clinical practice. The task force comprised a group of paediatric rheumatologists, rheumatologists experienced in imaging, radiologists, methodologists and patients from nine countries. Eleven questions on imaging in JIA were generated using a process of discussion and consensus. Research evidence was searched systematically for each question using MEDLINE, EMBASE and Cochrane CENTRAL. Imaging modalities included were conventional radiography, ultrasound, MRI, CT, scintigraphy and positron emission tomography. The experts used the evidence obtained from the relevant studies to develop a set of points to consider. The level of agreement with each point to consider was assessed using a numerical rating scale. A total of 13 277 references were identified from the search process, from which 204 studies were included in the systematic review. Nine points to consider were produced, taking into account the heterogeneity of JIA, the lack of normative data and consequent difficulty identifying pathology. These encompassed the role of imaging in making a diagnosis of JIA, detecting and monitoring inflammation and damage, predicting outcome and response to treatment, use of guided therapies, progression and remission. Level of agreement for each proposition varied according to the research evidence and expert opinion. Nine points to consider and a related research agenda for the role of imaging in the management of JIA were developed using published evidence and expert opinion.
Collapse
Affiliation(s)
- A N Colebatch-Bourn
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK Department of Rheumatology, Yeovil District Hospital, Yeovil, UK
| | - C J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - P Collado
- Hospital Universitario Severo Ochoa, Madrid, Spain
| | - M-A D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France Inserm U1173, Laboratoire d'Excellence INFLAMEX, Université Versailles St. Quentin, Montigny-le-Bretonneux, France
| | - R Hemke
- Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | | | - M Maas
- Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - A Martini
- Institut Gaslini, Genova, Italy Department of Pediatrics, University of Genova, Genova, Italy
| | - E Naredo
- Rheumatology Department, Hospital General Universitario Gregorio Maraňón, Madrid, Spain
| | - M Østergaard
- Copenhagen Center for Arthritis Research, Center of Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - M Rooney
- Queen's University Belfast, Belfast, UK
| | - N Tzaribachev
- Pediatric Rheumatology Research Institute, Bad Bramstedt, Germany
| | - M A van Rossum
- Academic Medical Centre, Emma Children's Hospital, Amsterdam, The Netherlands Department of Rheumatology, Jan van Breemen Research Institute/Reade, Amsterdam, The Netherlands
| | - J Vojinovic
- Faculty of Medicine University of Nis, Department of Pediatric Rheumatology, Clinic Center, Niš, Serbia
| | - P G Conaghan
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds , Leeds, UK
| | - C Malattia
- Institut Gaslini, Genova, Italy Department of Pediatrics, University of Genova, Genova, Italy
| |
Collapse
|
21
|
Ording Muller LS, Humphries P, Rosendahl K. The joints in juvenile idiopathic arthritis. Insights Imaging 2015; 6:275-84. [PMID: 25903287 PMCID: PMC4444796 DOI: 10.1007/s13244-015-0406-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/19/2015] [Accepted: 03/25/2015] [Indexed: 11/25/2022] Open
Abstract
Abstract Juvenile idiopathic arthritis is the most common rheumatic entity in childhood. Imaging has become an important supplement to the clinical assessment of children with JIA. Radiographs still play an important role in the workup, and long-term follow-up in children with JIA, but are not sensitive to findings in the early disease stage. Both ultrasound and MRI are more sensitive to inflammatory changes than clinical assessment alone. However, the differentiation between normal findings and pathology can be challenging, particularly in early disease. The objective of this review is to discuss the role of imaging in JIA, describe the typical findings on different modalities and highlight the challenges we face regarding the reliability and accuracy of the different methods for imaging the joints in children with JIA. Key Points • Imaging is an important supplement to the clinical examination in JIA. • Ultrasound is more sensitive for detecting synovitis than clinical examination alone. • MRI can depict all relevant structures in joint inflammation. • The differentiation between normal variants and pathology is difficult in children.
Collapse
Affiliation(s)
| | - Paul Humphries
- />Institute of Child Health, UCL, University College London Hospital NHS Trust and Great Ormond Street Hospital for Children, London, UK
| | - Karen Rosendahl
- />Department of Radiology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
22
|
Aoki C, Inaba Y, Choe H, Kaneko U, Hara R, Miyamae T, Imagawa T, Mori M, Oba MS, Yokota S, Saito T. Discrepancy Between Clinical and Radiological Responses to Tocilizumab Treatment in Patients with Systemic-onset Juvenile Idiopathic Arthritis. J Rheumatol 2014; 41:1171-7. [DOI: 10.3899/jrheum.130924] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective.Tocilizumab (TCZ), an antiinterleukin-6 receptor monoclonal antibody, is clinically beneficial in patients with systemic-onset juvenile idiopathic arthritis (sJIA). We investigated the clinical and radiological outcomes of TCZ therapy in patients with sJIA.Methods.We retrospectively evaluated 2 clinical trials (NCT00144599 and NCT00144612) involving 40 patients with sJIA who received intravenous TCZ (8 mg/kg) every 2 weeks. Clinical data and radiographs of the hands and large joints were assessed before and during TCZ treatment. The Poznanski score, modified Larsen scores of the hands and large joints, and Childhood Arthritis Radiographic Score of the Hip (CARSH) were recorded.Results.After a mean duration of 4.5 years of TCZ treatment, clinical data had improved significantly, the mean Poznanski score improved from −1.5 to −1.1, the mean Larsen score of the hands deteriorated from 7.0 to 10.0, the mean Larsen score for the large joints deteriorated from 5.9 to 6.8, and the CARSH worsened from 3.9 to 6.2. The Larsen score for the large joints improved in 11 cases (28%), remained unchanged in 8 cases (20%), and worsened in 21 cases (52%). Matrix metalloproteinase 3 (MMP-3) levels remained significantly higher (278 mg/dl) in patients with worsened Larsen scores than in patients with improved or unchanged scores (65 mg/dl). Logistic regression analysis showed that older age at disease onset was a significant risk factor for radiographic progression.Conclusion.The modified Larsen score of the large joints deteriorated in half the patients who had high MMP-3 levels during TCZ treatment and who were significantly older at disease onset.
Collapse
|
23
|
Rodriguez-Lozano AL, Giancane G, Pignataro R, Viola S, Valle M, Gregorio S, Norambuena X, Ioseliani M, Pistorio A, Magnaguagno F, Riganti S, Martini A, Ravelli A. Agreement among musculoskeletal pediatric specialists in the assessment of radiographic joint damage in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2013; 66:34-9. [PMID: 23983057 DOI: 10.1002/acr.22145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 08/20/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate agreement among musculoskeletal pediatric specialists in assessing radiographic joint damage in juvenile idiopathic arthritis (JIA). METHODS Two pediatric rheumatologists, 2 pediatric radiologists, and 2 pediatric orthopedic surgeons evaluated independently 60 radiographs of both wrists and hands of children with polyarticular-course JIA. Films were scored using an adapted and simplified version of the Larsen score, ranging from 0-5. Study radiographs were selected from 568 films used in a previous study aimed to validate an adapted pediatric version of the Sharp/van der Heijde (SHS) score. To enable comparison of specialists' scores with the adapted SHS score, the 60 radiographs were divided into 6 classes of severity of damage based on quintiles of the adapted SHS score. Agreement was evaluated in terms of absolute agreement and through weighted kappa statistics. RESULTS The pediatric radiologists tended to assign lower scores and to provide more frequently scores of 0 than did the other specialists. Weighted kappa for the 3 pairs of specialists ranged from 0.67-0.69, indicating substantial agreement. Absolute agreement ranged from 51.3-55.7%, depending on the pair of specialists examined. Both absolute and weighted kappa concordance between specialists' scores and the adapted SHS score were poorer for the pediatric radiologist than for the other specialists. CONCLUSION We observed fair agreement in the assessment of radiographic damage among pediatric specialists involved in the care of children with JIA. The radiologists tended to be more reserved than the rheumatologists and orthopedic surgeons in labeling radiographs as damaged or in considering changes as important.
Collapse
|
24
|
Abstract
Imaging assessments of the joints of children with juvenile idiopathic arthritis (JIA) are challenging, owing to the unique features of the growing skeleton. Traditionally, imaging studies in childhood arthritis have been based on conventional radiography. However, in the past few years, interest in the use of MRI and ultrasonography has increased. As a result, imaging has become a main area of clinical and research investigation in paediatric rheumatology. The chief advance in the field of conventional radiography has been the development and validation of paediatric scoring systems for the assessment of radiographic progression. Several studies have shown that MRI provides a precise quantification of synovitis in children with JIA. Furthermore, a high frequency of bone marrow oedema and bone erosions has been found early in the disease course. Ultrasonography has been proven to be superior to clinical examination in detecting synovitis, tenosynovitis and enthesitis. A high frequency of subclinical synovitis has been demonstrated in patients with JIA who have clinically inactive disease using both MRI and ultrasonography. However, more information from healthy children is needed to enable differentiation of the bone and cartilage abnormalities that reflect damage from those that are part of normal development using MRI or ultrasonography. This Review provides a summary of the current information on conventional radiography, ultrasonography and MRI in JIA and highlights the advantages and limitations of each imaging modality.
Collapse
|
25
|
Shire NJ, Dardzinski BJ. Picture-perfect: imaging techniques in juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/iim.11.63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
26
|
Sawhney S, Agarwal M. Outcome measures in pediatric rheumatology. Indian J Pediatr 2010; 77:1183-9. [PMID: 20938818 DOI: 10.1007/s12098-010-0208-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 07/14/2010] [Indexed: 11/30/2022]
Abstract
Children with rheumatologic disorders need periodic systematic evaluation of their disease status so that all aspects of the child's life that are affected can be adequately assessed. The commonest rheumatologic disease that afflicts children is Juvenile Idiopathic Arthritis (JIA). The child with JIA should have several domains assessed at regular intervals. These outcome measures include the physical, functional and the quality of life assessment measures. No single measure can capture the full impact of the disease on the child's life. This article highlights the key outcome measures in a child with JIA and introduces the readers to several disease measurement tools that have been developed for assessment of outcome for the child with JIA.
Collapse
Affiliation(s)
- Sujata Sawhney
- Pediatric Rheumatology Unit, Centre for Child Health, Sir Ganga Ram Hospital, New Delhi, India.
| | | |
Collapse
|
27
|
Synovial and inflammatory diseases in childhood: role of new imaging modalities in the assessment of patients with juvenile idiopathic arthritis. Pediatr Radiol 2010; 40:985-98. [PMID: 20432018 DOI: 10.1007/s00247-010-1612-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 02/06/2010] [Indexed: 10/19/2022]
Abstract
Juvenile idiopathic arthritis (JIA) represents a group of heterogeneous diseases characterized by a chronic inflammatory process primarily targeting the synovial membrane. A persistent synovitis is associated with an increased risk of osteocartilaginous damage.With the advent of effective structure-modifying treatment for JIA, it may be possible to significantly reduce or even completely prevent structural damage and associated functional disability. The trend towards early suppression of inflammation, in order to prevent erosive disease, shifts the emphasis away from conventional radiographic detectable structural damage to the slightest traces of early joint damage, and drives the need for alternative imaging techniques more sensitive in detecting early signs of disease activity and damage. In this regard MRI and US are playing an increasing role in the evaluation of arthritic joints.This article will review the key aspects of the current status and recent important advances of imaging techniques available to investigate the child with rheumatic disease, briefly discussing conventional radiography, and particularly focusing on MRI and US. In this era of advancing imaging technology, knowledge of the relative values of available imaging techniques is necessary to optimize the management of children with JIA.
Collapse
|