[Structural quality of rheumatology clinics for children and adolescents. Paper by a task force of the "Society of Pediatric and Adolescent Rheumatology" and of the "Association of Rheumatology Clinics in Germany"]

Rheumatic diseases in childhood and adolescence differ from those of adulthood according to type, manifestation, treatment and course. A specialized therapy, starting as early as possible, improves the prognosis, can prevent long-term damage and saves the costs of long-term care. Only a specialized pediatric care system can guarantee optimum quality of the processes involved and the results for rheumatology in childhood and adolescence within a global financial system. This requires adequate structural quality of the specialized clinics and departments for pediatric rheumatology. The management of rheumatic diseases in childhood and adolescence is comprehensive and requires a multidisciplinary, specialized and engaged team which can cover the whole spectrum of rheumatic diseases with their various age-dependent aspects. In order to guarantee an adequate, cost-efficient routine, a specialized center which concentrates on inpatient care should treat at least 300 patients with pediatric rheumatic diseases per year. The diagnoses should be divided among the various disease categories with at least 70% of them involving inflammatory rheumatic diseases. For the inpatient care of small children, an accompanying person (parent) is necessary, requiring adequate structures and services. Patient rooms as well as diagnostic (radiography, sonography, etc.) and therapeutic services (physiotherapy, occupational therapy, pool, etc.) must be adequate for small children and school children as well as adolescents. Suitable mother-child units must also be provided and a school for patients is required within the clinic. A pediatric rheumatologist must be available 24 h a day, and it must be possible to reach other specialists within a short time. For painful therapeutic procedures, age-appropriate pain management is obligatory. A continuous adjustment of these recommendations to changing conditions in health politics is intended.

Lebensqualität und psychosoziale Anpassung bei Kindern und Jugendlichen mit juveniler idiopathischer Arthritis und reaktiven Arthritiden

OBJECTIVE

We sought to measure self-reported health related quality of life (HRQOL) and psychosocial adaptation in children and adolescents with juvenile idiopathic arthritis (JIA) and reactive arthritis and to determine factors associated with these outcomes.

METHODS

We interviewed 72 children and adolescents with chronic arthritis, age 8-16, about HRQOL (KINDL-R-Questionnaire) and functional ability in activities of daily living (Childhood Health Assessment Questionnaire-CHAQ). Mothers reported behavior problems (Child Behavior Checklist-CBCL).

RESULTS

Children and adolescents with juvenile idiopathic arthritis and reactive arthritis reported lower HRQOL compared to normative data in several areas. Children reported lower QOL in the dimensions self-esteem; adolescents reported lower QOL in the dimensions physical well being and total QOL. Almost 20% of the sample appeared to have serious behavior problems, mostly social isolation and depression/anxiety. Functional limitations affected HRQOL and behavior problems. Inpatient children and adolescents and those with shorter disease duration reported lower QOL than outpatient children and adolescents and those with longer disease duration. Best predictors for impaired HRQOL were functional limitations, social isolation and depression/anxiety.

CONCLUSIONS

Self-reported HRQOL and behavior problems may be relevant outcome measures in children and adolescents with chronic arthritis and useful to monitor psychosocial support in this population.

The German etanercept registry for treatment of juvenile idiopathic arthritis

OBJECTIVE

To describe a registry set up to monitor children treated with etanercept in Germany and Austria.

METHODS

Giannini's criteria, duration of morning stiffness, number of swollen, tender and contracted joints, adverse events, and reasons for discontinuation were assessed.

RESULTS

322 patients with juvenile idiopathic arthritis (JIA) and 12 additional patients with non-JIA rheumatic diagnoses were included. Therapeutic efficacy was observed from one month after treatment was started. The number of patients with significant improvement and the degree of improvement increased during the first year. The mean (SD) number of tender and swollen joints decreased from 9 (9) and 8.4 (9) to 3.0 (6.5) and 4.5 (7) after one month, and to 2.2 (5.5) and 3.3 (5.5) after three months; morning stiffness decreased from 45 (65) minutes to 12 (30) and 7 (19) after one and three months (p<0.001 for all). Using Gianinni's criteria of 30%, 50%, and 70% improvement, a therapeutic response in JIA patients was achieved in, respectively, 66%, 54%, and 30% after one month, 78%, 61%, and 38% after three months, and 83%, 72%, and 52% after six months. Therapeutic efficacy was lower in patients with systemic onset arthritis. Overall tolerability was good: in 592 patient treatment-years there were 69 reports of adverse events in 56 patients, including one CNS demyelination. There were no opportunistic infections or lupus-like reactions. Treatment was discontinued in 53 JIA patients, in 25 because of lack of efficacy.

CONCLUSION

Etanercept treatment was safe and led to a significant improvement in most JIA patients resistant to conventional treatment.

The German version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report the results of the cross-cultural adaptation and validation into the German language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The German CHAQ was fully validated with 3 forward and 3 backward translations, while the CHQ has already been published and therefore it was revalidated. A total of 197 subjects were enrolled: 142 patients with JIA (5% systemic onset, 13% polyarticular onset, 8% extended oligoarticular subtype, and 74% persistent oligoarticular subtype) and 55 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the German versions of the CHAQ-CHQ are reliable, and valid tools for the functional, physical and psychosocial assessment of children with JIA.

Kidney involvement in a 17-year-old boy with eosinophilic fasciitis

Eosinophilic fasciitis (EF) is characterized by symmetrical scleroderma-like induration of skin over one or more distal extremities, peripheral eosinophilia, absence of Raynaud phenomenon and visceral involvement and a favourable response to systemically administered corticosteroids. Like other scleroderma-like disorders EF is rarely described in children. We report renal involvement in a 17-year-old boy with EF. Urinalysis disclosed proteinuria. Prior to corticosteroid therapy renal biopsy was performed which revealed ischemic collapse of glomerular capillaries and atrophy of tubules of the cortex. Electron-microscopic studies showed hyperplasia of the renin-producing epitheloid cells in the juxtaglomerular apparatus. Few other publications have depicted renal involvement in EF of quite different character. In these cases renal biopsy and histological classification is warranted because of prognostic and therapeutic implications.

Intraarticular hip treatment with triamcinolonehexacetonide in juvenile chronic arthritis

To evaluate the effect and tolerance of intraarticular Triamcinolonehexacetonide (TCH) in the course of chronic coxitis in juvenile chronic arthritis (JCA) in an open uncontrolled study. Since 1990 we treated patients < 16 years of age suffering from chronic coxitis with 1 mg/TCH/KG body weight. The patients were checked again 4-8 weeks after the treatment. Clinical and ultrasound courses were recorded with the help of ultrasound and joint scores. The evaluation took place 6, 12, 24 and 36 months after the treatment. At that time we give a report on the 12 months follow-up of 37 hip joints and the 24 months follow-up of 20 hip joints. The immediate effect of TCH influencing mobility, pain sensitivity and joint effusions of the patients is impressing. The long term effect of TCH has to be evaluated by regular check ups for at least 2 years. An individual comparison with the not treated contralateral joint would be desired if ethically justifiable. Most patients suffering from polyarticular diseases with a long course of coxitis needed more than one injection of TCH (mean reinjection time 5.8 months). Any avascular necrosis of the femoral heads or other complications were not observed.