The mortality rate and causes of death among juvenile idiopathic arthritis patients in Finland

OBJECTIVES

To explore mortality rates and causes of death in juvenile idiopathic arthritis (JIA) patients in Finland compared with the general population.

METHODS

All incident patients with JIA (age <16 years at the index day) during 2000-2014 were collected from the nationwide register maintained by the Social Insurance Institution of Finland and The National Population Registry identified three age-, sex- and residence-matched controls for each case. They were followed up together until 31st Dec 2015.

RESULTS

Altogether 4,180 JIA patients (62% females) were identified. Mean age at diagnosis was 8.3 years. The average follow-up time was 6.6 years (IQR 3.1-10.5). The patients were compared with 12,511 controls. During 28,941 follow-up years, 11 JIA patients (6 females, 5 males) and 23 controls (12 females, 11 males) died. The mean age at death was 20.3 (range: 11-30) in JIA patients and 23.1 (range: 9-29) years in the control group, (p=0.17). Cumulative mortality in JIA was 0.6% (95% Cl 0.3-1.2) compared to 0.6% (95% Cl 0.4-1.0) in the controls; (hazard ratio 1.44, 95% Cl 0.70-2.95). Accidents were the most common (54%) cause of death in JIA, whereas suicide (39%) in the controls. Substance abuse and depression contributed more to deaths in the controls (39%) than in the JIA patients (10%), (p=0.053).

CONCLUSIONS

The mortality rate was not elevated in patients with juvenile idiopathic arthritis.

Intraarticular infliximab therapy in patients with juvenile idiopathic arthritis: the role of musculoskeletal ultrasound and disease activity scores in monitoring therapy response

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children, with heterogeneous clinical features. Although therapeutic options are wide and in the majority of children symptoms improve with the combination of non-steroidal anti-inflammatory and disease-modifying drugs, there are a number of patients who do not respond to conventional therapy and who do not meet the criteria for systemic biologics, namely anti TNF-alpha. Those patients are potential candidates for intraarticular therapy with biologics and in this report we present the results of intra-articular infliximab treatment in a series of patients diagnosed with oligoarticular subtype of JIA.

METHODS

Twenty patients (30 joints) were treated with intraarticular infliximab and monitored by power Doppler musculoskeletal ultrasound according to the OMERACT and Juvenile Arthritis Disease Activity Score (JADAS 10) before intraarticular application and during the follow-up period of 18 months (0, 1, 12, 18 months).

RESULTS

The results showed statistically significant improvement in PD-MSUS measures and JADAS in both B mode and power Doppler mode scores (p<0.001, p<0.001, respectively) in patients treated with i.a. infliximab with persistent response in fifteen patients. The JADAS score, as well as the ultrasound scores, were significantly reduced during the follow-up period.

CONCLUSIONS

This study showed promising results, good safety and potential for the clinical benefit of intraarticular infliximab treatment in a selected group of patients with oligoarticular subtype of JIA.

Infection-Related Death among Persons with Refractory Juvenile Idiopathic Arthritis

Bacterial sepsis led to multiorgan failure in persons receiving immunosuppressive and antiinflammatory drugs.

Severe infections are emerging as major risk factors for death among children with juvenile idiopathic arthritis (JIA). In particular, children with refractory JIA treated with long-term, multiple, and often combined immunosuppressive and antiinflammatory agents, including the new biological disease-modifying antirheumatic drugs (DMARDs), are at increased risk for severe infections and death. We investigated 4 persons with JIA who died during 1994–2013, three of overwhelming central venous catheter–related bacterial sepsis caused by coagulase-negative Staphylococus or α-hemolytic Streptococcus infection and 1 of disseminated adenovirus and Epstein-Barr virus infection). All 4 had active JIA refractory to long-term therapy with multiple and combined conventional and biological DMARDs. Two died while receiving high-dose systemic corticosteroids, methotrexate, and after recent exposure to anti–tumor necrosis factor-α biological DMARDs, and 2 during hematopoietic stem cell transplantation procedure. Reporting all cases of severe infections and especially deaths in these children is of paramount importance for accurate surveillance.

Adalimumab: long-term safety in 23 458 patients from global clinical trials in rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis and Crohn's disease

BACKGROUND

As long-term treatment with antitumour necrosis factor (TNF) drugs becomes accepted practice, the risk assessment requires an understanding of anti-TNF long-term safety. Registry safety data in rheumatoid arthritis (RA) are available, but these patients may not be monitored as closely as patients in a clinical trial. Cross-indication safety reviews of available anti-TNF agents are limited.

OBJECTIVE

To analyse the long-term safety of adalimumab treatment.

METHODS

This analysis included 23 458 patients exposed to adalimumab in 71 global clinical trials in RA, juvenile idiopathic arthritis, ankylosing spondylitis (AS), psoriatic arthritis, psoriasis (Ps) and Crohn's disease (CD). Events per 100 patient-years were calculated using events reported after the first dose through 70 days after the last dose. Standardised incidence rates for malignancies were calculated using a National Cancer Institute database. Standardised death rates were calculated using WHO data.

RESULTS

The most frequently reported serious adverse events across indications were infections with greatest incidence in RA and CD trials. Overall malignancy rates for adalimumab-treated patients were as expected for the general population; the incidence of lymphoma was increased in patients with RA, but within the range expected in RA without anti-TNF therapy; non-melanoma skin cancer incidence was raised in RA, Ps and CD. In all indications, death rates were lower than, or equivalent to, those expected in the general population.

CONCLUSIONS

Analysis of adverse events of interest through nearly 12 years of adalimumab exposure in clinical trials across indications demonstrated individual differences in rates by disease populations, no new safety signals and a safety profile consistent with known information about the anti-TNF class.

Childhood acute lymphoblastic leukemia presenting with osteoarticular syndrome--characteristics and prognosis

Children with leukemia often present with osteoarticular syndrome as a first complaint thus mimicking juvenile idiopathic arthritis. The objective of the present study was to determine the frequency of osteoarticular syndrome at the onset of acute lymphoblastic leukemia in childhood, the clinical and laboratory specificity of such patients and the prognostic value of osteoarticular syndrome as an initial symptom.

PATIENTS AND METHODS

We studied 60 children with acute lymphoblastic leukemia at a mean age of 5 +/- 0.5 years between February 2002 and October 2007.

RESULTS

Osteoarticular syndrome was present as an initial symptom of leukemia in 18 (30.5%) patients. The oligoarticular involvement was prevalent--in 8 children (44%). Middle-sized joints were affected more commonly--in 10 patients (55.6%), followed by large joints and spine. Laboratory results in patients with osteoarticular syndrome show more often normal or slightly decreased platelet count, higher values of lactate dehydrogenase and rarely--leukocytosis (> 20 x 10(9)/l). Parablasts in the blood film were detected in 13 children (72.2%) with osteoarticular syndrome. Event-free survival in patients with osteoarticular syndrome is comparable to that of the remaining group of acute lymphoblastic leukemia patients. In conclusion we point out that there should be frequent blood tests in children with osteoarticular syndrome and timely bone marrow biopsy in cases with atypical signs of juvenile arthritis.

Remission status follow-up in children with juvenile idiopathic arthritis

OBJECTIVE

To characterize articular and systemic inflammatory activity in juvenile idiopathic arthritis (JIA), identifying remission status with and without medication.

METHODS

A total of 165 JIA cases, followed for a mean period of 3.6 years, were reviewed in order to characterize episodes of inactivity and clinical remission on and off medication. The resulting data were analyzed by means of descriptive statistics, survival analysis, by comparison of Kaplan-Meier curves, log rank testing and binary logistic regression analysis in order to identify predictive factors for remission or persistent activity.

RESULTS

One hundred and eight of the cases reviewed fulfilled the inclusion criteria: 57 patients (52.7%) exhibited a total of 71 episodes of inactivity, with a mean of 2.9 years per episode; 36 inactivity episodes (50.7%) resulted in clinical remission off medication, 35% of which were of the persistent oligoarticular subtype. The probability of clinical remission on medication over 2 years was 81, 82, 97 and 83% for cases of persistent oligoarticular, extended oligoarticular, polyarticular and systemic JIA, respectively. The probability of clinical remission off medication 5 years after onset of remission was 40 and 67% for patients with persistent oligoarticular and systemic JIA, respectively. Persistent disease activity was significantly associated with the use of an anti-rheumatic drug combination. Age at JIA onset was the only factor that predicted clinical remission (p = 0.002).

CONCLUSIONS

In this cohort, the probability of JIA progressing to clinical remission was greater for the persistent oligoarticular and systemic subtypes, when compared with polyarticular cases.

Treatment of refractory autoimmune diseases with autologous stem cell transplantation: focus on juvenile idiopathic arthritis

Autologous stem cell transplantation (ASCT) can be performed in a variety of refractory autoimmune diseases. A retrospective multicenter analysis is presented to evaluate safety and efficacy of ASCT for refractory juvenile idiopathic arthritis. In all, 18 of the 34 patients (53%) with a follow-up of 12 to 60 months achieved a drug-free complete remission. There were three cases (9%) of transplant-related mortality and two cases of disease-related mortality (6%). Infectious complications were seen frequently. We propose adjustments in future protocols to reduce this mortality in this high-risk patient group.

National study of cause-specific mortality in rheumatoid arthritis, juvenile chronic arthritis, and other rheumatic conditions: a 20 year followup study

OBJECTIVE

To quantify risks for cause-specific mortality among hospitalized patients with rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), and 4 other rheumatic conditions in a nationwide, population based cohort over a 20 year period.

METHODS

All subjects were identified from Scottish hospital inpatient records from 1981 to 2000 and were followed up by computer linkage to the national registry of deaths. Expected mortality was calculated from national mortality rates and was related to the observed incidence by the standardized mortality ratio (SMR) and the corresponding 95% confidence interval (95% CI).

RESULTS

Overall mortality was elevated in each of the 6 rheumatic conditions examined, most notably in JCA (males: SMR 3.4, 95% CI 2.0,5.5; females: SMR 5.1, 95% CI 3.2,7.8). Among patients with RA, there was an increased risk for death in all International Classification of Disease chapters other than those relating to mental disorders. Specific causes of death with an increased risk for subjects with RA included lung cancer [males: 1.4 (1.2,1.5); females: 1.6 (1.5,1.8)], hematopoietic malignancies [M: 1.8 (1.4,2.3); F: 2.0 (1.7,2.3)], coronary artery disease (CAD) [M: 1.6 (1.5,1.7); F: 1.95 (1.9,2.0)], respiratory infections [M: 1.9 (1.7,2.2); F: 2.4 (2.3,2.6)], chronic obstructive pulmonary disease [M: 1.8 (1.6,2.0); F: 2.1 (1.9,2.3)], and renal failure [M: 3.1 (2.5,3.9); F: 3.5 (3.0,4.0)]. Conversely, RA subjects were less likely to die from gastrointestinal tract malignancies [M: 0.82 (0.7,1.0); F: 0.8 (0.7,0.9)].

CONCLUSION

Population studies for primary data collection are required to extend our knowledge about the underlying mechanisms of early mortality in patients with rheumatic conditions.

Reactive haemophagocytic syndrome in children with inflammatory disorders. A retrospective study of 24 patients

BACKGROUND

The reactive haemophagocytic syndrome (RHS) is a little-known life-threatening complication of rheumatic diseases in children. It reflects the extreme vulnerability of these patients, especially those with systemic-onset juvenile chronic arthritis (JCA). This immunohaematological process may be triggered by events such as herpes virus infection and non-steroidal anti-inflammatory drug therapy. Treatment has not been standardized.

METHODS

We characterized this unusual disorder and determined its incidence by carrying out a retrospective study of patients identified over a 10-yr period in French paediatric units.

RESULTS

Twenty-four cases (nine males, 15 females) were studied. Eighteen had typical systemic-onset JCA, two had polyarthritis, two had lupus and two had unclassifiable disorders. Clinical features at diagnosis included high spiking fever (24 patients), enlargement of the liver and spleen (14), haemorrhagic diathesis (six), pulmonary involvement (12) and neurological abnormalities (coma or seizures) (12). RHS was the first manifestation of systemic disease in three cases. Admission to intensive care was required in ten cases. Hypofibrinogenaemia, elevated liver enzymes and hypertriglyceridaemia were found consistently. Phagocytic histiocytes were found in 14 of 17 bone marrow smears. RHS was presumed to have been precipitated by infection in 11 cases (four Epstein-Barr virus, three varicella-zoster virus, one parvovirus B19, one Coxsackie virus, one Salmonella, one Pneumocystis carinii) and by the introduction of medication in three cases (Salazopyrin plus methotrexate; morniflumate; aspirin). Macrophage activation was indicated by high levels of monokines in the serum of two patients. Twenty patients had only one episode, three had an early relapse and one patient had two relapses. The treatment regimen was tailored to each child as the clinical course was variable. There was no response to intravenous immunoglobulins, which were used in four cases. Intravenous steroids at doses ranging from conventional to pulse methylprednisolone induced remission in 15 of 21 episodes when used alone as the first-line treatment. Cyclosporin A was consistently and rapidly effective, both when used as second-line therapy in all seven of the episodes in which steroids failed and in all five patients who received it as their first-line treatment. This supports a central role of T lymphocytes in the haemophagocytic syndrome. Two patients died. One patient with lupus died of congestive fulminant heart failure after 4 days, despite treatment with intravenous steroids and immunoglobulins, and one patient with systemic-onset JCA died from multiorgan failure despite aggressive therapy with pulsed steroids and etoposide.

CONCLUSIONS

RHS may be a more common complication of systemic disease in childhood than previously thought. This life-threatening complication should be diagnosed promptly, as it calls for the immediate withdrawal of potentially triggering medications, anti-infective therapy when relevant, and urgent immunosuppressive treatment, measures that are very often effective. Cyclosporin A may be the drug of choice.

Increased mortality in adults with a history of juvenile rheumatoid arthritis: a population-based study

OBJECTIVE

To assess mortality in a population-based cohort of adults with a history of juvenile rheumatoid arthritis (JRA).

METHODS

The Rochester Epidemiology Project database was used to identify all cases of JRA diagnosed among Rochester, Minnesota residents under the age of 16 between January 1, 1960 and December 31, 1993. Fifty-seven patients in this cohort are now adults (ages 18-53 years, mean age 34.3 years), and this subgroup was contacted for a long-term followup study. The average length of followup from the time of diagnosis was 25.6 years.

RESULTS

Four deaths occurred in this cohort of 57 adults with a history of JRA. All 4 deceased patients had other autoimmune illnesses and died of complications of these diseases. The observed frequency of 4 deaths was significantly greater (P < 0.0026 by one-sample log-rank test) than the 1 death that would be expected among Minnesota whites of similar age and sex, and corresponds to a mortality rate of 0.27 deaths per 100 years of patient followup compared with an expected mortality rate of 0.068 deaths per 100 years of followup in the general population.

CONCLUSION

The results indicate a significant, unexpected increase in mortality in this population-based cohort of adults with a history of JRA in comparison with the rate in the general population. The deaths in this group were all associated with other autoimmune disorders, suggesting that special emphasis should be given to the diagnosis and treatment of other autoimmune diseases, including immunodeficiencies, in JRA patients. The frequency of deaths in this cohort suggests that JRA patients are at substantial risk for mortality, and highlights the need for longitudinal followup and care into adulthood.

Chlorambucil in severe juvenile chronic arthritis: longterm followup with special reference to amyloidosis

OBJECTIVE

To assess the effectiveness and side effects of chlorambucil therapy and patient outcome in juvenile chronic arthritis (JCA) treated with chlorambucil.

METHODS

Followup of 79 consecutive patients with JCA refractory to previous therapy, in whom chlorambucil treatment was initiated from 1982 to 1995. Mean treatment duration was 7 months in 72 patients and more than 20 months in 6 patients with amyloidosis and 1 with severe iridocyclitis.

RESULTS

Within 6 months, remission was attained in 41 patients (52%): 29 of these relapsed after a mean period of 2.5 years (range 0.3-8.3). Twenty-one (27%) patients did not respond. Seven out of 11 patients with secondary amyloidosis had proteinuria, which cleared completely in 4 and almost completely in 1. In 16 patients (20%) chlorambucil was stopped because of side effects, and in 1 because of infection. After a mean followup of 8.5 years, 14 patients (18%) were in complete remission without drugs, 34 (43%) had minor symptoms only, but 26 (33%) had limitations in daily activities. Five (6%) had died (2 of leukemia; 2 of infection, 0.5 and 3.3 years after withdrawal of chlorambucil; 1 of amyloidosis).

CONCLUSION

Chlorambucil was found to be a very potent drug for JCA with acceptable short term, but serious longterm side effects. It may still be useful in JCA complicated by amyloidosis.

Long-term outcome among patients with juvenile rheumatoid arthritis

Juvenile rheumatoid arthritis (JRA) is a chronic inflammatory disease primarily affecting the joints but also extra articular tissue. The long-term outcome of JRA has different aspects, which include disease outcome, mortality, iridocyclitis and stature. Several studies, which have addressed these issues, are reviewed in this article. In addition, functional, educational and employment status of patients with JRA are also reviewed. To facilitate better understanding of these various studies, a description of the terminology used in defining disease is provided. Several of the instruments that are available for assessing outcome among patients are described. The role of laboratory and radiological evaluation in predicting outcome is also addressed.

Dialysis treatment in patients with rheumatoid arthritis

The results of dialysis treatment in 24 rheumatoid arthritis patients, 20 chronic rheumatoid arthritis (RA) and 4 juvenile rheumatoid arthritis (JRA), were analysed. Presence of secondary amyloidosis, renal function, morbidity and survival were examined. Amyloidosis was present in 13 patients. Especially among amyloidosis patients, renal function declined rapidly in the last year before dialysis started. On average, 63 days per patient-year were spent in the hospital, 58% was dialysis-related, mainly due to vascular access problems. Hospitalization was even more widespread in amyloidosis patients (79 days, 72% dialysis-related). Median survival in RA patients with amyloidosis was 11 months; in RA patients without amyloidosis this was 29 months. Two-year survival was only 1 out of 10 for the RA amyloidosis patients; for the RA non-amyloidosis patients this was 5 out of 6 (p < 0.01). Cardiovascular causes of death were most frequent. In conclusion, high morbidity and low survival make RA patients with amyloidosis a high-risk group on renal replacement therapy.

Adult onset Still's disease in northern India: comparison with juvenile onset Still's disease

The present study compared the clinical and laboratory picture, the disease course and outcome in 31 patients having adult onset Still's disease (AOSD) with 23 patients having juvenile onset Still's disease (JOSD). The median age at disease onset was 20 and 7 yr for AOSD and JOSD patients, respectively. On analysing and comparing our data on these two groups, no significant differences emerged except that adults had a significantly lower time interval from disease onset to remission as compared to juveniles. Upon comparison of data on our AOSD patients with that published from abroad, rash, adenopathy and sore throat were less frequent. No clinical or laboratory variables were found to predict the subsequent disease course and outcome in either group. The functional outcome was good in about 70% of both groups and mortality was low. It is concluded that the clinical picture and outcome in AOSD is similar to that of JOSD.

Amyloidosis in juvenile chronic arthritis: a morbidity and mortality study

A retrospective study of 79 juvenile arthritic patients with reactive amyloidosis for a mean of 10 years (3 months-24.25 years) from the onset of amyloidosis was performed. Eighty percent of those treated with chlorambucil (n = 57) were alive compared with 23.5% of patients not treated with chlorambucil (n = 19) 10 years after diagnosis. Renal failure was the cause of death in 82.3% and infection in 11.7%. Side effects included one chlorambucil-treated patient who developed acute leukaemia, and seven patients who developed severe leucopenia and four thrombocytopenia. Fifteen patients are no longer on cytotoxic therapy and are in remission. Analysis of their fertility status showed that there were 5 normal births in 3 women and 2 terminations of pregnancy in 23 chlorambucil-treated women of child bearing age. Six women had ovarian failure. None of the male patients fathered a child.

A nutritional screening test for use in children and adolescents with juvenile rheumatoid arthritis

Protein-energy malnutrition (PEM) has been demonstrated in about 35% of patients with juvenile rheumatoid arthritis (JRA), but fewer than 8% of children with rheumatic diseases were reported in a national survey to have been seen by a pediatric dietitian. We demonstrate the development of a nutritional screening test for PEM in patients with JRA for use by all health care professionals. Nutritional assessment of 74 patients with JRA was conducted using a standardized 11 variable profile comprised of upper body anthropometric and biochemical measurements. The sensitivity, specificity, predictive values and index of validity were calculated for individual and selected clusters of nutritional variables to predict the need for referral for PEM compared to the independent review by 2 pediatric dietitians to refer or not refer to a dietitian for further evaluation or care. Arm circumference less than or equal to 10th percentile for age and sex matched norms was selected as the screening test for PEM in patients with JRA due to a combination of excellent measurement characteristics (sensitivity 0.80, specificity 0.86, positive predictive value 0.90, negative predictive value 0.73, index of validity 0.88) and ease of measurement.

Dismantling the pyramid

The suggestion is heard, with increasing frequency, that the therapeutic pyramid be dismantled and that medical management be reordered to treat juvenile rheumatoid arthritis as early and as decisively as possible to induce prompt remission of disease, thereby preserving function and the quality of life. We scrutinize paradigms that guide our treatment strategies, review current practices, update data derived from those practices, and propose reassessment for treatment in the 1990s.

Prognosis in juvenile chronic arthritis. Follow-up of 433 chronic rheumatic children

A total of 433 children, hospitalized in the Rheumatic Children's Hospital Garmisch-Partenkirchen, were followed on average for 15 years (range 10-22 years) after the onset of definite juvenile chronic arthritis. This paper reveals clearly that the different subgroups of chronic rheumatic disease in childhood with their different complications have a definite relationship to prognosis. Severe limitation with inability to attend normal school or employment occurred in 13.4% of children with systemic polyarticular arthritis (Still's syndrome) and 11.4% of the non-systemic cases, but not in the pauci-articular group. In the latter group 82.5% of the children remained without disability or with only slight impairment: this is significantly better than in the systemic or non-systemic polyarticular groups. Although the high incidence of chronic rheumatic iridocyclitis is common in children with pauci-articular arthritis, none of this group had been handicapped by severe eye complications or blindness, in contrast to several early cases with systemic or non-systemic polyarthritis. This might be due to regular eye checks in the pauci-articular group. Of the children in the systemic polyarticular group 10% were dwarfed. Mortality in the systemic group was 13.8%, in contrast to 1% in the non-systemic polyarticular and 0% in the pauci-articular arthritis group. Secondary amyloidosis was the most important cause of death, mainly in systemic cases. Of the children whose amyloidosis had been verified, 44% died in their second or third decades, mostly with uraemia.

Heberden oration, 1966. Categorization in medicine: a survey of Still's disease

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