Predictors of radiographic severity and functional disability in Turkish patients with ankylosing spondylitis

The objective of this study is to investigate the association between clinical and laboratory prognostic factors, radiographic severity, and functional limitations in Turkish patients with ankylosing spondylitis (AS). One hundred and two patients with AS were included in this study (66 male patients, 65%). All the necessary information regarding predictor variables, including clinical features, social status, and treatment regimens, were recorded diligently. Their spinal mobility was measured, and then, their disease activities were evaluated by using the Bath Ankylosing Spondylitis Disease Activity Index. Radiological damage (Bath Ankylosing Spondylitis Radiology Index, BASRI) and functional disability (Bath Ankylosing Spondylitis Functional Index, BASFI) were used to evaluate the outcome measures of AS. The male to female ratio was 1.8. Average age at symptom onset was 23.9 ± 28.24 years (6–54 years), and average disease duration was 16.15 ± 10.62 years. Occiput-to-wall distance, hand-to-floor distance, and the modified Schober's test results were worse in males. Hip involvement was more common in male patients, and all radiological measurements were worse in male patients than in the female ones. Disease duration, male sex, and renal stone occurrence were associated with higher radiological score. Erythrocyte sedimentation rate and the disease activity score were associated with high BASFI scores. Higher CRP levels and hip involvement were both associated with high BASRI and BASFI scores. Radiological hip involvement was determined to be an inauspicious predictor for AS (p < 0.0001). We determined a strong association of hip involvement, increased CRP levels, and renal stone history with severe radiographic damage. Hip involvement, disease duration, ESR, CRP levels, and lower socioeconomic status were all associated with a higher BASFI score.     

Physical disability, articular, and extra-articular damage in patients with juvenile idiopathic arthritis

Data on outcome of juvenile idiopathic arthritis (JIA) from the Indian subcontinent is limited. Juvenile Arthritis Damage Index (JADI) is a newly proposed index which measures articular (JADI-A) and extra-articular damage (JADI-E). We studied the outcome of JIA using JADI in Indian patients. We assessed the damage in patients with JIA using JADI, and to see if JADI scores correlate with various parameters of damage and disease activity. We studied 89 patients of JIA (excluding enthesitis-related arthritis) with a >/=1-year duration of the disease. Besides JADI, clinical assessment included active joint count, joints with limited mobility, ESR, and CHAQ. Radiological damage was assessed according to the Dale scoring system. Correlation of JADI with various parameters was done by Spearman's rank correlation coefficient. The patient's distribution of JIA subtypes was polyarticular (47), systemic onset (SoJIA 23), oligoarticular (15), psoriatic arthritis (one) and others (three). The median duration of disease was 5 years (1-20). JADI-A ranged from 0-61 (Median 2); 60.7% of children had articular damage. Thirty-five (39.3%) patients had extra-articular damage; out of which, growth failure was the commonest. Persistent oligoarticular subtype had lesser JADI-A score as compared to SoJIA and polyarticular JIA. JADI-A correlated significantly with (p < 0.01) with radiological damage (0.538), CHAQ (0.567), JADI-E (0.513), duration of disease (0.385), and loss of education years due to disease (0.352). Further it also correlated with measures of disease activity like: ESR (0.286), duration of morning stiffness (0.258, p < 0.05), physician's global assessment (rS 0.623), and parent's global assessment (0.446), Almost two-thirds of patients with JIA had articular damage and one third had extra-articular damage. JADI is a good tool to measure damage in children with JIA.     

Health related quality of life survey about children and adolescents with juvenile idiopathic arthritis

This study aimed to investigate the proxy-reported Health related quality of life (HRQOL) and its determinants in patients with juvenile idiopathic arthritis (JIA). It was hypothesized that HRQOL would decrease with worsening disease and disability. Data were available in cross-sectional study on children and adolescents with JIA according to the ILAR criteria. Patient demographics, type of JIA, clinical determinants and laboratory parameters relating to JIA were obtained for each patient. Functional disability was assessed using the parent’s or children’s version of the child health assessment questionnaire (CHAQ). The HRQOL was evaluated using the juvenile arthritis quality of life questionnaire (JAQQ). These questionnaires were previously translated and validated in Moroccan children. A total of 80 participants were enrolled with mean age of 11 [6–17 years], and female predominance (59%). Many patients (42.5%) had oligoarticular subtype; 31.3% polyarticular subtypes and 26.2% systemic form. The mean global score of JAQQ was 2.6 ± 1.3 (1–6). Patients with persistant oligoarticular had better gross motor function (P < 0.0001), better fine motor function (P < 0.0001), less psychosocial impact (P = 0.001), and less symptoms (P = 0.001) in comparison with polyarticular and systemic subtypes. The HRQOL assessed by the JAQQ was worse in adolescent patients in comparison with children except for symptoms (P = 0.15). The gender (P = 0.95), age at onset of JIA (P = 0.81), and evolution duration (P = 0.34) were not correlated with global score of JAQQ. The diagnosis delay was significantly associated with decrease of HRQOL (P = 0.001). The decrease of HRQOL was correlated with disease activity [pain (VAS), painful and swollen joints, erythrocyte sedimentation rate (for P < 0.0001)], with disability index (CHAQ) (P = 0.001) and presence of hip involvement (P = 0.01). This study suggests that JIA can have a significant adverse effect on the HRQOL of moroccan patients, particularly adolescents with polyarticular and systemic subtypes. Disease duration, disability score (CHAQ) and pain were the strongest determinants of poorer HRQOL.     

Economic impact of juvenile idiopathic arthritis and familial Mediterranean fever

The aim of the study was to determine the economical impact of juvenile idiopathic arthritis (JIA) and familial Mediterranean fever (FMF) in Turkey. A total of 100 patients (69 F/31 M) with JIA and 100 with FMF (68 F/32 F) who were consecutively seen in the outpatient clinic of the pediatric rheumatology department at Cerrahpasa Medical School between August 2008 and January 2009 were studied. Cost data were collected through a questionnaire filled out by the parents. The mean age (JIA: 11?±?5?years; FMF:12?±?4?years) and mean disease duration (JIA:5?±?3?years; FMF: 4?±?3?years) of the patients were similar. JIA patients were assigned to 5 subtypes (polyarticular: n?=?45, oligoarticular: n?=?30, systemic onset: n?=?13, psoriatic: n?=?6, and enthesopathy-related JIA: n?=?6). Forty-nine percent of the patients with JIA were treated with anti-TNF drugs and 61% with DMARDs. All patients with FMF were using colchicine. The total annual cost of JIA (€3,994?±?4,101) was considerably higher than that of FMF (€162?±?77) (P?<?0.001). Medication fee was the major determinant of total costs in both diseases constituting 85% in JIA and 39% in FMF. Among the subtypes of JIA, total annual costs were the highest among patients with polyarticular type (€6,045?±?4,078). Medications especially anti-TNF drugs were the major contributor among all determinants of costs in JIA. The low costs of health care system and prominent changes in the health care policies for the last 5?years in Turkey might have played role in our findings.     

Elevated serum receptor activator of NFκB ligand (RANKL), osteoprotegerin (OPG), matrix metalloproteinase (MMP)3, and ProMMP1 in patients with juvenile idiopathic arthritis

We studied the serum levels of receptor activator of nuclear factor-κB ligand (RANKL), osteoprotegerin (OPG), pro-matrix metalloproteinase (MMP) 1, MMP3, and tissue inhibitor of metalloproteinase (TIMP) 1 in patients with juvenile idiopathic arthritis (JIA) and correlated these with different disease variables. Sera of 70 patients with JIA (ILAR 2001 criteria) and 33 age- and sex-matched controls were assayed by enzyme-linked immunosorbent assay. Nonparametric tests were used for analysis of data. The subtype distribution of the JIA patients was: enthesitis-related arthritis (ERA) 24, polyarticular 22, systemic onset 13, oligoarticular 8, and others 3. The median level of RANKL, OPG, pro-MMP1, MMP3, and TIMP-1 were elevated in JIA patients as compared to controls (p < 0.001). There was no difference in levels among different types of JIA. RANKL/OPG ratio was elevated in all subtypes of JIA. MMP3/TIMP-1 ratio correlated with measures of disease activity including swollen and tender joint count, erythrocyte sedimentation rate, and disease activity score (rS 0.28, p < 0.05). Ours is the first study to show elevated RANKL in serum of patients with JIA. Further, our data suggest that patients with ERA have similar levels to other forms of JIA. Association of the MMP3/TIMP-1 ratio with disease activity suggests that it may be a useful biomarker for follow-up.     

Hip joint disease in psoriatic arthritis: risk factors and natural history

OBJECTIVE: To determine the natural history of hip joint disease in psoriatic arthritis (PsA) and identify clinical risk factors for its early identification. PATIENTS AND METHODS: 504 patients with PsA according to ESSG criteria were studied. Mean follow up was 5.7 years (range <1-45). Mean age at onset of psoriasis was 32 years and of PsA, 39 years. The most common pattern of PsA at onset was oligoarticular (49%) and at the latest examination, polyarticular (65%). Sacroiliitis or spondylitis was diagnosed in 94 (18.7%) patients. RESULTS: 32 (6.3%) patients developed psoriatic hip arthropathy, and of these, 26 (81%) also had sacroiliitis or spondylitis. In 7/17 (41%) patients the hip became affected within 1 year after the onset of PsA. Hip disease occurred more often in younger patients. Sex, pattern of peripheral arthritis, duration of psoriasis before arthritis affected the distal interphalangeal joints, dactylitis, or enthesitis were not associated with the risk of hip disease. Seventeen patients were followed up and nine required hip arthroplasty. Sixteen (50%) first had arthroplasty within 5 years after the onset of hip pain. CONCLUSIONS: Psoriatic hip arthropathy occurs infrequently in PsA and is associated with earlier onset of arthritis and psoriatic spondylitis. Bilateral hip involvement and rapid progression to hip arthroplasty are common.     

Anti-cyclic citrullinated peptide (anti-CCP) antibodies in children with juvenile idiopathic arthritis

OBJECTIVE: To determine if anti-cyclic citrullinated peptide antibodies (anti-CCP) can be detected in sera of patients with juvenile idiopathic arthritis (JIA) and if they can be used to identify patients with a more destructive course of disease. METHODS: One hundred serum samples of 71 patients with JIA taken at different time points in their disease course were analyzed by a commercially available anti-CCP ELISA. Followup serum samples from 28 patients were also tested. Correlations between anti-CCP and disease characteristics, medication, and radiological damage (presence of joint space narrowing and/or erosions) were also determined. RESULTS: The serum samples came from patients of all 8 different subtypes of JIA (mean age: 9.6 years, median: 10.5; disease duration mean: 39 months, median: 24) including 11 polyarticular rheumatoid factor positive (IgM-RF) patients. Anti-CCP was positive in 73% of the IgM-RF positive JIA patients and in 3% of the other JIA patients (p < 0.0001). Disease duration, medication, and anti-nuclear antibody positivity did not differ significantly between anti-CCP positive and negative patients. Testing of followup samples showed almost identical anti-CCP results. All IgM-RF positive JIA patients had radiological damage (p < 0.001). Of the anti-CCP positive patients, 80% had radiological damage resulting in a significant difference between anti-CCP positive and negative patients (p = 0.009) with an odds ratio (OR) of 12.7, but corrected for IgM-RF, the OR was no longer significant (p = 0.88). CONCLUSION: Anti-CCP antibodies can be detected in the sera of patients with JIA but almost exclusively in the subset of patients with polyarticular IgM-RF.     

Role of MRI in evaluation of hip joint involvement in juvenile idiopathic arthritis

Aim of the WorkTo evaluate the role of MRI in diagnosing hip arthritis and correlating it with clinical and laboratory assessments in juvenile idiopathic arthritis (JIA).Patients and MethodsThe study included 30 patients with JIA with mean age of 13.5 ± 4.5. Disease activity was evaluated by DAS28 score, physician’s global assessment (PGA–VAS), patient’s global assessment (VASglobal) and the assessment of functional ability by (CHAQ). Hip joint evaluation was assessed by hip pain on movement and the degree of limitation of motion (score 0–3). Plain radiography and MRI of the hip joint were performed for all patients. MRI score was done.ResultsMRI of hips was abnormal in 12 (40%) of all patients: 2/8 (25%) of the oligoarticular group, 4/13 (30.8%) of the polyarticular group, 5/7 (71.4%) of the systemic onset group and 1/2(50%) of the enthesitis related group. Comparing mean values of MR scores of the four clinical subsets showed significant difference (p < 0.001). Patients with active disease showed higher MR scores (3.7 ± 1.5) than those with inactive disease (2.1 ± .9) [p < 0.002]. Presence of effusion and gadolinium enhancement were significantly higher in active hips (p < 0.01 and p < 0.001 respectively). VAS–PGA and ESR were significantly correlated with MRI score (p < 0.02 and <0.05 respectively).ConclusionMRI of the hip plays an important role in the study of patients with JIA as it reveals early joint involvement and evaluates the extent of joint disease. This permits intervention at an appropriate time with suitable treatment. Clinical and laboratory findings are inadequate diagnostic tools for the assessment of hip arthritis when comparing with MRI.     

Therapeutic use of etanercept in polyarticular course juvenile idiopathic arthritis over a two year period

OBJECTIVE: To analyse the treatment response to etanercept in patients with polyarticular course juvenile idiopathic arthritis (JIA). METHODS: 22 patients with polyarticular course JIA (19 females, three males; mean age 13.9 years; mean disease duration 6.3 years; 15 with polyarticular onset, seven with systemic onset, one with residual systemic activity; eight rheumatoid factor positive; eight with erosive disease) were treated with etanercept for up to 24 months. Etanercept was given subcutaneously at 0.4 mg/kg twice a week. Treatment response was ascertained in an open prospective study. RESULTS: All patients showed impressive clinical improvement, with a decrease in swollen joint count by an average of 10.1 joints (mean of 49% decrease), a decrease in tender joint count by 9.3 joints (mean of 94%), and decrease in total joint count by 11.2 joints (mean of 48%). Duration of morning stiffness decreased to less than 10 minutes. Furthermore, haemoglobin concentration increased on average by 14 g/l (mean of 15.3%) and packed cell volume increased by 0.035 (mean increase of 12%), and erythrocyte sedimentation rate decreased on average by 42.8 mm/1st h (mean decrease of 64%). No major side effects were noted. CONCLUSION: Etanercept continues to be clinically effective and well tolerated in patients with polyarticular course JIA over a two year period.     

HLA B27 typing in 511 children with juvenile idiopathic arthritis from India

The enthesitis-related arthritis (ERA) category of juvenile idiopathic arthritis (JIA) is the most common category in India. HLA B27 has a high prevalence in ERA, and ILAR classification includes it in exclusion criteria for other categories, but due to its cost, it is not routinely done. We undertook this study to assess the prevalence of HLA B27 in ERA and other groups of juvenile arthritis in India. Consecutive patients of JIA ERA and select patients from other categories were recruited from a single tertiary care hospital over a span of 3 years. HLA B27 was tested using PCR. Five hundred and eleven children were studied: 312 had ERA, and 199 had other categories (29 oligoarthritis, 107 polyarthritis, 44 systemic onset JIA, 9 psoriatic arthritis and 10 undifferentiated). The prevalence of HLA B27 was highest in the ERA group (87 %) and correlated with the presence of sacroiliitis. Prevalence was 10.3 % in oligoarthritis, 16 % in polyarticular rheumatoid factor (RF)-positive arthritis, 26 % in RF-negative polyarticular arthritis, 66 % in psoriatic arthritis and 40 % in the unclassified and 0 % in systemic onset category. Twenty-seven children had a change in category of JIA as per ILAR owing to HLA B27 testing positive, most commonly in the RF-negative polyarthritis group. Only six of these had clinical features suggestive of Spondyloarthropathy. There is high prevalence of HLA B27 in ERA. Though HLA B27 testing helps in correct classification, a minority of these patients have features suggestive of spondyloarthropathy like back pain, enthesitis or sacroiliitis.     

A modified juvenile arthritis damage index to improve articular damage assessment in juvenile idiopathic arthritis—enthesitis-related arthritis (JIA-ERA)

Juvenile arthritis damage index (JADI) consists of two parts which measure articular (JADI-A) and extra-articular (JADI-E) damage in patients with juvenile idiopathic arthritis (JIA). It does not include assessment of cardiac dysfunction and joint areas commonly affected in enthesitis-related arthritis (ERA) category of JIA. We have tried to study if modification of JADI will improve its performance in JIA-ERA. We studied 101 consecutive patients of JIA-ERA. JADI-A was modified (JADI-AM) to include damage assessment of tarsal joints and lumbar spine. JADI-E was modified (JADI-EM) to include assessment of symptomatic cardiac dysfunction. The performances of the modified and standard JADI were compared. Ninety-seven patients were male. The median age was 18 years (9–36). At a median disease duration of 6 years (1–24), joint damage was observed in 47 as assessed by JADI-A. JADI-AM could identify 11 more patients (N = 58) with articular damage. JADI-AM had good correlation with number of joints with limitation of movement (Spearman’s [rS] = 0.9) and low to moderate correlation (rS < 0.7) with measures of disease activity and functional status. JADI-AM discriminated well among patients with different disability levels. Extra-articular damage was observed in 35, and modification of JADI-E with inclusion of cardiac dysfunction did not identify any additional patient. Thus, we propose a modification of the JADI-A (JADI-AM). In JIA-ERA, modification of JADI-A improves its ability to identify articular damage. Modification of the JADI-E may not be needed as symptomatic cardiac involvement is rare.     

Temporomandibular involvement in juvenile idiopathic arthritis

OBJECTIVE: To study occurrence as well as clinical signs and symptoms of temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) in a population representing all subtypes of JIA. METHODS: Ninety-seven consecutive children with JIA underwent orthodontic evaluation including an orthopantomogram (OPG). Further evaluation included patient characteristics, disease onset, course, and medical treatment. RESULTS: Forty-five percent of all children had TMJ involvement. Frequencies according to JIA subtypes: systemic 67%, oligoarticular (persistent and extended) 39%, rheumatoid factor (RF) negative polyarticular 59%, RF positive polyarticular 33%, enthesitis related arthritis 13%, psoriatic arthritis 33%, and other arthritis 50%. In children with a polyarticular course, irrespective of their disease onset, TMJ involvement was more frequent (55% vs 31% in oligoarticular course). In children with disease onset at a young age and/or an extended course of the disease, TMJ involvement was also more frequent. Pain during jaw excursion, absence of translation, asymmetry during maximal opening and protrusion, as well as crepitation during evaluation are predictors for TMJ involvement with a good specificity but a low sensitivity. Not all patients with TMJ involvement have clinical signs. CONCLUSION: Because of the high prevalence and discrepancy between clinical signs and presence of arthritis of the TMJ, regular orthodontic evaluation and OPG is recommended to recognize TMJ involvement and enable early intervention.     

Omega-3 fatty acids in juvenile idiopathic arthritis: effect on cytokines (IL-1 and TNF-α), disease activity and response criteria

This study aims to demonstrate the effect of omega-3 fatty acids (ω-3 FAs) supplements on the clinical manifestations, laboratory investigations, disease activity, functional capacity, response criteria as well as interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α) levels in juvenile idiopathic arthritis (JIA) patients. Twenty-seven JIA patients were included in this study. Dietary supplements of ω-3 FAs 2 g/day were given for 12 weeks. Juvenile arthritis disease activity score in 27 joints (JADAS-27) and pediatric American College of Rheumatology (ACR) response criteria were determined. Childhood Health Assessment Questionnaire (CHAQ) was used to measure the functional status. Assessment of serum IL-1 and TNF-α level was performed using enzyme-linked immunosorbent assay. The mean age of the patients was 12.78 ± 3.26 years, the disease duration was 5.93 ± 3.06 years, and the age at disease onset was 6.78 ± 3.26 years. The TNF-α and IL-1 were significantly higher in the JIA patients compared to the control. There was a significant improvement of active joint count, number of swollen joints, JADAS-27, CHAQ, TNF-α, and IL-1 levels. The pediatric ACR response criteria improved in 92.59% of the patients. The daily requirements of nonsteroidal anti-inflammatory drugs (NSAIDs) obviously decreased. ω-3 FAs supplements reduce the inflammatory response and improve the clinical manifestation in JIA patient. The daily intake of NSAID dose decreased thus reducing the risk of related side effects. Our results support the use of omega-3 fatty acids as an add-on therapy to conventional treatment of JIA.     

Anticyclic citrullinated peptide antibodies in juvenile idiopathic arthritis

Anticyclic citrullinated peptide (anti-CCP) antibodies have been detected in patients with juvenile idiopathic arthritis (JRA), particularly in those with polyarticular JIA. We analyzed the presence of anti-CCP antibodies of the IgG class in sera of patients with defined juvenile idiopathic arthritis (JIA) of various subgroups. One hundred and fifty-nine serum samples were investigated. Forty-five patients were diagnosed with JIA (15 male and 30 female) aged 1.9–17.3 years (median 12.9, mean 11.0). Thirty-eight samples were taken from patients suffering from other autoimmunopathies and 34 patients with other underlying diseases were taken at different time points in their disease course. Under 42 samples were taken from patients with noninflammatory diseases. Enzyme-linked immunosorbent assay (ELISA) was used for the detection of anti-CCP antibodies. Anti-CCP antibodies were found in 6.9% of all samples and in 4.4% patients with JIA. Disease duration and medication did not differ significantly between anti-CCP positive and negative patients. A review of the literature and our own results shows that anti-CCP antibodies can be detected in the sera of only some patients with JIA. Routine determination of anti-CCP cannot be recommended.     

Pattern of psoriatic arthritis in an Asian population (Malaysia)

Objective: To profile the pattern of psoriatic arthritis (PsA) and its relationship to disease duration. Methods: Forty‐six consecutive patients with PsA were entered into a cross‐sectional study. Demographic data, disease duration and disability were recorded. Joint involvement was documented at 6 months from onset and at presentation. X‐rays of the sacroiliac (SI) joints, thoracolumbar spine, and hands were taken. HLA B27 typing was done. Results: The male : female ratio was 2.3 : 1, mean age at onset of arthritis was 35.8 years and mean duration of PsA was 4.2 years. Oligoarticular involvement predominated (63%) at onset. Progression from oligoarthritis to polyarthritis occurred largely in the second year; 65.2% reported asymmetrical disease at onset while 50% had asymmetrical disease when disease duration was > 1 year. The frequency of involvement at onset was as follows: sausage toes, metatarsophalangeals (MTPs) and interphalangeals (IPs) in 50% (each), proximal interphelangeals (PIPs) in 47.8%, sausage fingers 34.7% and knees 30%. With mean duration of 4.2 years it was: sausage toe 71.1%, IP 69.5%, PIP and MTP 63%, knees 60.8%, distal interphalangeals (DIPs) 54.3%, sausage finger 52.1%, wrist 47.8%, followed by neck and back pain. Disability related to lower limb functions predominated and occurred early. Forty‐one percent had radiological sacroiliatis/spondylitis and 46% had erosive arthritis in the hands; 10.2% were HLA B27 positive. Conclusion: PsA was progressive, starting predominantly as an asymmetrical oligoarthritis and becoming largely polyarticular within 2 years from onset. Lower limb disability was evident early and erosive changes in hand X‐rays were seen in more than half the patients after 1 year.     

Nitric oxide levels and the severity of juvenile idiopathic arthritis

In this study, we evaluate the distribution of nitric oxide (NO) in the serum of juvenile idiopathic arthritis (JIA) patients, correlating it with parameters of the severity of the disease. Ninety-seven patients with mean age 11.7 years and disease duration 4.8 years, showing active disease or not, grouped as oligoarticular (n = 34), polyarticular (n = 29) and systemic (n = 34) group, presenting uveitis and positive RF with erosive arthritis or active disease and erosions had significantly high levels of NO than the inactive ones. NO correlated with TNF-α in the oligoarticular subtype (P < 0.03), with pain in the polyarticular subtype with active disease (P < 0.04) and with ESR in the systemic subtype with active disease (P < 0.03). TNF-α concentration was high in all patients with active disease, accompanying NO production. The data confirm the production of NO in JIA patients, indicating a possible positive correlation between the production of NO and severity of the disease.     

Do patients with juvenile idiopathic arthritis in remission exhibit active synovitis on joint ultrasound?

The aim of the study was to assess the presence and characteristics of subclinical synovitis using power Doppler (PD) ultrasonography on patients with juvenile idiopathic arthritis (JIA) in clinical remission and compare the findings with those of healthy children. A cross-sectional study was carried out involving the clinical (physical exam, functional capacity and laboratory tests) and ultrasonography evaluation of 34 joints (synovial fluid/hypertrophy, PD signal and bone erosion). Subclinical synovitis was defined as the presence of synovial hypertrophy/joint effusion with or without any PD signal. Thirty-six patients (11.5 ± 3.74 years) and 36 controls (sex and age matched) were evaluated (2,448 joints). Twenty-seven patients were in remission on medication (mean duration: 1.8 ± 2.2 years). Subclinical synovitis was detected in 41.7 % patients and 11.1 % controls (p = 0.003). Erosion was detected in three patients (8.3 %). Subclinical synovitis was found in 38/1,224 (3.1 %) joints in the patients (most affected: radiocarpal wrist, anterior elbow and tibiotalar ankle) and 8/1,224 (0.6 %) joints in the controls (most affected: radiocarpal wrist). Differences in subclinical synovitis between patients and controls were found in the elbows (p = 0.033) and ankles (p = 0.006). A greater frequency of subclinical synovitis was found in patients with the extended oligoarticular or polyarticular subtypes (p = 0.013), those at an older age at disease onset (p = 0.007) and using methotrexate (p = 0.049). Patients with JIA in remission exhibit subclinical synovitis more frequently than controls. Subclinical synovitis was more frequent in patients with the polyarticular involvement and those at an older age at disease onset.     

Absence of radiographic progression of hip arthritis during infliximab treatment for ankylosing spondylitis

This study aims to examine the impact of long-term treatment with the anti-TNF antibody infliximab on radiographic progression of hip arthritis in ankylosing spondylitis. Anteroposterior X-rays of the pelvis obtained at baseline from consecutive patients with ankylosing spondylitis and bilateral hip arthritis were compared with X-rays obtained after 6?±?2.5 years (mean?±?SD) of continuous infliximab treatment. Analysis was performed by the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-h) scoring system (min 0, max 4). Hip joint space width was also assessed by the average of measurements at three distinct sites between the acetabulum and femoral head. In 23 patients with active disease (21 men, mean age and disease duration of 45 and 16 years, respectively), the BASRI-h score at baseline was 1 in 7, 2 in 16, 3 in 16, and 4 in 7 hips (including two arthroplasties). Individual BASRI-h scores at baseline (2.50?±?0.86, mean?±?SD) remained unchanged in all patients at end of follow-up. At baseline, the average width of the whole joint space (3.56?±?0.70 mm, n?=?44) was not associated with disease activity measurements but negatively correlated with BAS functional index (Spearman r?=??0.5, P?=?0.007). After 2–10 years of infliximab treatment, the average width of the whole joint space in these patients (3.59?±?0.79 mm) was not reduced. These results suggest that radiographic progression of hip arthritis in ankylosing spondylitis may be arrested during infliximab treatment.     

Is it safe to use anti-TNF-α agents for tuberculosis in children suffering with chronic rheumatic disease?

To determine the incidence of latent tuberculosis infection and evaluate the follow-up protocol of the patients diagnosed with juvenile idiopathic arthritis (JIA) and other chronic rheumatologic diseases treated with anti-TNF-α treatment (etanercept, infliximab, adalimumab) in Turkey, 144 patients were evaluated retrospectively for the development of tuberculosis. Patients were evaluated every 6?months for tuberculosis using history, physical examination, tuberculin skin test (TST), chest radiographs, and, when required, examination of sputum/early morning gastric aspirates for acid-fast bacilli and chest tomography. A tuberculin skin test over 10?mm induration was interpreted as positive. Patients were diagnosed with JIA (n?=?132), enthesitis-related arthritis (ERA; n?=?14), juvenile psoriatic arthritis (JPsA; n?=?4), chronic idiopathic uveitis (n?=?4), and chronic arthritis related to FMF (n?=?8). Mean age was 12.25?±?3.96?years (4.08–19.41?years), mean duration of illness was 5.86?±?3.77?years (0.66–15?years), and the mean duration of anti-TNF-α treatment was 2.41?±?1.47?years (0.6–7?years). Anti-TNF-α agents prescribed were etanercept (n?=?133), infliximab (n?=?30), and adalimumab (n?=?6). When unresponsive to one anti-TNF-α therapy, patients were switched to another. There was no history of contact with individuals having tuberculosis. During follow-up, seven patients (4.8%) with positive TST were given INH prophylaxis. One oligoarticular JIA patient (0.69%) diagnosed with secondary uveitis who had been followed for 5?years and had been using infliximab for 2?years, developed a positive Quantiferon-TB test while on INH prophylaxis. He was started on an anti-tuberculosis drug regimen. In conclusion, anti-TNF-α treatment in children with chronic inflammatory disease is safe. Follow-up every 6?months of children on anti-TNF-α treatment with respect to tuberculosis by the pediatric infectious disease department is important to prevent possible complications.     

Juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease in childhood, which represents a nonhomogeneous group of disorders that share the clinical manifestation of arthritis lasting at least 6 wk under the age of 16. The exact diagnosis requires exclusion of other diseases that cause arthritis. The exact etiopathogenesis of JIA is still unknown. The interactions between genetic factors, environmental exposures and immune mechanisms are thought to contribute to pathogenesis of the disease. The “International League Against Rheumatism” classification divides JIA into 7 subtypes: oligoarticular JIA, rheumatoid factor (RF) positive polyarticular JIA, RF negative polyarticular JIA, systemic-onset JIA, enthesitis-related arthritis, juvenile psoriatic arthritis and undifferentiated JIA. Each subgroup of JIA is characterized by a different mode of presentation, disease course and outcome. The improvements in treatment of JIA in the last 2 decades, such as the early introduction of intraarticular corticosteroids, methotrexate and biologic agents, have dramatically upgraded the prognosis of the disease. If untreated, JIA may cause devastating results, such as disability from joint destruction, growth retardation, blindness from chronic iridocyclitis, and even multiple organ failure and death in systemic-onset JIA. The aim of treatment is the induction of remission and control the disease activity to minimize the pain and loss of function, and to maximize quality of life. JIA is a disease having a chronic course, which involves active and inactive cycles over the course of years. Recent studies showed that nearly half of the patients with JIA enter adulthood with their ongoing active disease. This review elucidates how recent advances have impacted diagnosis, pathogenesis and current treatment.