Development of an observation method for assessing pain behaviors in children with juvenile rheumatoid arthritis

Objective. To develop an observation method for assessing pain behaviors in children with juvenile rheumatoid arthritis (JRA). Methods. Thirty children with JRA performed a standardized sequence of activities for video recording, and correlations between the pain behaviors observed on the videotapes and established measures of pain, depression, and functional disability were determined. Results. Pain behaviors were reliably observed (kappa coefficients 0.53-0.79). Total pain behaviors were significantly correlated with subjective reports of pain (r = 0.50) and disability levels (r = 0.64). These behaviors were not significantly associated with children's depression ratings (r = 23). Conclusion. The results indicate that the behavioral observation method provides a reliable and valid measure of pain associated with JRA. Measurement of pain behaviors may be especially useful in treatment outcome studies because these behaviors are relatively independent of depression.     

Primary juvenile fibromyalgia. Psychological adjustment,family functioning,coping, and functional disability

Objectives. 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. Methods. Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. Results. All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. Conclusion. The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.     

Links between teacher assessment and child self - assessment of mental health and behavior among children affected by HIV/AIDS

Teachers are considered to be one of the most important influences in the lives of students. Teachers' assessments of students may be a primary source of information on children's mental and behavioral health; however, this topic has received little attention in research. We examined this issue through linking teachers' ratings of students and mental and behavioral outcomes of children affected by HIV. The hypothesis is that teacher ratings will be predictive of specific child mental and behavioral health outcomes. A quantitative cross-sectional design with self-administered paper-and-pencil instruments was used. The sample included 1221 children (aged 6–18, grades 1–11) affected by HIV including 755 orphans who lost one or both parents to AIDS and 466 vulnerable children living with HIV-infected parents in a central province of China. The corresponding teacher sample included 185 participants. Each child completed an assessment inventory of demographic information and mental and behavioral health measures. Teachers completed a questionnaire about children's school performance. SEM analyses revealed a good model fit according to all fit indices: comparative fit index = 0.93, root mean square error of approximation = 0.07, and standardized root mean square residual = 0.04. Structural equation modeling revealed that problem ratings by teachers were positively associated with child loneliness and behavioral problems, social competence ratings by teachers were negatively related to child depression, and personal growth and social interaction ratings by teachers were negatively related to child loneliness, depression, and trauma. The current study represents a unique contribution to the field in that it recognizes that teachers can be a valuable source of information on children's psychological health. Results from this study have implications for health prevention and intervention for children and families suffering from HIV/AIDS.     

Serial measurements of soluble interleukin 2 receptor levels (sIL2-R) in children with juvenile rheumatoid arthritis treated with oral methotrexate.

OBJECTIVE--To investigate the potential clinical utility of serial levels of sIL2-R as a marker of disease activity among children with juvenile rheumatoid arthritis (JRA) treated with methotrexate (MTX). METHODS--sIL2-R levels, measured by ELISA, were evaluated in 16 JRA patients (10 polyarticular, six systemic-onset) treated with oral, weekly MTX. sIL2-R values were compared with those of 49 normal controls. Medical record review was used to obtain relevant clinical data. Joint counts (number of swollen joints) were used as indicators of clinical change. A reduction of 50% in joint counts between pre and post treatment measurements was considered a clinically significant response. RESULTS--The mean (SEM) sIL2-R value of pre treatment JRA of 1728(290) U/ml was significantly higher than the post treatment value of 921(229) U/ml (Wilcoxon Rank test, p < or = 0.001). Pre treatment values were also significantly different from the mean(SEM) of healthy controls of 519(19) U/ml (p < 0.001). Pre treatment sIL2-R levels of 2417(291) U/ml in systemic-onset JRA were significantly higher than sIL2-R values in polyarticular JRA patients of 1218(884) U/ml (Mann-Whitney rank test p < 0.001). Among the 13/16 children with good therapeutic responses (> or = 50% improved), the range of sIL2-R decreases was 154-2641 U/ml (mean 842 U/ml); sIL2-R levels increased in the three children with poor clinical responses to methotrexate. CONCLUSIONS--sIL2-R levels paralleled the course of disease in all patients. sIL2-R levels may be useful for monitoring therapeutic responses in children with JRA.     

Measurement of health status in children with juvenile rheumatoid arthritis

Objective. To develop and validate a self- or parent-administered instrument for measuring functional status in children with juvenile rheumatoid arthritis (JRA). Methods. We adapted the Stanford Health Assessment Questionnaire (HAQ) for use in children ages 1–19 years, by adding several new questions, such that for each functional area, there was at least 1 question relevant to children of all ages. The face validity of the instrument was evaluated by a group of 20 health professionals and parents of 22 healthy children. The questionnaire was then administered to parents of 72 JRA patients (mean age 9.1 years, onset type systemic in 16, polyarticular in 21, pauciarticular in 35). Results. The instrument showed excellent internal reliability (Cronbach's α = 0.94), with a mean inter-item correlation of 0.6. The convergent validity was demonstrated by strong correlations of the Disability Index (average of scores on all functional areas) with Steinbrocker functional class (Kendall's tau b = 0.77, P < 0.0001), number of involved joints (Kendall's tau b = 0.67, P < 0.0001), and morning stiffness (Kendall's tau b = 0.54, P < 0.0001). Spearman's correlation coefficient between Disability Index scores from questionnaires administered to parents and those from questionnaires administered to older children (>8 years) was 0.84 (n = 29; P < 0.001), showing that parents can accurately report for their children. The test–retest reliability, studied at a 2-week interval, revealed virtually identical Disability Index scores measured on the 2 occasions (0.96 versus 0.96; P > 0.9 by paired t-test; Spearman's correlation coefficient = 0.8, P < 0.002). Conclusion. The Childhood HAQ, which takes less than 10 minutes to complete, is a valid, reliable, and sensitive instrument for measuring functional status in children with JRA.     

Sulphasalazine in the treatment of children with chronic arthritis

The ainich of study was to investigate the efficacy and toxicity of sulphasalazine (SASP) in the treatment of children with chronic arthritis. The medical records of 36 children (25 boys, 11 girls) who received SASP for the treatment of chronic arthritis were reviewed. Twenty-one patients had juvenile spondyloarthropathies (JSA) (eight juvenile ankylosing spondylitis (JAS), 13 undifferentiated JSA (uJSA) and 15 had juvenile rheumatoid arthritis (JRA). The patients received SASP therapy for a mean of 2.5 years (range 3 weeks to 8.1 years). Clinical and laboratory data were reviewed retrospectively to determine the effects of treatment. A clinically significant response occurred in 23 (64%) children: remission in 14 (39%) (JRA 5, JSA 9) and improvement (25% reduction in joint count) in nine (25%) (JRA 4, JSA 5). There was no difference in response rate between JR and JSA patients (p=0.11), but the time to remission shorter in JSA patients (mean 5 months) JRA patients (mean 25 months) (p=0.024). Twelve of the 36 patients discontinued non-steroidal anti-inflammatory drugs, and six of eight patients discontinued prednisolone. A significant fall in erythrocyte sedimentation rate and rise in haemoglobin occurred in SASP-treated patients (p<0.005) comparing most recent results with pretreatment levels. Side-effects occurred in four of 36 patients (11%); only one patient who had persisting severe diarrhoea required discontinuation of SASP. It was concluded that SASP appears to be effective and safe in the treatment of JRA and JSA patients. As a second-line agent, SASP is the drug of first choice for patients with JSA; for JRA patients SASP may be a useful, possibly less toxic alternative to methotrexate.     

Clinical relevance of IgA rheumatoid factor (RF) in children with juvenile rheumatoid arthritis

This study proposed to investigate the prevalence and clinical relevance of serum immunoglobulin A (IgA) rheumatoid factor (RF) in juvenile rheumatoid arthritis (JRA) as published reports vary in their conclusion. Sera of 82 children with JRA and 25-age and sex-matched healthy children were measured for IgA RF by an enzyme linked immunoassay using human IgG as the antigen. Forty-three percent of the disease population were positive and the prevalence in pauciarticular, polyarticular and systemic onset was 9/18 (50%), 21/47 (44.7%) and 5/17 (27.7%) respectively when mean + 2SD of normal was taken as the cut-off value. By defining the upper limit of normal as mean + 6SD, 16/47 (34%) were positive in the polyarticular as compared to 2/18 (11.1%) in pauciarticular and 1/17 (5.8%) of systemic onset disease groups. The prevalence in the polyarticular subset with the upper cut-off limit was significantly higher than the pauciarticular and the systemic onset group (P < 0.05). Furthermore, the mean level of IgA RF was significantly higher in the polyarticular group compared to the mean level in the systemic onset group (P < 0.05). The mean level of IgA RF was also significantly higher (P < 0.05) in 61 children with active diseases. Received: 29 January 1999 / Accepted: 10 August 1999     

Sleep and its relationship to pain, dysfunction, and disease activity in juvenile rheumatoid arthritis

OBJECTIVE: To determine what sleep abnormalities may exist in children with juvenile rheumatoid arthritis (JRA). and their relationship to pain, dysfunction. and disease activity. METHODS: Twenty-five children with active JRA (11 pauciarticular, 9 polyarticular, 5 systemic) had their sleep assessed by parallel, validated patient and parent questionnaires (Sleep Self-Report, SSR, and Children's Sleep Habits Questionnaire, CSHQ). Disease activity was assessed by parent and physician global assessments (on a 5 point scale: 0 = no disease activity to 4 = very severe disease), erythrocyte sedimentation rate (ESR), and numbers of swollen and limited joints. Functional assessment was based on parental completion of the Juvenile Arthritis Functional Assessment Report (JAFAR). Pain was assessed by the average pain visual analog scale of the Varni Pediatric Pain Questionnaire. Results were compared to those from 45 healthy age and sex matched controls by Mann-Whitney U tests, and correlated with variables of JRA disease activity, function, and pain using Spearman correlations. RESULTS: Patients with JRA had higher total score on the CSHQ (p < 0.0001), as well as subscales assessing night wakings, parasomnias. sleep anxiety, sleep-disordered breathing, and morning wakening/daytime sleepiness (p < 0.0001-0.05). There were no correlations between CSHQ scores and JRA disease activity or pain variables, but the total score on the SSR did correlate with pain (r = 0.56, p = 0.005). CONCLUSION: We conclude that sleep abnormalities are common in children with JRA, and are multi-dimensional.     

Comparing the self-reported referral and management preferences of pediatricians and family physicians for children with juvenile rheumatoid arthritis

OBJECTIVE: The symptoms of juvenile rheumatoid arthritis (JRA) are often first recognized by primary care physicians. Little is known about the determinants of the initial management and referral patterns of these physicians for children with JRA. We compared the self-reported preferences and practices of pediatricians (PD) and family physicians (FP) in the diagnosis and management of children with JRA. METHODS: Surveys were mailed to a national random sample of 700 PD and 867 FP. Questions included prior experience with JRA, usual patterns in the diagnosis and management of JRA, perception of the need for guidelines for referral and management of this condition, and physician demographic information. Data analysis included univariate and bivariate analysis. RESULTS: Response rates were 69% for PD and 49% for FP. Most respondents had seen very few JRA cases in the previous 5 years. Only 1% of respondents reported that they provided all diagnosis and management for patients with JRA. Forty-two percent of PD and 32% of FP refer all JRA diagnosis and management to subspecialists, while 46% of PD and 61% of FP refer only to confirm the diagnosis and guide initial therapy (p = 0.011). More PD than FP (PD 92% vs FP 76%; p = 0.001) referred patients with JRA to pediatric rheumatologists, while more FP than PD referred to general rheumatologists (PD 17% vs FP 37%; p = 0.001). The majority of FP reported feeling more comfortable managing rheumatologic disease in adults than children (82%). Few respondents felt that they were up to date on the latest advances in JRA treatment (PD 10% vs FP 4%; p = 0.024). CONCLUSION: Multiple factors may contribute to physicians' referral practice, including a patient's clinical status and the physician's beliefs of inadequacy of training and inability to stay up to date. The pattern of care that children with JRA receive likely will be influenced by initial presentation to a PD or to a FP.     

Comparison of peak isometric knee extensor torque in children with and without juvenile rheumatoid arthritis

This study compared peak isometric knee extensor torque in children with juvenile rheumatoid arthritis (JRA) and healthy children. A secondary purpose was to determine the relationship between measures of articular disease severity and peak isometric knee extensor torque. Peak torque was measured with a computerized dynamometer. Twenty-eight children with JRA and 28 children without JRAwere matched for age, sex, and body surface area. Peak isometric knee extensor torque was significantly lower among the children with JRA than their respective control (P < 0.05, paired Student's t-test, one-tailed). There was no relationship between peak torque and measures ofarticular disease severity among the children with JRA. Subjects complained of quadriceps muscle discomfort as a result of the isometric muscle test. One child with JRA complained of increased knee pain and swelling. Peak isometric knee extensor torque appears to be a useful variable for characterizing muscle function deficits in children with JRA. Isometric muscle performance did not correlate with articular disease severity. The results suggest that isometric strengthening programs are indicated for this patient population. We recommend that clinicians monitor patients for joint and muscle symptoms during exercise training sessions.     

Efficacy and safety of the combination fluticasone propionate plus salmeterol in asthmatic preschoolers: An observational study

Background: Inhaled Corticosteroids (ICS) are the cornerstone of asthma management in pediatric patients. However, in some cases, asthma is not adequately controlled on ICS alone. Long-acting beta₂-agonists (LABA) are one of the available additional therapies but their use has rarely been studied among children younger than 5 years. Objective: The aim of this observational study was to evaluate the efficacy and safety of the combination of fluticasone propionate and salmeterol (FP/SA) in asthmatic children younger than 5 years of age. Methods: A retrospective study of 796 children under the age of 5 years (2.87 ± 1.22 years, 64.2% males), who were treated with FP/SA was conducted. Hospitalization rates, frequency of wheezing, exercise induced asthma, nocturnal wheeze and drug-related side-effects were recorded through children's medical records. Results: The children had previously received short-acting β₂-agonists (73%), ICS (17%), montelukast (1%), and ICS with montelukast (2%). Mean duration of therapy with FP/SA was 12.45 ± 9.14 months. After adjusting for age, gender, and duration of treatment, a 89% reduction was recorded in annual hospitalization rates (from 27.13% before treatment to 3.01% after FP/SA therapy, p < 0.001), a 71% reduction in incidence of exercise-induced asthma (36.8% vs. after 10.6%, p < 0.001), a 81% reduction in nocturnal asthma (33.7% vs. after: 6.4%, p < 0.001), as well as in frequency of wheezing (p < 0.01),. No previous treatment carry-on effect was observed. No major drug-related side-effects occurred in the study group. Conclusions: Combination therapy (FP/SA) is well-tolerated and highly effective in asthmatic children under the age of 5 years.     

An educational needs assessment of children with juvenile rheumatoid arthritis

Objective. Our objective is to describe the use of the PRECEDE model (predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation) to organize needs assessment data in order to define self-management behaviors and plan an educational intervention for children with juvenile rheumatoid arthritis (JRA) and their famihies. Methods. Analysis was done of needs assessment data collected from several sources: 1) literature review, 2) survey of parents of 51 children with JRA, 3) group interview of seven parents of children with JRA, 4) results of pilot programs, and 5) clinical experience of an interdisciplinary pediatric rheumatology team. Results. Two sets of interrelated behavioral factors were identified through the needs assessment: 1) those related to managing the school environment to facilitate optimal participation and to minimize schoolrelated disability, and 2) those related to treating pain and stiffness, intervening in the disease process, and preserving joint function. Conclusion. Both of these sets of behavioral factors may be related to the optimization of children's mobility, joint function, and autonomy of activities of daily living and should be targets of an educational intervention.     

Social, emotional, and behavioral functioning of children with juvenile rheumatoid arthritis

OBJECTIVE: To investigate the hypothesis that children with juvenile rheumatoid arthritis (JRA) would have more social and emotional problems than case-control classmates. METHODS: Using a case-control design, children with JRA (n = 74), ages 8-14, were compared with case-control classmates (n = 74). Peer relationships, emotional well-being, and behavior, based on peer-, teacher-, parent-, and self-report scores on common measures, were compared using analysis of variance. RESULTS: Relative to case-control classmates, children with JRA were similar on all measures of social functioning and behavior. Mothers reported more internalizing symptoms in the child with JRA, but child self reports and father reports showed no differences. Scores on all standardized measures were in the normal range for both the JRA and the case-control groups. CONCLUSION: Children with JRA were remarkably similar to case-control children on measures of social functioning, emotional well-being, and behavior. These findings are not supportive of disability/stress models of chronic illness in childhood and suggest considerable psychological hardiness among children with JRA.     

A family retreat as a comprehensive intervention for children with arthritis and their families

Objective . Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment. Methods . Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child. Results . Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed. Conclusions . Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.     

Psychological disorders in patients with evacuation disorders and constipation in a tertiary practice

OBJECTIVE: We aimed to evaluate the prevalence of psychological impairment in patients with rectal evacuation disorders and the influence of psychological disorder on the early outcome of behavioral treatment. METHODS: We retrospectively reviewed the medical records of patients with rectal evacuation disorders referred for biofeedback retraining at a tertiary referral center. The psychological disorder was classified using the DSM IV criteria. Outcome of biofeedback treatment of evacuation at 2 wk was based on symptoms or on the ability to spontaneously expel a balloon placed in the rectum. Improvements in the groups without versus with a psychological disorder or an eating disorder were compared by Fisher's exact test. RESULTS: In the 60 patients (55 women; 5 men; mean age, 38 yr), psychological disorders were identified in 39 (65%); also noted were eating disorder (n = 5), rumination syndrome (n = 3), pain disorder (n = 6), anxiety-depression (n = 10), a combination of depression and pain disorder (n = 3), and a combination of eating disorder with anxiety-depression and pain disorder (n = 12). There was an association between psychological status and outcome at 2 wk of behavioral treatment for evacuation disorder (p = 0.03). The coexistence of eating disorder and psychological disorder resulted in an unfavorable outcome (p = 0.02), compared with those without psychological disorder. CONCLUSION: Psychological impairment was identified in 65% of the patients with evacuation disorder and constipation in a tertiary care practice, and has a significant negative impact on the outcome of behavioral treatment. These data reinforce the importance of a multidisciplinary approach in the management of these patients.     

Children's Attitudes to Alcohol and Awareness of Alcohol-Related Problems*

An interview study of 8–9-year-old New Zealand children and their mothers revealed considerable consistency in reports of the children's experience with alcohol. The majority had tried alcohol and a quarter had at least a sip or drink in a typical month. The context of use was a parental one for the majority of children. Two-thirds of their fathers and 40% of their mothers had at least one drink in a typical week and there was a small positive relationship between parents' use and the frequency of the child's alcohol use. The children's attitudes towards alcohol were assessed using the Jahoda Judgement of Photographs Task and despite their personal use of alcohol the majority of children demonstrated negative attitudes to alcohol. This was particularly marked among the half of the children who were aware of an alcohol-related problem in their immediate social environment. Among the other half of the children, unaware of any alcohol-related problems, there was a tendency for the children of parents who drank more to have more positive attitudes.     

Differences in the profiles of circulating levels of soluble tumor necrosis factor receptors and interleukin 1 receptor antagonist reflect the heterogeneity of the subgroups of juvenile rheumatoid arthritis

OBJECTIVE: To determine whether levels of soluble tumor necrosis factor receptor 55 (sTNFR55), sTNFR75, and interleukin 1 receptor antagonist (IL-1Ra) can differentiate different subtypes of juvenile rheumatoid arthritis (JRA), and to determine if the levels of these proteins correlate with disease activity. METHODS: Serum sTNFR (55 and 75) and IL-1Ra levels were measured by ELISA in 34 patients with JRA and these values were correlated with disease subtype and activity. RESULTS: Serum sTNFR55 levels were significantly elevated in patients with systemic onset JRA (SoJRA) (mean +/- 2 SD, 2.9 +/- 1.8 ng/ml) (p < or = 0.05) compared to rheumatoid factor positive (RF+) polyarticular JRA (2.1 +/- 0.6), RF-polyarticular JRA (1.5 +/- 0.6), and pauciarticular JRA (1.4 +/- 0.4). There was a trend for elevation of sTNFR75 levels in patients with SoJRA compared to other subtypes (p = 0.08). More patients had elevated levels of sTNFR75 than sTNFR55 (15 vs 7). This was true for all subsets (SoJRA 7 vs 5; polyarticular JRA 4 vs 2; and pauciarticular JRA 4 vs 0). In contrast to sTNFR, IL-1Ra levels were significantly elevated in RF+ polyarticular JRA compared to the other subgroups (p < or = 0.001). We found statistically significant Pearson correlations between (1) sTNFR75 and hemoglobin concentration: and (2) IL-1Ra and number of active joints and number of joints with effusions. CONCLUSION: The increased serum level of sTNF receptors in SoJRA suggests that TNF is likely more important than IL-1 in systemic inflammation and in particular in SoJRA. Conversely, IL-1 is likely more important in the inflammatory arthritis of JRA and in particular in the pathogenesis of RF+ polyarticular JRA. Our results suggest that cytokines have differing roles in JRA subtypes and likely reflect JRA subtype heterogeneity.     

New-onset juvenile dermatomyositis. Comparisons with a healthy cohort and children with juvenile rheumatoid arthritis

Objective. To determine, in a case-control study, if patients with new-onset juvenile dermatomyositis (juvenile DM) have increased symptoms prior to onset, exposure to certain environmental conditions, frequency of familial autoimmune diseases, or antibody titers, compared with 2 control groups. Methods. A structured interview with the families of 80 children with juvenile DM, 40 children with juvenile rheumatoid arthritis (JRA), or 23 healthy children, from the same geographic area as the children with juvenile DM, was conducted. All children's sera were tested for antibody to Toxoplasma gondii, herpes simplex virus (HSV), or coxsackievirus B (CVB). Results. A high proportion of children with juvenile DM had constitutional symptoms 3 months before the disease-onset date (P = 0.013 versus control children). Children with JRA had more relatives with rheumatoid arthritis (P = 0.0001) and pernicious anemia (P = 0.003) than did children with juvenile DM or healthy children. Among children ⩽7 years of age, elevated enteroviral titers were more frequent in those with juvenile DM (81%) and in healthy controls (90%) than in those with JRA (64%), suggesting a common environmental exposure. Titers to T gondii, HSV, or CVB 1-6 were normal. Conclusion. Frequencies of familial autoimmune disease, exposure to environmental factors, or elevated antibody titers to T gondii, HSV, or CVB are not increased in juvenile DM. Children with juvenile DM do have symptoms of illness 3 months before the disease-onset date, and young patients have elevated enteroviral titers, as do young geographic controls.     

Ultrasonography of the hip in the evaluation of children with seronegative juvenile rheumatoid arthritis

OBJECTIVE: To find an objective measure of hip joint effusion with ultrasound (US) in patients with juvenile rheumatoid arthritis (JRA). METHODS: The hip joints of 24 children with JRA were evaluated with US. All patients were negative for rheumatoid factor and antinuclear antibodies. Patients with unilateral or bilateral hip pain, swelling, or limitation of range of motion were included. In each hip, the distance from the femoral neck to joint capsule was measured. Values were compared to measurements in a control group of 24 children with no history of hip joint or rheumatic disease. Statistically significant differences between the 2 groups were analyzed by t test. Two standard deviations above the control group mean was used as the standard for an effusion. RESULTS: There was a statistically significant difference in US joint space between the children with JRA and the control subjects (p < 0.001). The mean in the control group was 0.43 cm and the mean in the JRA group was 0.60 cm. A distance of 0.59 cm from femoral neck to joint capsule was determined to be consistent with an effusion. Using this standard, 71% of the children with JRA had effusion in at least one hip, and 25% had effusion bilaterally. No control subjects had measurements above this level. CONCLUSION: Ultrasonography is effective in the evaluation of hip joint involvement in patients with JRA, and may be useful in facilitating the diagnosis, classification, and followup of this illness.     

Effects of compression bandaging with or without manual lymph drainage treatment in patients with postoperative arm lymphedema.

We examined the effects of low stretch compression bandaging (CB) alone or in combination with manual lymph drainage (MLD) in 38 female patients with arm lymphedema after treatment for breast cancer. After CB therapy for 2 weeks (Part I), the patients were allocated to either CB or CB + MLD for 1 week (Part II). Arm volume and subjective assessments of pain, heaviness and tension were measured. The mean lymphedema volume reduction for the total group during Part I was 188 ml (p < 0.001), a mean reduction of 26% (p < 0.001). During Part II the volume reduction in the CB + MLD group was 47 ml (p < 0.001) and in CB group 20 ml. These differences were not significant (p = 0.07). A percentage reduction of 11% (p < 0.001) in the CB + MLD group and 4% in the CB group was significantly different (p = 0.04). In both the CB and the CB + MLD group, a decrease of feeling of heaviness (p < 0.006 and p < 0.001, respectively) and tension (p < 0.001 for both) in the arm was found, but only the CB + MLD group showed decreased pain (p < 0.03). Low stretch compression bandaging is an effective treatment giving volume reduction of slight or moderate arm lymphedema in women treated for breast cancer. Manual lymph drainage adds a positive effect.