Ana Paola N. Lotito

Juvenile rheumatoid arthritis of the knee: evaluation with contrast-enhanced color Doppler ultrasound

Abstract.Background. Contrast-enhanced color Doppler ultrasonography is a non-radiation-bearing tool that can be of value for assessment of inflammatory and vascular synovial changes in juvenile rheumatoid arthritis (JRA). Objectives. To evaluate the effect of contrast-enhanced color Doppler ultrasound (US) in the evaluation of synovial changes in the knees of children with JRA. Materials and methods. Sagittal color Doppler sonograms of 31 knees in 22 patients with JRA and of 10 knees in 5 control subjects were obtained before (at baseline) and after (at peak contrast phase) intravenous injection of SHU 508. Images were assessed for overall mean pixel intensity within the synovial tissue and for peak enhancement ratios {[(mean pixel intensity values at maximum contrast enhancement–unenhanced mean pixel intensity values)/unenhanced mean pixel intensity values] × 100}. The joints were classified into three groups by clinical/laboratory criteria: group A (active disease in the knee), n = 9; group B (quiescent disease with serum chemistry levels of active disease), n = 12 and group C (remission disease), n = 10. Results. Mean color pixel intensity values were markedly increased by the use of US contrast agents in groups A (P = 0.004) and B (P = 0.0001), did not reach statistical significance in group C (P = 0.06) and remained essentially unchanged in the control group (P = 0.25). Enhancement ratios for the three groups of JRA patients were not different (P = 0.38) (mean ± SD, 720 % ± 402 for group A, 731 % ± 703 for group B and 314 % ± 263 for group C). Conclusion. Contrast-enhanced color Doppler imaging holds promise for the detection of active synovial inflammatory disease in subclinical cases of JRA, thereby allowing earlier treatment and improved clinical outcome.

Macrophage activation syndrome associated with systemic juvenile idiopathic arthritis

OBJECTIVE To describe the characteristics of macrophage activation syndrome associated with juvenile idiopathic arthritis. DESCRIPTION This is a retrospective study involving 462 patients with juvenile idiopathic arthritis. Seven (1.5%) of those patients suffered from systemic onset juvenile idiopathic arthritis and developed macrophage activation syndrome. The median age of the juvenile idiopathic arthritis onset was 3 years and 10 months and the median duration of juvenile idiopathic arthritis before macrophage activation syndrome was 8 years and 4 months. All of them presented with fever, jaundice, hepatosplenomegaly, bleeding, pancytopenia, abnormal liver function tests and abnormal coagulation profile. Three cases presented associated infections and one patient developed macrophage activation syndrome two weeks after the administration of sulfasalazine. Three patients died and the macrophage hemophagocytosis was present in five. The treatment of macrophage activation syndrome included pulse therapy with methylprednisolone in all of them, cyclosporine A in three, plasma exchange in two and intravenous immunoglobulin in two. COMMENTS Macrophage activation syndrome is a complication of the systemic onset juvenile idiopathic arthritis with a high morbidity and mortality rate.

Prática de vacinação em crianças com doenças reumáticas

INTRODUCAO/OBJETIVOS: Avaliar a pratica clinica com relacao a verificacao do cartao vacinal e a indicacao de vacinas especificas em pacientes com doencas reumaticas pediatricas em uso de diferentes drogas, e evidenciar a possivel associacao entre frequencia de vacinacao e tempo de pratica clinica dos reumatologistas pediatricos do estado de Sao Paulo. MATERIAL E METODOS: Um questionario foi enviado para os reumatologistas pediatricos do Departamento de Reumatologia da Sociedade de Pediatra de Sao Paulo. Esse instrumento incluiu questoes sobre tempo de pratica em Reumatologia Pediatrica, vacinacao de pacientes com Lupus Eritematoso Sistemico Juvenil (LESJ), artrite idiopatica juvenil (AIJ), dermatomiosite juvenil (DMJ) e imunizacao de acordo com os tratamentos utilizados. RESULTADOS: Cartao de vacinacao foi visto por 100% dos profissionais na primeira consulta e por 36% anualmente. Vacinas de agentes vivos nao foram recomendadas para pacientes com LESJ, AIJ e DMJ em 44%, 64% e 48%, respectivamente. Os profissionais foram divididos em dois grupos: A ( 16 anos, n = 13). Nenhuma diferenca estatistica foi observada no uso de vacinas de agentes vivos e vacinas de agentes inativos ou componentes proteicos em relacao ao tratamento nos dois grupos (P > 0,05). Alem disso, os grupos foram similares em relacao a opiniao sobre a gravidade de imunossupressao em pacientes com LESJ, AIJ e DMJ com ou sem atividade e a terapeutica utilizada (P > 0,05). CONCLUSOES: A frequencia de vacinacao por reumatologistas pediatricos de Sao Paulo e baixa, especialmente apos a primeira consulta, e nao e influenciada pelo tempo de pratica profissional.

Consenso de imunização para crianças e adolescentes com doenças reumatológicas

Criancas e adolescentes com doencas reumatologicas apresentam maior prevalencia de doencas infecciosas quando comparados com a populacao em geral, em decorrencia de atividade da doenca, possivel deficiencia imunologica secundaria a propria doenca, ou uso de terapia imunossupressora. A vacinacao e uma medida eficaz para a reducao da morbidade e mortalidade nesses pacientes. O objetivo deste artigo foi realizar um consenso de eficacia e seguranca das vacinas em criancas e adolescentes com doencas reumatologicas infantis baseadas em niveis de evidencia cientifica. Imunizacao passiva para os pacientes e orientacoes para as pessoas que convivem com doentes imunodeprimidos tambem foram incluidas. Os 32 pediatras reumatologistas membros do Departamento de Reumatologia da Sociedade de Pediatria de Sao Paulo (SPSP) e/ou da Comissao de Reumatologia Pediatrica da Sociedade Brasileira de Reumatologia elaboraram o consenso, sendo que alguns desses profissionais estao envolvidos em pesquisas e publicacoes cientificas nesta area. A pesquisa dos termos eficacia e/ou seguranca das diferentes vacinas em criancas e adolescentes com doencas reumatologicas foi realizada nas bases de Medline e Scielo, de 1966 ate marco de 2009, incluindo revisoes, estudos controlados e relatos de casos. O grau de recomendacao e o nivel cientifico de evidencias dos estudos foram classificados em quatro niveis para cada vacina. De um modo geral, as vacinas inativadas e de componentes sao seguras nos pacientes com doencas reumatologicas, mesmo em uso de terapias imunossupressoras. Entretanto, vacinas com agentes vivos atenuados sao, em geral, contraindicadas para os pacientes imunossuprimidos.Incidence of infectious diseases is higher in children and adolescents with rheumatic diseases than in the general population due to disease activity, possible immune deficiency secondary to the disease itself, or the use of immunosuppressive drugs. Vaccination is effective in reducing morbidity and mortality in those patients. The objective of this study was to establish an evidence-based consensus on the efficacy and safety of vaccination in children and adolescents with rheumatic diseases. Passive immunization of patients and guidelines for people who live with immunosuppressed patients were also included. The 32 pediatric rheumatologists of the Rheumatology Department of the Pediatrics Society of Sao Paulo, (SPSP, from the Portuguese), Sao Paulo, SP, Brazil, and/or the Commission on Pediatrics Rheumatology of the Brazilian Society of Rheumatology are responsible for this consensus; some of those professionals are involved on research and scientific publications in this field. The words efficacy and/or safety of different vaccines in children and adolescents with rheumatologic diseases were searched in Medline and Scielo data bases from 1966 to March 2009, including reviews, controlled studies, and case reports. The degree of recommendation and the scientific evidence of the studies were classified in four levels for each vaccine. As a rule, inactive and protein components vaccines are safe for patients with rheumatologic diseases, even in the presence of immunosuppressive therapy. However, live attenuated vaccines are, in general, contraindicated for immunosuppressed patients.

Acupuntura em adolescentes com fibromialgia juvenil

Objective: To describe the use of acupuncture in the treatment of adolescents with juvenile fibromyalgia. Methods: Retrospective study of patients with juvenile fibromyalgia (American College of Rheumatology criteria) submitted at least to 11 weekly sections of acupuncture. The evaluations before and after acupuncture included: demographic data, musculoskeletal pain findings, pain visual analog scale (VAS), algometry, and myalgic index (MI). These patients could be treated with analgesics, amitriptyline and aerobic physical activity. The results before and after acupuncture were compared by non-parametric Wilcoxon test. Results: 38 patients had juvenile fibromyalgia in eight consecutive years, 13 had all information in their medical and acupuncture records. Seven of the 13 patients improved in three parameters (number of tender points, pain VAS and MI). The median number of tender points and VAS was significantly higher before than after treatment with acupuncture sections [14 (11-18) vs. 10 (0-15), p=0.005; 6 (2-10) vs. 3 (0-10), p=0.045; respectively]. In contrast, the median MI was significantly lower before treatment [3.4 (2.49-4.39) vs. 4.2 (2.71-5.99), p=0.02]. None of the patients with juvenile fibromyalgia had adverse events as sociated with acupuncture. Conclusions: Acupuncture is a traditional chinese medicine modality that can be used in pediatric patients with fibromyalgia. Future controlled studies are necessary.

Correlation between osteochondral changes depicted by magnetic resonance imaging and disease progression

PURPOSE To determine the consequences of the chronic use of systemic corticosteroids in children with juvenile rheumatoid arthritis by means of evaluating osteochondral effects depicted by magnetic resonance imaging. PATIENTS AND METHODS We reviewed clinical and magnetic resonance imaging findings in 69 children (72 knees) with juvenile rheumatoid arthritis. Two groups were studied. Group I: 34 (49.3%) children had previous or current use of systemic corticotherapy (22 girls; 12 boys; mean age: 11.3 years; mean disease duration: 5.9 years; mean corticotherapy duration: 2.9 years; mean cumulative dose of previous corticosteroids: 5000 mg); Group II: 35 (50.7%) children had no previous use of corticosteroids (27 girls; 8 boys; mean age: 11.7 years; mean disease duration: 5.3 years). The groups were compared statistically. RESULTS In the group that had received corticotherapy (Group I), osteochondral abnormalities were significantly correlated to long-standing disease (>3.5 years; p<0.001). This correlation was not found in the group that had no previous history of corticotherapy (Group II). No correlations were established between median dose of corticosteroids and magnetic resonance imaging findings. CONCLUSION It is important to further investigate the long-term intra-articular effects of systemic corticotherapy to ensure that the side effects of the aggressive therapy will not be more harmful for the joints than the symptoms suffered over the natural course of the disease.

Acupuncture in adolescents with juvenile fibromyalgia

Objective: To describe the use of acupuncture in the treatment of adolescents with juvenile fibromyalgia. Methods: Retrospective study of patients with juvenile fibromyalgia (American College of Rheumatology criteria) submitted at least to 11 weekly sections of acupuncture. The evaluations before and after acupuncture included: demographic data, musculoskeletal pain findings, pain visual analog scale (VAS), algometry, and myalgic index (MI). These patients could be treated with analgesics, amitriptyline and aerobic physical activity. The results before and after acupuncture were compared by non-parametric Wilcoxon test. Results: 38 patients had juvenile fibromyalgia in eight consecutive years, 13 had all information in their medical and acupuncture records. Seven of the 13 patients improved in three parameters (number of tender points, pain VAS and MI). The median number of tender points and VAS was significantly higher before than after treatment with acupuncture sections [14 (11-18) vs. 10 (0-15), p=0.005; 6 (2-10) vs. 3 (0-10), p=0.045; respectively]. In contrast, the median MI was significantly lower before treatment [3.4 (2.49-4.39) vs. 4.2 (2.71-5.99), p=0.02]. None of the patients with juvenile fibromyalgia had adverse events as sociated with acupuncture. Conclusions: Acupuncture is a traditional chinese medicine modality that can be used in pediatric patients with fibromyalgia. Future controlled studies are necessary.

Acupuntura en adolescentes con fibromialgia juvenil

Objective: To describe the use of acupuncture in the treatment of adolescents with juvenile fibromyalgia. Methods: Retrospective study of patients with juvenile fibromyalgia (American College of Rheumatology criteria) submitted at least to 11 weekly sections of acupuncture. The evaluations before and after acupuncture included: demographic data, musculoskeletal pain findings, pain visual analog scale (VAS), algometry, and myalgic index (MI). These patients could be treated with analgesics, amitriptyline and aerobic physical activity. The results before and after acupuncture were compared by non-parametric Wilcoxon test. Results: 38 patients had juvenile fibromyalgia in eight consecutive years, 13 had all information in their medical and acupuncture records. Seven of the 13 patients improved in three parameters (number of tender points, pain VAS and MI). The median number of tender points and VAS was significantly higher before than after treatment with acupuncture sections [14 (11-18) vs. 10 (0-15), p=0.005; 6 (2-10) vs. 3 (0-10), p=0.045; respectively]. In contrast, the median MI was significantly lower before treatment [3.4 (2.49-4.39) vs. 4.2 (2.71-5.99), p=0.02]. None of the patients with juvenile fibromyalgia had adverse events as sociated with acupuncture. Conclusions: Acupuncture is a traditional chinese medicine modality that can be used in pediatric patients with fibromyalgia. Future controlled studies are necessary.