Systematic review and network meta-analysis of different nonsteroidal anti-inflammatory drugs for juvenile idiopathic arthritis

BACKGROUND Various non-steroidal anti-inflammatory drugs(NSAIDs)have been used for juvenile idiopathic arthritis(JIA).However,the optimal method for JIA has not yet been developed.AIM To perform a systematic review and network meta-analysis to determine the optimal instructions.METHODS We searched for randomized controlled trials(RCTs)from PubMed,EMBASE,Google Scholar,CNKI,and Wanfang without restriction for publication date or language at August,2023.Any RCTs that comparing the effectiveness of NSAIDs with each other or placebo for JIA were included in this network meta-analysis.The surface under the cumulative ranking curve(SUCRA)analysis was used to rank the treatments.P value less than 0.05 was identified as statistically significant.RESULTS We included 8 RCTs(1127 patients)comparing 8 different instructions including meloxicam(0.125 qd and 0.250 qd),Celecoxib(3 mg/kg bid and 6 mg/kg bid),piroxicam,Naproxen(5.0 mg/kg/d,7.5 mg/kg/d and 12.5 mg/kg/d),inuprofen(30-40 mg/kg/d),Aspirin(60-80 mg/kg/d,75 mg/kg/d,and 55 mg/kg/d),Tolmetin(15 mg/kg/d),Rofecoxib,and placebo.There were no significant differences between any two NSAIDs regarding ACR Pedi 30 response.The SUCRA shows that celecoxib(6 mg/kg bid)ranked first(SUCRA,88.9%),rofecoxib ranked second(SUCRA,68.1%),Celecoxib(3 mg/kg bid)ranked third(SUCRA,51.0%).There were no significant differences between any two NSAIDs regarding adverse events.The SUCRA shows that placebo ranked first(SUCRA,88.2%),piroxicam ranked second(SUCRA,60.5%),rofecoxib(0.6 mg/kg qd)ranked third(SUCRA,56.1%),meloxicam(0.125 mg/kg qd)ranked fourth(SUCRA,56.1%),and rofecoxib(0.3 mg/kg qd)ranked fifth(SUCRA,56.1%).CONCLUSION In summary,celecoxib(6 mg/kg bid)was found to be the most effective NSAID for treating JIA.Rofecoxib,piroxicam,and meloxicam may be safer options,but further research is needed to confirm these findings in larger trials with higher quality studies.

Serum Zinc and Copper Level in Juvenile Idiopathic Arthritis (JIA) Patients and Its Correlation with Disease Duration-A Tertiary Hospital Study

Background: Juvenile Idiopathic Arthritis (JIA) is the most prevalent rheumatic disease in children. It is associated with abnormal levels of serum zinc (Zn) and copper (Cu) as during inflammation serum copper concentration increases and zinc decreases. Objective: To assess the serum Zn and Cu levels in different sub-types of JIA patients and their correlation with the disease duration. Methods: This cross-sectional study was conducted over twelve months at the Pediatric Rheumatology Division, Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University. Sixty-nine JIA cases that fulfilled the International League of Association for Rheumatology (ILAR) criteria were taken as cases and age and sex-matched healthy children were considered as controls. The serum Zn and Cu tests were done using the spectrophotometric method with INDIKO PLUS Drug Analyzer. Data were recorded in a pre-designed questionnaire. Data were checked, verified and analyzed manually where continuous variables were analyzed using unpaired t-test and categorical variables using the ANOVA test. Pearson’s correlation coefficient test was used to see the correlation of serum zinc and copper levels with disease duration. Results: Boys were predominant in both case and control groups, with the majority within the 10 to 16-year-age group. Enthesitis-related arthritis (ERA) was the most common subtype followed by sJIA, Oligo JIA, Poly JIA (RF-) and unclassified subtypes. Disease duration was found less than 12 months in 30.4% of JIA patients. Serum analysis revealed a statistically significant reduction in mean zinc levels and increased copper levels in JIA patients compared to controls. This study observed a negative correlation between serum zinc levels and disease duration, whereas serum copper levels exhibited a positive correlation with disease duration. Conclusion: In conclusion, this study revealed that JIA patients exhibit alterations in serum zinc and copper levels. Serum copper levels showed a positive correlation and serum zinc levels showed a negative correlation with the duration of the disease.

Thalidomide Is an Adjunct Therapy for the Refractory Systemic Juvenile Idiopathic Arthritis Patients in a Tertiary Hospital Study

Background: Systemic JIA (sJIA) is one of the subtypes of JIA, which is most difficult to treat among all JIA cases. About 50% of sJIA cases did not respond to traditional disease modifying anti-rheumatic drugs (DMARDs)—metho-trexate (MTX). Thalidomide is an immunomodulating and anti-inflammatory drug that induces sustained improvement of refractory sJIA cases. Objectives: To evaluate the efficacy of thalidomide in refractory sJIA patients. Methods: This was a prospective interventional study carried out in the Paediatric Rheumatology and Immunology follow-up clinic run by the Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from January 2019 to July 2020. Twenty-five sJIA patients who were refractory to conventional DMARDs were included in this study. These patients were prescribed thalidomide at a dose of 3 - 5 mg/kg/day for six months and efficacy was assessed by using juvenile arthritis disease activity score (JADAS 27) at 12th and 24th weeks of treatment. Result: Active joint counts and ESR improvement were observed in 90.69%, 97.67% and 69.84%, 100% of sJIA patients respectively at 12th and 24th weeks of treatment. Improvement of physicians and parent global assessment of VAS were 77.56%, 97.43% and 70.62% and 96.04% respectively at 12th and 24th weeks of treatment. Improvement of the total score of JADAS-27 was 77.51% at 12th week and 97.52% at 24th of week follow-up which was statistically significant. Somnolence, constipation and paresthesia were found as common adverse effect in this study. Conclusion: Efficacy of thalidomide was assessed by JADAS 27 criteria showed significant improvement in refractory sJIA patients in this study. It may be concluded that Thalidomide is safe and effective as an adjunct therapy of refractory sJIA patients.

Vaccination coverage in children with juvenile idiopathic arthritis,inflammatory bowel diseases,and healthy peers:Cross-sectional electronic survey data

BACKGROUND Patients with immune-mediated diseases,such as juvenile idiopathic arthritis(JIA)and inflammatory bowel disease(IBD)are at increased risk of developing infections,due to disease-related immune dysfunction and applying of immunosuppressive drugs.AIM To evaluate vaccine coverage in patients with IBD and JIA,and compare it with healthy children.METHODS In the cross-sectional study we included the data from a questionnaire survey of 190 Legal representatives of children with JIA(n=81),IBD(n=51),and healthy children(HC,n=58).An electronic online questionnaire was created for the survey.RESULTS There were female predominance in JIA patients and younger onset age.Parents of JIA had higher education levels.Employment level and family status were similar in the three studied groups.Patients with JIA and IBD had lower vaccine coverage,without parental rejection of vaccinations in IBD,compare to JIA and healthy controls.The main reason for incomplete vaccination was medical conditions in IBD and JIA.IBD patients had a lower rate of normal vaccine-associated reactions compared to JIA and HC.The encouraging role of physicians for vaccinations was the lowest in JIA patients.IBD patients had more possibilities to check antibodies before immune-suppressive therapy and had more supplementary vaccinations compared to JIA and HC.CONCLUSION JIA and IBD patients had lower vaccine coverage compared to HC.Physicians'encouragement of vaccination and the impossibility of discus about future vaccinations and their outcomes seemed the main factors for patients with immune-mediated diseases,influencing vaccine coverage.Further investigations are required to understand the reasons for incomplete vaccinations and improve vaccine coverage in both groups,especially in rheumatic disease patients.The approaches that stimulate vaccination in healthy children are not always optimal in children with immunemediated diseases.It is necessary to provide personalized vaccine-encouraging strategies for parents of chronically ill children with the following validation of these technics.

Current Review of Systemic Juvenile Idiopathic Arthritis: What Do Paediatricians Need to Know?

Systemic juvenile idiopathic arthritis is classified as an autoimmune entity and a subtype of juvenile idiopathic arthritis, although it has many features of autoinflammatory-type of diseases. This review article will elaborate on the disease’s pathogenesis and its proposed relation to autoinflammatory diseases including defective innate immunity and phagocytosis response leading excessive cytokine release. It also explains the disease’s epidemiology, clinical phenotype, diagnostic challenges, complications and current advancements in the treatment of systemic juvenile idiopathic arthritis, such as IL-1 and IL-6 antagonists and their impact on the disease trajectory. Care of patients with systemic juvenile idiopathic arthritis requires a comprehensive multidisciplinary team to optimize the care and avoid complications of the disease itself such as growth impairment, macrophage activation syndrome or the complications of immunosuppressant and immunomodulatory treatments.

A 10-Year Saudi Experience of Using Adalimumab in Treating Juvenile Idiopathic Arthritis

Background: Traditionally, management of Juvenile Idiopathic Arthritis (JIA) involves use of non-steroidal anti-inflammatory drugs (NSAIDS) or disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate (MTX) or sulfasalazine;or steroids. However, in several cases, a low therapeutic response or important side effects is encountered. This study reports our experience in using adalimumab in JIA patients by assessing the efficacy and safety of this treatment in this category of patients. Methods: A retrospective study was conducted among 38 patients with JIA at the Pediatric Department, King Abdulaziz Univesrity Hospital, Jeddah, Saudi Arabia, in the period January 2005-March 2016. Patients’ records were reviewed and relevant demographic and clinical data were collected. Data were analyzed using SPSS version 21 and represented using tables. Results: The 38 patients were distributed as 11 (28.9%) males and 27 (71.1%) females;mean ± SD age was 11.91 ± 4.54 (range = 3 - 19) years. Mean ± SD (range) disease duration was 3.26 ± 2.52 (0 - 12) years and most frequent diagnoses included polyarticular rheumatoid factor (RF) negative form 12 (31.6%), followed by systemic and oligoarticular JIA with 9 (23.7%) cases each. Before adalimumab, fever was present in 13 (34.2%) cases, followed by rash in 8 (21.0%) cases;while 21 (55.3%) were asymptomatic. Thirty-one (81.6%) were in failure of MTX, 19 (50%) of steroids, 7 (18.4%) of NSAIDS and 3 (7.9%) had had intraarticular injections. Biologically, ANA, RF and anti-CCP were positive in 22 (57.9%), 8 (21.1%) and 4 (10.5%) of the cases, respectively. Uveitis was present in 11 (28.9%) of the patients. Analysis of adalimumab efficacy showed 10 (52.6%) cases of complete remission, 9 (23.7%) of partial remission and 9 (23.7%) other where treatment was discontinued. Major adverse effects included local pain (4 [10.5%]), new onset uveitis (1 [2.6%]) and rash (1 [2.6%]), responsible of 1case of treatment discontinuation. Predictors for complete remission on adalimumab were oligoarticular form (β = 3.450, p = 0.009) and negative RF (β = 2.381, p = 0.036);while predictors for nonresponse, whether complete or partial, were polyarticular form (β = ?3.784, p = 0.005) and positive anti-CCP (β = ?3.178, p = 0.021). Conclusion: Adalimumab is an efficient and relatively safe alternative in the treatment of JIA with relatively high remission rates and lower rates of adverse effects. Further multicentre experiences are warranted to prove its efficacy and safety in the Saudi patients.

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 2decades, 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.

Operative stabilization of the remaining mobile segment in ankylosed cervical spine in systemic onset- juvenile idiopathic arthritis:A case report

We describe a case of a 19-year-old young man with oligoarthritis type of juvenile idiopathic arthritis, who presented with several month duration of lower neck pain and progressive muscular weakness of all four limbs. X-rays of the cervical spine demonstrated spontaneous apophyseal joint fusion from the occipital condyle to C6 and from C7 to Th2 with marked instability between C6 and C7. Surgical intervention began with anterolateral approach to the cervical spine performing decompression, insertion of cage and anterior vertebral plate and screws, followed by posterior approach and fixation. Care was taken to restore sagittal balance. The condition was successfully operatively managed with multisegmental, both column fixation and fusion, resulting in pain cessation and resolution of myelopathy. Postoperatively, minor swallowing difficulties were noted, which ceased after three days. Patient was able to move around in a wheelchair on the sixth postoperative day. Stiff neck collar was advised for three months postoperatively with neck pain slowly decreasing in the course of first postoperative month.On the follow-up visit six months after the surgery patient exhibited no signs of spastic tetraparesis, X-rays of the cervical spine revealed solid bony fusion at single mobile segment C6-C7. He was able to gaze horizontally while sitting in a wheelchair. Signs of myelopathy with stiff neck and single movable segment raised concerns about intubation, but were successfully managed using awake fiber-optic intubation. Avoidance of tracheostomy enabled us to perform an anterolateral approach without increasing the risk of wound infection. Regarding surgical procedure, the same principles are obeyed as in management of fracture in ankylosing spondylitis or Mb. Forestrier.

Characterization of microbiota in systemic-onset juvenile idiopathic arthritis with different disease severities

BACKGROUND Systemic-onset juvenile idiopathic arthritis (SoJIA) is one of most serious subtypes of juvenile idiopathic arthritis. Although the pathogenesis of SoJIA remains unclear, several studies have suggested a correlation between gut dysbiosis and JIA. Further understanding of the intestinal microbiome may help to establish alternative ways to treat, or even prevent, the disease. AIM To explore alterations in fecal microbiota profiles in SoJIA patients and to evaluate the correlations between microbiota and clinical parameters. METHODS We conducted an observational single-center study at the Pediatric Department of Peking Union Medical College Hospital. Children who were diagnosed with SoJIA at our institution and followed for a minimum period of six months after diagnosis were recruited for the study. Healthy children were recruited as a control group (HS group) during the same period. Clinical data and stool samples were collected from SoJIA patients when they visited the hospital. RESULTS The SoJIA group included 17 active and 15 inactive consecutively recruited children;the control group consisted of 32 children. Firmicutes and Bacteroidetes were the two most abundant phyla among the total sample of SoJIA children and controls. There was a significant difference among the three groups in observed species, which was the highest in the Active-SoJIA group, followed by the Inactive-SoJIA group and then HS group (Active-SoJIA vs HS: P = 0.000;and Inactive-SoJIA vs HS: P = 0.005). We observed a lower Firmicutes/Bacteroidetes ratio in SoJIA patients (3.28 ± 4.47 in Active-SoJIA, 5.36 ± 8.39 in Inactive-SoJIA,and 5.67 ± 3.92 in HS). We also observed decreased abundances of Ruminococcaceae (14.9% in Active-SoJIA, 17.3% in Inactive-SoJIA, and 22.8% in HS;Active-SoJIA vs HS: P = 0.005) and Faecalibacterium (5.1% in Active-SoJIA, 9.9% in Inactive-SoJIA, and 13.0% in HS;Active-SoJIA vs HS: P = 0.000) in SoJIA compared with HS. By contrast, the abundance of Bacteroidaceae was the highest in the Active-SoJIA group, followed by the Inactive-SoJIA and HS groups (16.5% in Active-SoJIA, 12.8% in Inactive-SoJIA, and 9.7% in HS;Active-SoJIA vs HS: P = 0.03). The Spearman correlation analysis revealed a negative correlation between Proteobacteria or Enterobacteriaceae and juvenile arthritis disease activity score on 27 joints (JADAS-27). CONCLUSION The composition of the intestinal microbiota is different in SoJIA patients compared with healthy children. The dysbiosis presents partial restoration in inactive status patients.

Systemic Form of Juvenile Idiopathic Arthritis: Epidemiological, Clinical, Paraclinical and Therapeutic Aspects of 13 Cases in Abidjan

Objective: To describe the epidemiological, clinical, paraclinical and therapeutic aspects of systemic juvenile idiopathic arthritis observed in Abidjan. Materials and Method: This retrospective and descriptive study covered 13 children suffering from systemic juvenile idiopathic arthritis selected in the Rheumatology Department of University Hospital Center of Cocody in Abidjan (Cote d’Ivoire) from January 2005 to December 2015. We were interested to the sociodemographical, clinical, paraclinical and therapeutic aspects. Results: The systemic form of the juvenile idiopathic arthritis represented 0.2% of the 4608 rheumatologic diseases and 70.58% of the JIA. We selected 6 boys and 7 girls, with an average age of 10.8 years and mostly going to school (84.61%). The diagnostic delay was 18 months. The main clinical signs were fever and joint damage observed each in 100% of cases, impaired general condition (92.30%) and tumor syndrome (83.33%). Biological signs were characterized by hyperleukocytosis (69.20%) and the presence of a biologic inflammatory syndrome (on average, erythrocyte sedimentation rate 59.6 mm and C Reactive Protein 56.4 mg/l). The cervical damage was the essential functional complication (38.46%). The major treatment has been a therapeutic combination based on corticotherapy and methotrexate (100%) with 1 death case by macrophage activation syndrome. Conclusion: Systemic juvenile idiopathic arthritis is rarely diagnosed in the rheumatologic practice in Abidjan. It concerns children relatively big, and is characterized by a febrile polyarthritis with impaired general condition and tumor syndrome. This systemic form is treated by corticotherapy and methotrexate.

Growth Pattern in Children with Juvenile Idiopathic Arthritis: A Retrospective Study

Aim of this study is to assess growth pattern in children with juvenile idiopathic arthritis (JIA) and factors associated with growth retardation. Methods: A retrospective chart review of all cases of JIA following up at Pediatric Department of King Abdulaziz University Hospital, between July 2000 to July 2016. Demographic, clinical and biological data were collected and analyzed as risk factor for growth retardation. These included age, gender, age at diagnosis, disease duration, type of JIA, the presence of uveitis, rheumatoid factor (RF) positivity, antinuclear antibody (ANA) titer and treatment. Growth pattern was assessed as the percentile for height-for-age, weight-for-age and weight-for-height in reference to the Growth Chart for Saudi Children and Adolescents. Change in percentile rank was divided into 3 categories: regression (a drop of ≥1 percentile);stable (uphold of the same percentile);and progression (change for a superior percentile). Results: A total 78 children were eligible, 52.6% females, mean ± SD age = 9.94 ± 4.92 years, and age at diagnosis = 7.44 ± 4.52 years, mean ± SD [range] disease duration = 2.93 ± 2.70 [6 months;15 years]. The most frequent types of JIA were systemic (33.3%), oligoarticular (30.8%) and polyarticular negative RF (26.9%). Other parameters included positive ANA in 41.0%, positive RF in 7.7% and uveitis in 9.0%. The most frequent treatment was methotrexate (59.0%), followed by biological therapy (47.4%), non-steroid anti-inflammatory drugs (43.6%) and prednisolone (33.3%). Growth data were available for 67 (85.9%) children, and assessments showed 36% cases of break of the growth curve in both height-for-age and weight-for-age percentiles and 31% in weight-for-height percentiles. In all three parameters, there were shifts towards lower percentiles from time of diagnosis to last follow-up, in both males and females. Correlation and regression analysis showed low age at diagnosis and disease duration to be significant predictors for growth retardation severity. Conclusion: One in three children with JIA has growth retardation, the severity of which is predicted by low age at disease onset and long disease duration.

Health-Related Quality of Life of Children and Adolescents with Juvenile Idiopathic Arthritis in Western Saudi Arabia

Objectives: To evaluate the effect of Juvenile Idiopathic Rheumatoid Ar-thritis (JIA) on the health-related quality of life (HRQOL) in Saudi children. Methods: A cross-sectional study was conducted in a tertiary hospital in Jeddah, Saudi Arabia to evaluate the HRQOL of children aged ≤ 18 years who had JIA using the childhood health assessment questionnaire modified for Arab children (CHAQ-MAC). Such questionnaire investigates 34 activities of daily life (ADL) classified into 8 life domains. Children or their parents were invited for face-to-face interview, and a phone interview was done for patients who missed their appointments during the period between February and July 2017. A statistical model was used to calculate a total CHAQ.MAC score (range = 0 - 33;Cronbach’s alpha = 0.966);with higher values indicating poorer HRQOL. Results: Of a total of 44 children (male ratio = 0.63;mean ± SD age = 9.95 ± 5.44), Systemic-onset JIA was the most frequent type (27.3%), followed by polyarticular (15.9%) and oligoarticular (13.6%). Pain was reported among 43.2% (frequently in the knee, in 27.3%) whereas morning stiffness was reported in 20.5%. The mean CHAQ.MAC score = 2.89 (75th centile = 3.00). With respect of ADLs, up to 22.7% of the children complained of difficulty;and 31.8% reported a difficulty in at least one of the 34 investigated ADLs. With respect of the life domain, children reported difficulties for activities (27.3%), dressing & grooming and hygiene (13.6%), and eating (6.82%). According to the life domain, 4.5% to 13.6% of the children needed help to execute the related ADLs and up to 9.1% used aids or devices. Poor HRQOL was associated with articular pain (p = 0.003) and specific medication (p = 0.043). Con-clusion: Children with arthralgia and those on specific treatment are at higher risk of impaired QOL, which emphasizes the need for systematic screening for treatment adverse effects and joint pain and implementation of efficient management to improve HRQOL.

Update on biologic therapies for juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis(JIA)is the most common rheumatic disease of childhood,and juvenile idiopathic associated uveitis(JIA-U)is the most frequently noted extra-articular manifestation.JIA-U can present asymptomatically and lead to ocular complications,so regular screening and monitoring are needed to prevent potentially sight-threatening sequelae.Topical glucocorticoids such as prednisolone acetate are usually the first line of treatment for anterior uveitis associated with JIA-U,but long-term use may be associated with cataract,ocular hypertension and glaucoma.Disease modifying anti-rheumatic drugs(DMARDs)such as methotrexate allow tapering of the corticosteroids to prevent long-term complications.Biologic therapies have been increasingly used as targeted therapies for JIA-U,particularly monoclonal antibodies targeting the proinflammatory cytokine TNF-αsuch as adalimumab and infliximab.One recent,multicenter,prospective,randomized clinical trial provided evidence of the efficacy of adalimumab with methotrexate for JIA-U compared to methotrexate alone.Another clinical trial studying the interleukin-6 inhibitor tocilizumab for JIA-U showed promise in tapering topical corticosteroids.Additionally,JAK inhibitors are emerging biologic therapies for JIA-U in patients refractory to TNF-αinhibitors,with a clinical trial assessing the efficacy of baricitinib for JIA-U underway.While clinical trials on these novel biologics are limited,further investigation of these agents may provide additional therapeutic options for JIA-U.

Distinct Cytokine Profiles in Patients with Oligoarticular Juvenile Idiopathic Arthritis after <i>in</i><i>Vitro</i>Blockade of T Cells by Cyclosporine and Abatacept

Oligoarticular juvenile idiopathic arthritis (oJIA) is an antigen-driven and lymphocyte-mediated disorder affecting the adaptive immune system. Auto reactive T cells produce pro-inflammatory cytokines as IFN-γ and IL-17. Failure of regulatory T cells leads to decreased production of anti-inflammatory IL-10 and results in the loss of immune tolerance. Therapeutic strategies suppress T cell dependent immune responses and consequently inhibit the process of inflammation. The aim of the study was to investigate the effect of T cell suppression on the cytokine network in oJIA patients. Therefore we examined the cytokine concentration after in vitro inhibition of T cells by cyclosporine and abatacept in patients with persistent oJIA and healthy control subjects. This single center cohort study consisted of oJIA affected children and control subjects. Cytokine profiles from cell culture supernatants were examined with multiplex fluorescent bead immunoassay by flow cytometry. High amounts of IL-17 were only observed in the collective of oJIA patients after T cell stimulation. Cyclosporine suppresses its concentration effectively. IL-2 and IFN-γ are present in both groups. We found IL-6 and TNF-α in high concentrations after T cell activation. While TNF-α concentration is suppressed by both drugs, IL-6 concentration remains high in oJIA patients. Concentrations of IL-4 and IL-10 were not found to be influenced in status of activation or suppression. In conclusion, the results of the present study imply that IL-17 is the crucial T cell cytokine in oligoarticular JIA. Only cyclosporine could inhibit the secretion of IL-17 effectively. IL-2 and IFN-γ are not specific for oligoarticular JIA. Both cytokines are found as well in healthy control subjects after T cell stimulation. Relevant pro-inflammatory macrophage cytokines in oligoarticular JIA are TNF-α and IL-6. T cell suppression by cyclosporine and abatacept inhibits TNF-α but not IL-6 effectively. Production of anti-inflammatory cytokines is not influenced by T cell suppression.

Distinct Cytokine Profiles in Patients with Oligoarticular Juvenile Idiopathic Arthritis after <i>in</i><i>Vitro</i>Blockade of Interleukin (IL)-1 and Tumor Necrosis Factor (TNF)-α

Oligoarticular juvenile idiopathic arthritis (oJIA) is an antigen-driven and lymphocyte-mediated autoimmune disorder with irregularity in the adaptive immune system. Auto reactive T cells, activated by cartilage-derived auto antigens, produce pro-inflammatory cytokines as IFN-γ and IL-17. Failure of regulatory T cells leads to decreased anti-inflammatory cytokine IL-10 production and results in the loss of immune tolerance. This activation of innate and adaptive immunity stimulates the release of pro-inflammatory cytokines IL-1, IL-6 and TNF-α. Thus, inhibition of these cytokines is considered as an appropriate therapeutic strategy for oJIA. The aim of this study was to investigate whether the blockade of a single cytokine pathway in the present cytokine setting causes an unfavourable imbalance in the cytokine system or whether the blockade is sufficient to suppress the inflammatory condition. We examined the cytokine secretion after in vitro inhibition of IL-1 and TNF-α of patients with oJIA and healthy subjects. This single center cohort study consisted of oJIA affected children and control subjects. Cytokine profiles from cell culture supernatants were examined with multiplex fluorescent bead immunoassay by flow cytometry. Adalimumab prevents highly effective and very selective effect of the cytokine TNF-α. Due to its structure, the mode of action of etanercept is difficult to display. In addition, adalimumab and etanercept appear in vitro suppressive to IFN-γ. The efficiency of both substances is particularly supported by the increased secretion of anti-inflammatory cytokine IL-4. In contrast, anakinra unselectively inhibits the pro-inflammatory macrophage cytokines. To conclude, our observations suggest that inhibition of IL-1 or TNF-α may contribute to the unselective decline of other pro-inflammatory cytokines in oJIA patients. The selective anti-inflammatory effect of cytokine inhibitors is most likely supported by an increase of IL-4 or IL-10. It still remains to be elucidated whether the reduced IFN-γ secretion is maybe causative for the increased susceptibility to infections with opportunistic pathogens.

Expression of FLICE-inhibitory Protein in Synovial Tissue and Its Association with Synovial Inflammation in Juvenile Idiopathic Arthritis

Objective To examine the expression of FLICE-inhibitory protein (FLIP) in juvenile idiopathic arthritis (JIA) and analyze its correlation with synovial inflammation. Methods The expression of FLIP was assessed in 11 JIA and 3 normal synovial tissue samples by reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. The cell types expressing FLIP were further characterized,and the correlation of FLIP expression with the degree of synovial inflammation,as well as the activity of caspase 8 was then analyzed. Results RT-PCR revealed the expression of FLIP mRNA in all 11 JIA samples,but not in 3 normal synovial tissues. In JIA,FLIP expression could be found in both the lining and sublining layers,mainly in the macrophage-like cells. Moreover,the expression of FLIP in JIA synovial tissues was positively correlated with the degree of synovial inflammation (r=0.563,P<0.05). Conclusion The expression of antiapoptotic FLIP in JIA synovial tissue and its correlation to accumulation of inflammatory cells in synovial tissue suggests that FLIP potentially extends the lifespan of synovial cells and thus contributes to the progression of joint destruction.

A Single-Center Experience of Systemic Onset Juvenile Idiopathic Arthritis at a Tertiary Hospital in Jeddah, Saudi Arabia

Background and Objective: Systemic-onset juvenile idiopathic arthritis (JIA) is a major and prevalent subset of arthritis among children and it has a broad spectrum of clinical presentation, course and prognosis. This study described the clinical presentation of systemic-onset JIA in a Saudi-based cohort. Methods: A retrospective chart review was performed of the medical records of children with systemic-onset JIA who were followed up at King Abdul Aziz University Hospital, Jeddah, between January 1997 and December 2013. Patients’ files were reviewed for demographic, clinical, and paraclinical data, which were analyzed using the statistical Package for the Social Sciences. Results: We included 20 patients of both genders (8 boys and 12 girls). The mean age of disease onset was 7 (4.5) years. The most common presenting symptoms were fever (100%), arthritis (100%), and rash (55%). Hepatomegaly (5%), abdominal (5%) and pulmonary manifestations (3%) were less frequent manifestations. Most patients had high white blood cell counts (50%), elevated erythrocyte sedimentation rates (80%) and C-reactive protein levels (90%). The interval between onset of symptoms and diagnosis was 9.4 (12.5) weeks. Patients were treated with non-steroidal anti-inflammatory drugs, methotrexate, steroids, anti-tumor necrosis agents, and disease-modifying anti-rheumatic drugs. Bone marrow biopsy was conducted to exclude malignancy in 20% of the patients. Conclusion: Saudi children with systemic-onset JIA present with prolonged fever and arthritis (mainly oligoarticular rather than polyarticular). Physicians should be aware of the presentation of systemic-onset JIA in our setting in order to make prompt diagnosis and treatment decisions as early as possible. Carful follow-up of febrile patients is paramount to reaching the diagnosis early and initiating treatment.

Anemia in Juvenile Idiopathic Arthritis (JIA) and Other Pediatric Rheumatologic Diseases: A Retrospective Study

Objectives: The present study estimated the prevalence of anemia among children and adolescents with pediatric rheumatological diseases in a referral center, and analyzed the associated clinical and biological parameters. Methods: A retrospective chart review included 49 children with rheumatological diseases, who were diagnosed by a pediatric rheumatologist and classified according to the International League of Associations for Rheumatology (ILAR) guidelines and criteria endorsed by the American College of Rheumatologists. Anemia was defined as hemoglobin level lower than the 5th centile for the corresponding age and gender. Disease activity was indicated by serum levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), where available. Results: Participants were aged 2 - 18 years (mean ± SD = 10.41 ± 4.23 years), 38 (77.6%) of them had JIA, and 8 (16.3%) had systemic lupus erythematosus. The most frequent subtype of JIA was the polyarticular (16 out of 38, 42.1%), followed by systemic (14, 36.8%). The prevalence of anemia was 46.9% (95% CI = 32.5% - 61.7%), with no significant difference between JIA and other diseases or between the different JIA subtypes. Nevertheless, anemia was more frequently observed in younger patients (age 2 - 6 years: 69.2% vs <48%) and those with elevated ESR (68.8% vs 33.3%) or CRP (60.0% versus 45.2%), compared with their counterpart respectively;however, only the association with ESR was statistically significant (p = 0.049). No agreement was found between CRP and ESR (Kappa = 0.140). Conclusion: Anemia is frequent in JIA and other rheumatologic diseases in children, concerning approximately 50% of the patients and responding to anemia of inflammation as the major pathophysiological mechanism. Further research is warranted to provide more accurate insight into the pathophysiological mechanisms and clinical characteristics of anemia in pediatric rheumatological disease and to measure its morbidity, to provide efficient and evidence-based management strategies.

A Rare Case of Chronic Recurrent Multifocal Osteomyelitis with Undifferentiated Juvenile Idiopathic Arthritis, Uveitis, and Psoriasis

We report here a 17-year-old boy with a complicated presentation of undifferentiated juvenile idiopathic arthritis, vision-threatening uveitis and chronic recurrent multifocal osteomyelitis (CRMO) in the pelvis. His severe iritis needed subtenon injections and only responded to infliximab after failing multiple biologics. Unfortunately he later developed infliximab-associated psoriasis. A combination of infliximab and ustekinumab induced remission of his arthritis, osteomyelitis, uveitis and psoriasis without experiencing severe infections.

The Relationship between Bone Mineral Density and Dietary Intake in Moroccan Children with Juvenile Idiopathic Arthritis

Background and objective: The aim of this study was to evaluate the association between dietary intake and bone mineral density in children with juvenile idiopathic arthritis (JIA). Methods: A cross-sectional study carried out in Morocco between May 2010 and June 2011, covering out patients with JIA. The characteristics of patients were collected. The nutritional status was assessed by a food questionnaire including data of food intake during 7 consecutive days using 24-hour dietary recall. Food intake was quantified using the software Bilnut (Bilnut version 2.01, 1991). Bone mineral density (BMD in g/cm2) was measured by DXA method (X-ray absorptiometry) on a Lunar Prodigy. Results: The study consisted of 33 patients with JIA (4 - 16 years old). The median age of patients was 10.4 ± 4.3 years. Median disease duration was 2 (1 - 4.5) years. The group of patients with low dietary intake of proteins was associated with low BMD (p = 0.03). Low BMD was related with low intake of magnesium (p = 0.007) and vitamin C (p = 0.04) in children aged between 4 and 9 years. Low intake of vitamin E and folate was associated with high BMD in the other range of children (p < 0.001). Conclusion: This study suggests that low intake of protein and of some micronutrients (magnesium, vitamin C, vitamin E and folate) influence bone mass in children with JIA. Prospective studies with a larger number of patients seem to be necessary in order to confirm our findings.