الفهرس 
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Abstract
Juvenile idiopathic arthritis (JIA) is an autoimmune chronic inflammation of one or more joints, characterized by an onset before the age of 16 years, persist for more than six weeks, and is of unknown etiology.
Although the aetiopathogenesis is unclear, the inflammatory process is thought to be of multifactorial origin, and to result from both genetic and environmental factors. The persistence of synovial inflammation may cause cartilage and bone damage and, ultimately, lead to permanent alterations in joint structures and serious impairment of physical function.
In recent years, musculoskeletal ultrasound (MSUS) has been recommended for the evaluation of treatment response and the detection of subclinical synovitis in rheumatoid arthritis . MSUS may be equally important in children.
The current study is therefore designed to determine whether patients in clinical remission show either pathologic gray-scale or power Doppler findings on US examination indicating persistent structural abnormalities (gray scale) and/or evidence of active inflammation (pathologic power Doppler signals) and also to determine the value of musculoskeletal ultrasound in prediction of disease flare in juvenile idiopathic arthritis patients.
This was a longitudinal prospective blind case control study carried out at the Rheumatology and Rehabilitation clinic in Sohag University Hospital during the period from January 2019 to May 2023. This study was conducted on 50 children referred to the rheumatology outpatient clinic in Sohag University Hospital, diagnosed as juvenile idiopathic arthritis patients (group 1), according to the criteria of the International League of Associations for Rheumatology (ILAR). Patients were considered in clinical remission by the Wallace’s criteria, and they were compared with 50 healthy children as a control group (group 2).
o All patients had been subjected to the following at 0 points of our study: Current age, age of disease onset, disease duration, disease subtype, clinical remission (on and off medication) and time on clinical remission.
o The following parameters had been considered in the clinical assessment at 0 points of our study and we repeated the same assessment after 6 months and after 12 months of follow up :
• Active joint count
• Physician’s global visual analog scale (VAS) (0–10)
• Parent or patient’s global VAS (0–10)
• JADAS10 and cJADAS10 to quantify clinical disease activity
• Medications used: (NSAIDs), corticosteroids, synthetic DMARDs, and biologics.
• Patient Reported Outcome questionnaires :
o The Egyptian Arabic version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR)
o Arabic version of Childhood Health Assessment Questionnaire (CHAQ).
o Patients undergone the following laboratory tests at 0 points of our study and then the same tests had been repeated after 6 months and after 1 year of follow up:
* CBC, ESR ,CRP, RF,ACPA, ANA, ALT, AST , Serum creatinine ,urine analysis.
* Ophthalmologic assessment to detect active uveitis.
o Muscloskeletal Ultrasonographic evaluation had been carried out at 0 points of our study and then we repeated the same evaluation after 6 months and after 1 year of follow up:
All patients underwent an ultrasound examination at the beginning of the study and every 6 months thereafter over one year. The ultrasound examinations were performed by a radiologist and a rheumatologist.
Ultrasound examinations were done in twelve joints bilaterally: 2nd to 5th metacarpophalangeal joints (MCPs) and 2nd to 5th proximal interphalangeal joints (PIPs) of the hands , wrists, elbows, knees, ankles. Gray scale and power Doppler assessment done according to the evaluation procedures standardized by the European League Against Rheumatism (EULAR).
Control group: 50 healthy children aged between 3 and 16 years old.
Our results revealed that synovitis (especially grade 2), positive PD activity (especially grade 2), subclinical synovitis, and bone erosions (especially grade 3) observed during MSK US examinations were associated with a higher risk of JIA flare after 6 months and 12 months of follow up in patients who were initially in clinical remission at the beginning of our study. Also, positive RF, ANA, or ACPA was associated with a higher risk of flare. In addition, we noticed that a significant higher frequency of flare occured in female patients with older age at onset & polyarticular RF+ve. On the other hand, we observed that using a methotrexate drug combined with a biological therapy associated with a lower risk of JIA flare.
Therefore adding a MSUS examination to the clinical examination in JIA patients might produce a more accurate assessment of disease activity and prediction of flare than the clinical examination alone.
Recommendations
• Adding a MSUS examination to the clinical examination in JIA patients might produce a more accurate assessment of disease activity and prediction of flare than the clinical examination alone.
• We should delay withdrawal of medications in patients with clinical remission on medication who have synovitis and positive PD signal on US examination due to the risk of JIA flare.
• Joints with synovitis and positive PD signal should be monitored more frequently due to the risk of flare and long-term joint damage.
• Further studies are needed with larger scales for confirming our results upon longer durations of follow up and we hope to be multicenter studies.