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Rheumatology

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G121 PREVALENCE OF OBESITY IN PAEDIATRIC RHEUMATOLOGY OUTPATIENTS

R. Wilshire1, B. Johnson1, G. Shaikh2, J. E. McDonagh3.1Departments of Rheumatology and 2Endocrinology, Birmingham Children’s Hospital; 3Institute of Health, University of Birmingham, UK

Background: There is an increasing concern of the prevalence and impact of obesity in childhood and adolescence and its potential antecedents of adult morbidities. Coincident rheumatic disease potentially contributes further with mobility difficulties and/or steroid therapy, for example. In consideration of the development of a multidisciplinary health promotion intervention, the aim of this study was to establish the prevalence of obesity in children/young people seen within rheumatology clinics.

Methods: The height and weight of patients with simple demographic data was recorded in consecutive rheumatology outpatient clinics at a UK children’s hospital. BMI for age data were then calculated and patients fulfilling the criteria for overweight or obesity according to the International Obesity Task Force cut-offs were identified.1

Results: Initial data were collected on 112 consecutive outpatients of whom 75 were female. The mean age was 10.29 years (range 0.73 to 17.33 years). Diagnoses included juvenile idiopathic arthritis (JIA; n = 78), SLE (n = 7), juvenile dermatomyositis (JDMS; n = 12), and other rheumatological conditions (n = 15). Twenty patients (18%) were currently receiving oral prednisolone. A fifth (20.54%, 23/112) of the total population was classified as overweight (including seven on prednisolone) and 6.25% (7/112) as obese (including one on prednisolone). Within the sysltemic JIA subtype, 7/13 were overweight or obese compared with 16/65 in the remaining JIA subtypes, 5/12 JDMS and 1/7 SLE groups. Data on additional patients are being collected currently with particular reference to disease subgroup and steroid therapy.

Conclusions: This pilot study suggests the prevalence of obesity in children and young people with chronic rheumatic disease is similar to their healthy peers (15.4% overweight, 4% obese; p = 0.052) and is not solely explained by steroid therapy. Health promotion interventions are therefore worthy of further study particularly in view of the additional risk of morbidities in rheumatic disease. Targeting of interventions is suggested by the trend towards greater prevalence is certain disease subgroups.

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G122 DEVELOPMENT OF HEALTH INFORMATION AND PROMOTION LEAFLETS FOR ADOLESCENTS WITH CHRONIC RHEUMATIC CONDITIONS

J. Hackett1, B. Johnson1, R. Wilshire1, J. E. McDonagh2.1Departments of Rheumatology, Birmingham Children’s Hospital, UK; 2Institute of Health, University of Birmingham, UK

Background: A need for age appropriate information for adolescents with rheumatic disease has been reported by young people and professionals alike.12 The National Service Framework for Children (2004) further suggests the need for health promotion materials that are appropriate for young people’s psychosocial and cognitive stages of development. The aim of this study was to identify the opinions of young people in develloping a range of health promotion literature for adolescents.

Methods: Five patient information leaflets were designed by a rheumatology therapy team. Forty leaflets were then sent to 20 young people attending the adolescent rheumatology clinic. Patients were asked to complete a questionnaire to elicit their views regarding the leaflets and any suggestions for future topics. The young people were asked to score a range of descriptors on a 5 point scale (1 = lowest negative score, 5 = highest positive score). Open ended questions were also included to elicit further information.

Results: Initial data were collected from 10 young people (50% completion) of whom 5 were female and the majority had juvenile idiopathic arthritis (8/10) The median age was 13.5 years (range 12 to 17 years). Each young person was asked to comment on two leaflets. The mean scores for the descriptors for each leaflet are shown in the table. The young people also made a number of suggestions regarding improvements to the leaflets which were then incorporated in final versions. Additional topics for future leaflets including pain management, medications and their sideeffects, sexual health, drugs and alcohol, coping with every day activities, support groups, websites and contact numbers were also suggested.

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Conclusions: This study provides further evidence that young people consider written information regarding generic health related issues important. It demonstrates the value of consulting young people prior to and during the development of such resources as they provide useful insights and ideas for future developments.

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G123 GROWING UP AND MOVING ON IN RHEUMATOLOGY: DISEASE KNOWLEDGE IN A MULTICENTRE COHORT OF ADOLESCENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

J. E. McDonagh, K. L. Shaw, T. R. Southwood.On behalf of BSPAR, University of Birmingham, Birmingham, UK

Background: A key component of transitional care is the acquisition of knowledge about the chronic condition and its management by the young person and their family. Evidence suggests that disease education needs to be individually tailored and revisited to ensure comprehension and retention. The aim of this study was to assess the baseline knowledge of adolescents with juvenile idiopathic arthritis (JIA) and the impact of a transitional care programme on their knowledge of JIA and its management.

Methods: A knowledge questionnaire was administered to 308 adolescents with JIA and 301 of their caregivers prior to the implementation of a programme of transitional care and 6 and 12 months afterwards. Designed for self-completion, the questionnaire utilised a multiple-choice format and comprised 16 items (plus 3 supplementary questions for patients with experience of specific anti-rheumatic drugs). Each question had a stem and then 6 possible answers including “don’t know”. There was only one correct answer for each stem. One point was awarded to each right answer and summed to give a final knowledge score (0–16).

Results: Despite median disease duration of 5.7 years, the median knowledge scores were 8 and 11 for adolescents and their caregivers at baseline. In a multiple regression model, adolescent baseline knowledge was predicted by age at time of assessment, parental knowledge, parent rated general health, and socioeconomic status, which collectively explained 45.2% of the variation in scores. Parental knowledge was predicted by socioeconomic status, parental gender, qualifications, ethnicity, adolescent knowledge, disease activity, and adolescents having a statement of special educational need, which explained 33.3% of the variation. Adolescent and parental knowledge scores significantly improved 6 months after implementation of the programme and continued to improve at the 12 month assessment. This improvement was greatest for the 11 year old adolescents. However, while improvements were observed, the knowledge of adolescents and their parents was less than optimal.

Conclusions: Arthritis related knowledge in adolescents and their parents is less than optimal, but can be improved by a structured programme of transitional care especially if introduced during early adolescence. The predictive factors observed in this study may help health professionals to identify individuals at risk of poor knowledge. However, the role of other factors need further study.

G124 EVALUATION OF CLINICAL FINDINGS AND MRI IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS AND HIP INVOLVEMENT

K. Nistala1, J. Barbar1, K. Foster1, C. Ryder1, K. Johnson1, J. E. McDonagh2.1Birmingham Children’s Hospital, Birmingham, UK; 2Institute of Child Health, Birmingham, UK

Aims: Hip involvement in juvenile idiopathic arthritis (JIA) is common and is a cause of significant functional impairment. However, clinical evaluation for inflammation is difficult because of the hip’s anatomical location. In patients with long standing arthritis classical markers for synovitis, pain, and restriction may not distinguish between active inflammation and previous joint damage. The aim of this study was to compare clinical assessment of hip arthritis with MRI as the gold standard for detecting inflamed synovium.

Method: We retrospectively reviewed the case notes of the past 28 patients with JIA (mean age 14.3 years, mean disease duration 5.4 years) and 2 non-JIA controls. Indication for MRI was hip pain or restriction. We recorded symptoms of hip pain, the clinician’s assessment of hip arthritis, ESR, and active joint count. MRIs were reported blind to clinical details simultaneously by 2 radiologists. Any disagreement was resolved by consensus. 56 hips were scored for signs of active synovitis with 1 point for each of the following: effusion, gadolinium enhancing synovium >2 mm, and peri-articular bone oedema (Maximum score per hip = 3).

Results: Control patients scored 0. Patients with a history of pain had significantly higher MRI scores (mean score per hip 1.8 v 1, Kruskall Wallis p 0.04). ESR and total active joint count did not correlate with MRI scores. In one patient, judged clinically to have inactive disease, each hip scored 3 points on MRI. In a further patient judged to have active disease, MRI scored 0 and injection of intra-articular steroids was cancelled.

Conclusion: Our findings suggest than hip disease in JIA may be missed by clinical examination alone. The long term consequences of sub-clinical hip disease are unclear but are potentially concerning. MRI may prevent the incorrect assignment of hip arthritis.

G125 ARTHROPATHY IN CHILDREN WITH INFLAMMATORY BOWEL DISEASE

F. McErlane, C. Gillon, T. Irvine, M. Beresford, J. Davidson.Royal Liverpool Children’s Hospital NHS Trust, Liverpool, UK

Introduction: Arthropathy associated with inflammatory bowel disease (IBD) is well recognised in adults but poorly documented in childhood. Previous retrospective case series quote a prevalence of 12–17%. Joint involvement is usually described as an inflammatory arthropathy affecting the large joints, particularly the hips, knees, and ankles. This study aims to determine the prevalence and pattern of joint involvement in childhood IBD.

Method: Children with IBD under the care of the gastroenterologists were identified and invited to participate in this cross-sectional observational study. Demographic, diagnostic, and management data were collected for each participant. Each family was invited to complete a short questionnaire on joint and muscle symptoms together with a validated functional questionnaire (childhood health assessment questionnaire). Children with musculoskeletal symptoms were then offered an appointment with a rheumatologist for further assessment. Symptoms and examination findings were documented on a standardised pro forma and appropriate management instituted.

Results: 110 patients have been recruited to the study. 25 children (23%) describe significant musculoskeletal symptoms. Of these, 16 (60%) have arthralgia and 6 (24%) have myalgia. In the majority with arthralgia there was an identifiable cause unrelated to their IBD, for example hypermobility. A true inflammatory arthropathy was found in only 3 children (12%).

Conclusions: Joint symptoms are common in childhood IBD but may result from some alternative pathology. Careful assessment of joint symptoms is essential if appropriate management is to be offered. A true inflammatory arthropathy is uncommon.

G126 DETECTION AND IDENTIFICATION OF BACTERIAL DNA IN SYNOVIAL FLUID FROM JUVENILE IDIOPATHIC ARTHRITIS PATIENTS USING BROAD-RANGE 16S rDNA PCR

F. Bibi1, N. Brown1, G. Kingsley2, T. R. Southwood1.1University of Birmingham, Birmingham, UK; 2GKT School of Medicine, London, UK

Background: There are several forms of juvenile idiopathic arthritis (JIA). An infectious aetiology has been implicated, and there is indirect evidence that antigens, including those from Gram negative enteric bacteria, may drive intra-articular inflammation in some forms of JIA.

Method: To address this question, we have used an optimised nested broad-range bacterial 16S ribosomal DNA PCR to detect bacterial DNA in synovial fluid and peripheral blood (PB) from patients with JIA. Potential environmental contamination of specimens was monitored.

Results: Bacterial DNA was detected in 25/76 JIA patients (33%, 16 SF positive), 2/4 children with other inflammatory disease, and 4/20 adult controls (0/11 non-arthritic, 0/5 rheumatoid arthritis, 4/4 reactive arthritis). A wide range of bacteria were identified in synovial fluid from patients with JIA, including species of Bacillus, Micrococcus, Nocardia, and Staphylococcus (associated with arthritis), Clavibacter and Herbaspirillum (not known to be human pathogens), and several unrecognised bacterial sequences.

Conclusion: Statistical correspondence analyses indicated associations between bacterial genera and 2 clinical subgroups of JIA (systemic arthritis and oligoarthritis), but no associations with any clinical subgroup were demonstrated at the bacterial species level. Analysis of TLR4 polymorphisms in some patients did not reveal any associations with a genetic predisposition to infection. This study supports the concept that bacteria may be involved in the pathogenesis of chronic inflammation in JIA.

G127 AUTOLOGOUS HAEMATOPOIETIC STEM CELL TRANSPLANTATION FOR REFRACTORY JUVENILE IDIOPATHIC ARTHRITIS IN THE UK: EXPERIENCE 2000–2005

M. Abinun1, P. A. Veys2, H. E. Foster1, L. R. Wedderburn2.1Newcastle General Hospital, Newcastle upon Tyne, UK; 2Great Ormond Street Hospital, London, UK

As part of the multi-centre European trial, autologous haematopoietic stem cell transplantation (AHSCT) in severely ill children with refractory juvenile idiopathic arthritis (JIA) in the UK is funded and monitored by the Department of Health - National Specialist Commissioning Advisory Group (NSCAG). Following the agreed guidelines,1 children referred for the procedure from paediatric rheumatologists are assessed by one of the ‘independent panel’ members identified from the British Society for Paediatric and Adolescent Rheumatology (BSPAR). After bone marrow or peripheral blood stem cell harvest, patients undergo immunosuppressive conditioning (cyclophosphamide; fludarabine; anti T cell globulin) followed by infusion of T cell depleted autologous CD34+ stem cells.

Since the starting of the programme in March 2000, 12 patients with refractory JIA who had failed the conventional therapy with corticosteroids and high dose methotrexate (6 of whom had as well failed the treatment with anti-TNF alpha agents) were referred for AHSCT. Of 6 transplanted patients, 5 achieved complete and 1 partial response (follow up 1–5 years).2 Three patients opted not to proceed with AHSCT and the independent assessor deferred the procedure for one. Two patients died prior to the procedure (disease related mortality), both due to central venous line (CVL) related bacterial sepsis.

Response seen after AHSCT can indeed be dramatic in the way of clinical (joint inflammation and synovitis) and psychological improvement, possibility of anti-inflammatory and immunosuppressive treatment withdrawal, and catch-up growth. However, this experimental treatment carries significant risk of opportunistic infections, mainly due to the selection of the patient group referred for the treatment (end of spectrum severe disease, refractory to and with multiple complications, and side effects of long term immunosuppression pre-transplant). This is associated with conditioning related toxicity and further prolonged T cell hypofunction post-transplant. Therefore, administration of antimicrobial prophylaxis and replacement immunoglobulin is mandatory during the period of immune function reconstitution, usually up to 12 months post AHSCT.

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G128 ADVERSE EVENTS IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS PRESCRIBED ETANERCEPT REPORTED TO THE BRITISH SOCIETY FOR PAEDIATRIC AND ADOLESCENT RHEUMATOLOGY (BSPAR) BIOLOGICS AND NEW DRUG REGISTER (BNDR)

C. L. Cummins1, H. E. Foster2, J. Rahman1, C. B. Cotter1, T. R. Southwood on behalf of BSPAR BNDR Group.1University of Birmingham, Birmingham, UK; 2University of Newcastle, Newcastle, UK

Aims: Large scale surveillance systems for the collection of information on drug safety are essential to maximise the chances of detecting rare but potentially serious adverse events. The BSPAR BNDR was established in the UK in January 2004 to collect information from juvenile idiopathic arthritis (JIA) patients treated with the TNFα blocker etanercept, methotrexate, or both drugs. Adverse events experienced in patients recruited to the register to date are described below.

Methods: Data on patient demographics, disease classification and activity, treatment history, health events, and drug related adverse events were collected at baseline and at 3 months, 6 months, and annually after commencing either of the study drugs.

Results: By December 2004, 88 etanercept and 8 methotrexate JIA patients had been recruited. Thirty three adverse events were reported; 17 (55%) in etanercept treated patients, 9 (29%) in those prescribed methotrexate, and 5 (16%) in those who had taken both in the preceding 3 months. A relationship between etanercept or methotrexate and the adverse event was suspected in 15 (48%) events. Ten events were considered possibly related to etanercept and included: injection site reactions (3), disordered and heavy menstruation (2), severe flare of eczema, rash on thighs, frequent upper respiratory tract infections, severe JIA flare, and chicken pox. Ten events were considered possibly related to methotrexate, including: abnormal liver function resulting in permanent or temporary cessation of the drug (2), vomiting, secondary amenorrhea, and hair loss. Other events included: hip replacement (3), severe disease flare (2), high blood pressure, ankle fracture, bone marrow aspiration, shortness of breath, mononucleosis (etanercept), vertebral collapse, umbilical hernia surgery (methotrexate), fever and other symptoms (2), headache, and gastroenteritis (both).

Conclusion: Even at this early stage, events of potential significance for children (for example eczema flare) and adolescents (for example heavy menstruation) have been reported, demonstrating the importance of establishing drug safety registers in paediatric populations.

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