Joints In Juvenile Idiopathic Arthritis Research Articles

Provider assessment of the temporomandibular joint in Juvenile idiopathic arthritis: a retrospective analysis from the CARRA database

BackgroundTemporomandibular joint (TMJ) involvement is an often underrecognized complication of juvenile idiopathic arthritis (JIA) that can cause decreased mandibular growth, altered facial morphology, and orofacial pain. It is estimated that the TMJ is affected in 30–45% of children with JIA. Standardized physical examination and imaging evaluations are important in accurately assessing active TMJ arthritis and sequalae. Little is known about the rate at which providers evaluate TMJ involvement in their clinical practice.MethodsData were obtained from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. Data fields related to assessment for TMJ arthritis were added in 2019. Patients were included in the study if they had a diagnosis of JIA and had data recorded between January 2020 and August 2021. Standard descriptive statistics were used to describe demographic and clinical features.ResultsA total of 17,761 visits were reviewed for a total of 7473 patients with JIA. A total of 52.7% of patients had maximal mouth opening (MMO) recorded as finger breadths or total incisal distance (TID). Only 8% had TID measured. A total of 5.0% had MRI with contrast performed. A total of 939 patients had a diagnosis of TMJ arthritis. Of these, 28.5% had an MRI documented, 83% had an MMO documented, and 40% had TID measured. Few patient-level characteristics were statistically related to having MMO assessed. MRI was more likely to be obtained in older and in female patients. MMO was recorded at a given visit > 80% of the time at 17 sites, and it was recorded < 1% of the time at 8 sites. MRIs were infrequently performed at all sites, with 27 sites having no MRIs obtained and only 7 sites having an MRI obtained at > 10% of visits.ConclusionsMMO is not consistently measured in patients with JIA, and it is rarely measured quantitatively. Similarly, TMJ MRIs are rarely obtained in patients with JIA. Site of care is more associated with TMJ assessments than patient-level characteristics. These data suggest that provider education is needed to improve the assessment of the TMJ in patients with JIA to enable earlier recognition and prevent long-term complications.

A clinical perspective on imaging in juvenile idiopathic arthritis

In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity, and predict disease course and outcome in children with juvenile idiopathic arthritis (JIA). Over the past few decades, great efforts have been made to improve the quality of diagnostic imaging and to reach a consensus on which methods and scoring systems to use. However, there are still some critical issues, and the diagnosis, course, and management of JIA are closely related to clinical assessment. This review discusses the main indications for conventional radiography (XR), musculoskeletal ultrasound (US), and magnetic resonance imaging (MRI), while trying to maintain a clinical perspective. The diagnostic-therapeutic timing at which one or the other method should be used, depending on the disease/patient phenotype, will be assessed, considering the main advantages and disadvantages of each imaging modality according to the currently available literature. Some brief clinical case scenarios on the most frequently and severely involved joints in JIA are also presented.Graphical abstract

Comparison between ultrasound and magnetic resonance imaging of the temporomandibular joint in juvenile idiopathic arthritis: A systematic review.

The objectives of this systematic review were to evaluate the correlation between Ultrasound (US) and Magnetic Resonance Imaging (MRI) in patients with JIA and to investigate the association with Temporomandibular Disorders (TMD). The protocol was registered in PROSPERO (CRD42022312734). Databases Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature were searched. Eligibility criteria were patients with JIA subjected to diagnostic evaluation using US and MRI. No language restrictions were applied. After duplicate study selection, data extraction and risk of bias assessment according to Cochrane were conducted. Data extraction of patients was conducted by two independent authors. Five observational studies were included with 217 participants (153 females and 64 males; mean age 11.3 years). The quality of the studies was overall satisfactory. The correlation between US and MRI in children with JIA was 'moderate' in acute arthritis while the chronic arthritis correlated positively in two studies. Even if MRI remains the more accurate imaging modality for the detection of TMJ of patients with JIA, US may be useful to early detect pathological conditions and to address the patient with JIA and putative TMJ involvement to a more accurate diagnosis with MRI and consequent appropriate treatment management. MRI should be deemed necessary only secondary to less-invasive assessments with US just to confirm the diagnosis or to increase sensitivity, accuracy of positive predictive values detected.

Advances in Musculoskeletal Imaging in Juvenile Idiopathic Arthritis.

Over the past decade, imaging of inflammatory arthritis in juvenile arthropathies has significantly advanced due to technological improvements in the imaging modalities and elaboration of imaging recommendations and protocols through systematic international collaboration. This review presents the latest developments in ultrasound (US) and magnetic resonance imaging (MRI) of the peripheral and axial joints in juvenile idiopathic arthritis. In the field of US, the ultra-wideband and ultra-high-frequency transducers provide outstanding spatial resolution. The more sensitive Doppler options further improve the assessment and quantification of the vascularization of inflamed tissues, and shear wave elastography enables the diagnosis of tissue stiffness. Concerning MRI, substantial progress has been achieved due to technological improvements in combination with the development of semiquantitative scoring systems for the assessment of inflammation and the introduction of new definitions addressing the pediatric population. New solutions, such as superb microflow imaging, shear wave elastography, volume-interpolated breath-hold examination, and MRI-based synthetic computed tomography open new diagnostic possibilities and, at the same time, pose new challenges in terms of clinical applications and the interpretation of findings.

The reliability of Juvenile Arthritis Magnetic Resonance Imaging Scoring system in the evaluation of the shoulder joint in juvenile idiopathic arthritis.

We aimed to evaluate shoulder joint by magnetic resonance imaging (MRI) using the Juvenile Arthritis Magnetic Resonance Imaging Scoring (JAMRIS) system in children with juvenile idiopathic arthritis (JIA) and to compare clinical, laboratory parameters and disease activity scores with MRI parameters. A total of 32 shoulder joints of 20 patients (16 males, 4 females; mean age: 8.9±3.5 years; range, 2.5 to 14 years) with a known diagnosis of JIA and a clinical suspicion of shoulder joint involvement and underwent MRI were included. Reliability was determined by inter- and intra-observer correlation coefficients. Correlation of the clinical and laboratory parameters with JAMRIS scores was done using the non-parametric tests. Sensitivity of clinical examination to detect shoulder joint arthritis was also determined. Of the 32 joints, 27 joints in 17 patients showed MRI changes. Seven joints in five patients fulfilled the definition of clinical arthritis, all revealed MRI changes. In 25 joints without clinical arthritis, early and late MRI changes were seen in 19 (67%) and 12 (48%) joints, respectively. The inter- and intra-observer correlation coefficients for JAMRIS system were excellent. No correlation was found between MRI parameters, clinical, laboratory, and disease activity scores. The sensitivity of clinical examination to detect shoulder joint arthritis was 25.9%. The JAMRIS system is reliable and reproducible to determine shoulder joint inflammation in JIA. Detection of shoulder joint arthritis by clinical examination has a poor sensitivity.

Differentially Expressed Inflammation-Regulating MicroRNAs in Oligoarticular Juvenile Idiopathic Arthritis.

To evaluate microRNA expression in synovial fluid (SF), plasma, and leukocytes from patients with juvenile idiopathic arthritis (JIA). MicroRNA expression in pooled JIA plasma and SF was assessed by absolute quantitative droplet digital PCR array. The results were validated in individual patient samples. MicroRNA content in leukocytes and extracellular vesicles was evaluated by real-time PCR in JIA blood and SF. Blood microRNA expression was compared with healthy controls (HCs). Principal component analysis was used to profile JIA plasma and SF microRNAs, and the potential biological consequences of microRNA dysregulation were investigated by pathway analysis. MiR-15a-5p and miR-409-3p levels were higher in JIA plasma than in HC plasma. JIA SF contained elevated levels of miR-21-5p, miR-27a-3p, miR-146b-5p, miR-155-5p, and miR-423-5p, and decreased miR-192-5p and miR-451a, compared to JIA plasma. Extracellular vesicle analysis demonstrated variable encapsulation among selected microRNAs, with only miR-155-5p being represented substantially in extracellular vesicles. SF leukocytes also had higher expression of miR-21-5p, miR-27a-3p, miR-146b-5p, and miR-155-5p, and lower expression of miR-409-3p and miR-451a, relative to blood. No differences were observed between JIA and HC blood leukocytes. Clusters of microRNAs were commonly altered in JIA joint fluid and leukocytes compared to JIA blood samples. In silico analysis predicted that differentially expressed microRNAs in JIA target the transforming growth factor (TGF)-β pathway. The expression of multiple microRNAs is dysregulated in JIA both locally and systemically, which may inhibit the TGF-β pathway. These findings advance our knowledge of JIA immunopathogenesis and may lead to the development of targeted therapies.

Physical Examination Tool for Swollen and Tender Lower Limb Joints in Juvenile Idiopathic Arthritis: A Pilot Diagnostic Accuracy Study

Background: Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children, with lower limb involvement highly prevalent. Recent evidence has highlighted the lack of specific lower limb physical examination (PE) tools for clinicians assisting the paediatric rheumatology team in identifying lower extremity disease in patients with JIA. Early clinical detection may lead to more prompt and targeted interventions to reduce lower limb problems in children with JIA. The aim of this pilot study is to provide preliminary data on the diagnostic accuracy of a lower limb PE tool in JIA. Methods: Children with JIA requiring magnetic resonance imaging (MRI) on their lower limb joints per their usual care were eligible. Lower limb joint counts were conducted clinically by a podiatrist and paediatric rheumatologist using the proposed twenty joint per side, PE tool. The PE were compared to MRI assessments completed by two independent paediatric radiologists. Data were analysed using agreement (observed, positive and negative) and Cohen’s kappa with 95% CIs. Results: Fifteen participants were recruited into the study in which 600 lower limb joints were clinically examined. Statistical analysis showed excellent inter-rater reliability between podiatrist and paediatric rheumatologist for both joint swelling and tenderness. Results of the intra-rater reliability of the podiatrist using the PE tool indicated excellent percentage agreements (98.5–100%) and substantial kappa coefficients (0.93–1). The inter-rater reliability between radiological assessments contrasted the PE results, showing low agreement and poor reliability. Comparisons between PE and MRI resulted in poor kappa coefficients and low agreement percentages. The most agreeable joint between MRI and PE was the ankle joint, while the worst performing joint was the sub-talar joint. Conclusion: Results indicate potential clinical reliability; however, the validity and diagnostic accuracy of the proposed PE tool remains unclear due to low kappa coefficients and inconsistent agreements between PE and MRI results. Further research will be required before the tool may be used in a clinical setting.

Neutrophils Lose the Capacity to Suppress T Cell Proliferation Upon Migration Towards Inflamed Joints in Juvenile Idiopathic Arthritis.

Neutrophils are highly abundant in synovial fluid of rheumatic inflamed joints. In oligoarticular juvenile idiopathic arthritis (JIA), synovial fluid neutrophils have impaired effector functions and altered phenotype. We hypothesized that these alterations might impact the immunoregulatory interplay between neutrophils and T cells. In this study we analyzed the suppressive effect of neutrophils, isolated from blood and synovial fluid of oligoarticular JIA patients, on CD4+ T cells activated by CD3/CD28 stimulation. JIA blood neutrophils suppressed T cell proliferation but synovial fluid neutrophils from several patients did not. The loss of T cell suppression was replicated in an in vitro transmigration assay, where healthy control neutrophils migrated into synovial fluid through transwell inserts with endothelial cells and synoviocytes. Non-migrated neutrophils suppressed proliferation of activated CD4+ T cells, but migrated neutrophils had no suppressive effect. Neutrophil suppression of T cells was partly dependent on reactive oxygen species (ROS), demonstrated by impaired suppression in presence of catalase. Migrated neutrophils had reduced ROS production compared to non-migrated neutrophils. A proteomic analysis of transwell-migrated neutrophils identified alterations in proteins related to neutrophil ROS production and degranulation, and biological processes involving protein transport, cell-cell contact and inflammation. In conclusion, neutrophils in synovial fluid of children with JIA have impaired capacity to suppress activated T cells, which may be due to reduced oxidative burst and alterations in proteins related to cell-cell contact and inflammation. The lack of T cell suppression by neutrophils in synovial fluid may contribute to local inflammation and autoimmune reactions in the JIA joint.

Temporomandibular joint in juvenile idiopathic arthritis: magnetic resonance imaging measurements and their correlation with imaging findings.

The aim of this study was to investigate the TMJ components in patients with juvenile idiopathic arthritis (JIA) and to compare them with a control group based on magnetic resonance imaging (MRI) measurements. This study comprised an assessment of MRI measurements of 96 temporomandibular joints (TMJ) following classification criteria set by the International League of Associations for Rheumatology (ILAR). Three measurements were considered for study: condyle excursion angle (CEA), height of articular eminence (HAE) and inclination of articular eminence (IAE). All TMJs were assessed by linear measurements made by using the OnDemand 3D software. The comparison between the groups was performed by using Mann-Whitney's test. Lower measurement values were found for IAE, HAE and CEA in JIA patients (P-values < 0.001, 0.005 and < 0.001, respectively). The study showed the differences in MRI measurements between JIA patients and controls, with the former with the lowest indices.

Utilizing ultrasound findings of a single indicator joint to assess non-systemic juvenile idiopathic arthritis

BackgroundMusculoskeletal ultrasound (MSUS) has been used worldwide in adult patients with rheumatoid arthritis (RA) but is beginning to play an increasing role in patients with juvenile idiopathic arthritis (JIA). The aim of this study was to investigate the application of MSUS findings of a single indicator joint in JIA to assess the disease activity and classify disease subtype.MethodsThirty-five non-systemic JIA patients with a total of 62 visits were retrospectively recruited in this study. Among the involved joints, the joint with highest value of grey-scale (GS) plus power Doppler (PD) (=GSPD) was selected as the indicator joint at each visit. The correlations between each MSUS parameter (GS, PD, GSPD) of indicator joints and the Physician Global Assessment (PGA) score, the Childhood Health Assessment Questionnaire-disability index (CHAQ-DI), and laboratory data were analyzed. The ultrasound features in different subtypes of JIA were also compared.ResultsPD was weakly correlated with the PGA score (rho = 0.323, p = 0.010), while both GS and GSPD were moderately correlated with the PGA score (rho = 0.405, p = 0.001; rho = 0.434, p = 0.000). On the other hand, GS, PD, and GSPD were weakly correlated with CHAQ-DI. Although erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) had a weak correlation with PGA, they were not statistically correlated with GS, PD, or GSPD. The proportions of effusion, synovial hypertrophy, and enthesopathy in three different subtypes, showed significant differences (Fisher’s exact test, p = 0.037; p = 0.004; p = 0.019). Enthesopathy was only seen in joints of enthesitis-related arthritis (ERA), but not in joints of polyarthritis and oligoarthritis.ConclusionsMSUS is an acceptable non-invasive tool for the patients with JIA, particularly for those with non-systemic JIA, that might assist disease classification, and whose parameters of the indicator joints may potentially contribute to the evaluation of disease activity.

Magnetic resonance imaging findings in the sternoclavicular joint in juvenile idiopathic arthritis and comparison with clinical examination.

The sternoclavicular joint (SCJ), an important link between the appendicular and axial skeleton, though involved in 41% of rheumatoid arthritis patients, has not been studied in juvenile idiopathic arthritis (JIA). Hence, this cross-sectional study was done to delineate the magnetic resonance imaging (MRI) findings in SCJ in JIA and compare with the clinical examination to diagnose SCJ arthritis. Of the 116 JIA patients attending the pediatric rheumatology clinic, twenty-one patients (42 SC joints) were evaluated by 1.5 T MRI using the four components of early and late inflammatory changes-synovial hypertrophy, bone marrow edema (BME), cartilage lesions, and bone erosions. Results were compared with clinical assessment of SCJ arthritis. Of the 42 SCJ evaluated (21/116 patients), MRI changes were seen in 27 SCJs (15 patients, 12.9% of 116 JIA patients). Early MRI changes were seen in 60% of joints found normal on clinical examination, with as much as 1/4th of them revealing late destructive changes. Synovial hypertrophy, BME, cartilage lesions, and bone erosions were seen in 5, 15, 4, and 10 patients, respectively. Sensitivity and specificity of clinical examinations to evaluate SC joint involvement were 55.5% and 53.3%, respectively. MRI evaluation of the SCJ in JIA revealed findings in 15/21 enrolled patients. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. Clinical examination was found to be neither sensitive nor specific. Key Points • MRI could delineate both early and late inflammatory changes in SCJ in JIA. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. • The frequency of SC joint involvement in JIA was at least 12.9% of patients in our study. • Clinical examination for evaluating SC joint arthritis has low sensitivity (55.5%) and specificity (53.3%).

Magnetic resonance imaging of the knee joint in juvenile idiopathic arthritis.

Juvenile idiopathic arthritis (JIA) is an umbrella term for a group of diseases in children younger than 16 years old lasting six weeks or longer. Synovitis may lead to destructive and irreversible joint changes with subsequent functional impairment. Prompt diagnosis is essential to prevent permanent joint damage and preserve joint functionality. In the course of JIA both the axial and peripheral skeleton may be involved in the inflammatory process, but the knee joint is most frequently affected. New drugs and treatment protocols have forced the need for diagnosis at the earliest possible stage. Magnetic resonance imaging (MRI) allows early detection of lesions and constitutes a superior diagnostic imaging method. Synovitis, tenosynovitis, enthesitis, bursitis, osteitis, cartilage loss, bone cysts, and erosions are lesions diagnosed in JIA, and they can be precisely imaged in MRI.This article aims to present MRI inflammatory features of the knee in children with JIA based on the literature.

Current status of MR imaging of juvenile idiopathic arthritis.

Juvenile idiopathic arthritis (JIA) is the most common chronic arthropathy in the pediatric population. Although the diagnosis is essentially clinical for many affected joints, MR imaging has become an important tool for the assessment of joints that are difficult to evaluate clinically, such as temporomandibular and sacroiliac joints, and for screening of inflammatory changes in the entire body by whole body MRI (WBMRI) assessment. The utilization of MR imaging is challenging in the pediatric population given the need for discrimination between pathological and physiological changes in the growing skeleton. Several multicentric multidisciplinary organizations have made major efforts over the past decades to standardize, quantify, and validate scoring systems to measure joint changes both cross-sectionally and longitudinally according to rigorous methodological standards. In this paper, we (1) discuss current trends for the diagnosis and management of JIA, (2) review challenges for detecting real pathological changes in growing joints, (3) summarize the current status of standardization of MRI protocols for data acquisition and the quantification of joint pathology in JIA by means of scoring systems, and (4) outline novel MR imaging techniques for the evaluation of anatomy and function of joints in JIA. Optimizing the role of MRI as a robust biomarker and outcome measure remains a priority of future research in this field.

P12 Arthrodesis in paediatric patients with erosive ankle arthritis by a single surgeon: a Scottish perspective

Abstract Background From our experience, a small cohort of patients with juvenile idiopathic arthritis (JIA) develop irreversible damage to ankle and subtalar joints despite immunosuppression with methotrexate and multiple biologic agents. In this case series, we describe 4 patients with JIA and erosive damage to ankle or subtalar joints who underwent arthrodesis by a single surgeon between 2011-2017 due to longstanding pain and impaired function despite medical and orthotic interventions. We assessed patient satisfaction regarding the procedure in terms of pain and function. There are no previous case series describing arthrodesis of ankle and subtalar joints in JIA. A case series of 8 patients with severe tibiotalar JIA who had arthrodiastasis (joint distraction) reported an improvement in pain and functional scores. Methods In this retrospective case series we reviewed the records of 4 paediatric patients with JIA in Scotland who underwent ankle arthrodesis performed by a single orthopaedic surgeon between 2011 and 2017. Questionnaires were posted out to each patient. These included Manchester-Oxford Foot scores (MOxFQ) and EQ5D scores. Results Time from diagnosis to commencing methotrexate (MTX) was 22 (6-30) months, time from diagnosis to biologic therapy was 5 (2-8) years and time to arthrodesis was 10 (6-14) years (Table 1). Age at surgery was 16 (13-20) years. Prior to surgery all patients reported significant ankle pain and 2 patients needed to wear an ankle-foot orthosis (AFO). Radiological features before surgery in these patients included marked degenerative changes and loss of articular cartilage in the ankle joints on MRI. All patients reported favourable scores in terms of function and pain following ankle or subtalar arthrodesis. Two patients expressed that they wished they had undergone surgery sooner. P12 Table 1:Patient CharacteristicsPatientJIA SubtypeComorbidityAge at diagnosis of JIA (years)Systemic TherapyNo of joint injection episodesVisual Analogue Pain Score Post-Surgery1RF –ve PolyarticularNil8MTX3EtanerceptAdalimumabAbatacept2Extended oligoarticularUveitis3MTX41/10Adalimumab3RF –ve PolyarticularNil6MTX40/10Etanercept4RF –ve PolyarticularTrisomy 21, VSD closure, obstructive sleep apnoea11MTX7EtanerceptTocilizumab Conclusion This case series helps demonstrate patient satisfaction in the small group of patients in our service where irreversible erosive disease caused pain and dysfunction not responsive to medical therapy. Conflicts of Interest The authors declare no conflicts of interest.

P03 Service evaluation of ankle damage in a single centre paediatric cohort of juvenile idiopathic arthritis

Poster presentation Tuesday 8 October Background The ankle is one of the most commonly affected joints in juvenile idiopathic arthritis (JIA) and ankle joint damage is a known complication. The frequency of ankle damage in modern JIA cohorts is unknown and optimal management pathways are unclear. Magnetic resonance imaging (MRI) is the most sensitive imaging modality for the assessment of joint damage. The aim of this analysis was to investigate the demographics, disease features and management of JIA patients with MRI changes consistent with ankle damage. Methods A single-centre, retrospective study over a four year period was conducted. JIA cases with damage based on MRI features were included in the study. MRI was reviewed by an experienced musculoskeletal radiologist and joint damage was defined as radiological evidence of cartilage loss or joint space narrowing. A standardised electronic pro forma was used to record demographics, disease features and treatments received. Results Fifty one JIA cases had an MRI scan during the study period and 16/51 (31%) had radiological evidence of ankle damage at a median interquartile range (IQR) follow-up of 7.6 (6.9 – 11.0) years; 7/16 (44%) had developed bilateral ankle damage. The median (IQR) duration of symptoms at diagnosis was 2(1.0-10.5) months. The mean age at diagnosis and at detection of ankle damage was 5.2 years and 12.1 years respectively. The most frequent JIA subtype was oligo-articular extended (50%), and 50% were ANA positive. The median (IQR) duration between detection of ankle damage and first episode of ankle synovitis was 5.4 (4.6 – 6.4) years. Ankle synovitis was present at diagnosis in 10/16 (62%). Median (IQR) number of ankle corticosteroid injections before the ankle damage was detected was 3 (2-3), one patient had evidence of damage at diagnosis. Median (IQR) number of any type of ankle imaging done before the ankle damage was detected was 1 (1-3). The median (IQR) time to start methotrexate from diagnosis was 6 (0 - 29.5) months and median (IQR) number of biologic and synthetic DMARDs used at follow-up were 3.5 (2.2 – 4.0). 7/16 (44%) patients had undergone an orthopaedic surgical procedure for their ankle damage. Conclusion Ankle synovitis at presentation and an extended oligo-articular disease course were common in this cohort of children and young people (CYP) with JIA and ankle damage. Ankle damage is an important challenge in JIA; a substantial number of this cohort ultimately required surgical intervention. There is an urgent need to develop a care pathway designed to improve early recognition and management of evolving ankle joint damage in JIA. Our analysis suggests that attention may need to focus on CYP presenting with ankle synovitis, particularly those who develop a poly-articular disease course, may merit high levels of vigilance with be at particularly high risk. Conflicts of Interest The authors declare no conflicts of interest.

T-Cell Compartmentalization and Functional Adaptation in Autoimmune Inflammation: Lessons From Pediatric Rheumatic Diseases.

Chronic inflammatory diseases are characterized by a disturbed immune balance leading to recurring episodes of inflammation in specific target tissues, such as the joints in juvenile idiopathic arthritis. The tissue becomes infiltrated by multiple types of immune cell, including high numbers of CD4 and CD8 T-cells, which are mostly effector memory cells. Locally, these T-cells display an environment-adapted phenotype, induced by inflammation- and tissue-specific instructions. Some of the infiltrated T-cells may become tissue resident and play a role in relapses of inflammation. Adaptation to the environment may lead to functional (re)programming of cells and altered cellular interactions and responses. For example, specifically at the site of inflammation both CD4 and CD8 T-cells can become resistant to regulatory T-cell-mediated regulation. In addition, CD8 and CD4 T-cells show a unique profile with pro- and anti-inflammatory features coexisting in the same compartment. Also regulatory T-cells are neither homogeneous nor static in nature and show features of functional differentiation, and plasticity in inflammatory environments. Here we will discuss the recent insights in T-cell functional specialization, regulation, and clonal expansion in local (tissue) inflammation.

Imaging of the Temporomandibular Joint in Juvenile Idiopathic Arthritis: How Does Quantitative Compare to Semiquantitative MRI Scoring?

Contrast-enhanced magnetic resonance imaging (MRI) is commonly used to evaluate temporomandibular joint (TMJ) disease in patients with juvenile idiopathic arthritis (JIA). However, MRI assessments have been limited by qualitative reporting, the presence of enhancement in normal joints, and a lack of standardized protocols. The purpose of the present study was to compare a quantitative MRI analysis using an enhancement ratio (ER) to a new semiquantitative system developed by Outcome Measures in Rheumatology and Clinical Trials (OMERACT). We performed a retrospective cross-sectional study of children with JIA who had undergone TMJ MRI with gadolinium enhancement at Boston Children's Hospital. The predictor variables were demographic data (sex, age at MRI) and disease-related findings (JIA subtype and arthritis medication at MRI). The outcome variables were OMERACT scores and ER (ratio of TMJ synovium and longus capitis muscle pixel intensities). The ER was compared with the OMERACT total, inflammatory, and damage scores using Pearson's correlation analysis and multivariable linear regression. Statistical significance was evaluated using the Student t test and analysis of variance with significance set at P<.05. Inter- and intraexaminer reliability were evaluated using intraclass correlation coefficients (ICCs). The sample included 50 subjects (84% female) with a mean age of 12.7±3.9years and 124 MRI scans. The mean ER was 2.5±0.9 (normal, <1.55). The mean OMERACT total was 4.9±3.3. Controlling for age, sex, JIA subtype, and medication, for every 1-U increase in ER, the OMERACT increased by 3.11 for the total (P<.001), 1.01 for the inflammatory (P<.001), and 0.86 for the damage (P<.001) scores. The intra- and interrater consistency was better for the ER (ICC, 0.83 and 0.96, respectively) than for OMERACT (ICC, 0.77 and 0.35, respectively). Quantitative evaluation of TMJ synovial enhancement using the ER is easier to score and has superior intra- and interrater agreement; however, it can only assess inflammation. Semiquantitative assessment of TMJ using the OMERACT adds data about chronic changes. Using both systems might provide the most accurate assessment of JIA status.

Management of Temporomandibular Joint Arthritis in JIA: Tradition-based or Evidence-based?

Only a decade ago, the temporomandibular joint (TMJ) was referred to as “the forgotten joint in juvenile idiopathic arthritis (JIA)” owing to a lack of clinical and research attention1. More recently, with the finding that TMJ arthritis is seen in a majority of patients with JIA2, an increasing amount of research has focused on this joint. TMJ arthritis may cause pain, impair joint and masticatory function, and affect dentofacial growth, leading to facial asymmetry and bite disturbances. TMJ destruction from arthritis significantly harms oral health and general quality of life3. Despite progress in research, strategies for management of TMJ arthritis are still based primarily on conviction and tradition rather than science. Systemic therapy is frequently ineffective in controlling TMJ disease4. By tradition, local management with intraarticular corticosteroid injection (IACI) is a common backup plan5,6. This has evolved from the decades-long effective use of IACI in management of adult temporomandibular disorder7. In early translation of this technique to children with JIA, it was found to be safe and effective8. IACI improves TMJ/mandibular function and provides pain relief for patients with JIA9. Further study, however, has found that the clinical benefits of IACI usually dissipate within the … Address correspondence to Dr. P. Stoustrup, Vennelyst Blvd. 9-11, 8000 Aarhus C, Denmark. E-mail: pstoustrup{at}odont.au.dk

Physical Examination Tools Used to Identify Swollen and Tender Lower Limb Joints in Juvenile Idiopathic Arthritis: A Scoping Review.

Background Juvenile idiopathic arthritis (JIA) is the most common form of rheumatic disease in childhood and adolescents, affecting between 16 and 150 per 100,000 young persons below the age of 16. The lower limb is commonly affected in JIA, with joint swelling and tenderness often observed as a result of active synovitis. Objective The objective of this scoping review is to identify the existence of physical examination (PE) tools to identify and record swollen and tender lower limb joints in children with JIA. Methods Two reviewers individually screened the eligibility of titles and abstracts retrieved from the following online databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL. Studies that proposed and validated a comprehensive lower limb PE tool were included in this scoping review. Results After removal of duplicates, 1232 citations were retrieved, in which twelve were identified as potentially eligible. No studies met the set criteria for inclusion. Conclusion Further research is needed in developing and validating specific PE tools for clinicians such as podiatrists and other allied health professionals involved in the management of pathological lower limb joints in children diagnosed with JIA. These lower limb PE tools may be useful in conjunction with existing disease activity scores to optimise screening of the lower extremity and monitoring the efficacy of targeted interventions.

Time to Reconsider Management of the Temporomandibular Joint in Juvenile Idiopathic Arthritis

The temporomandibular joints are often affected by juvenile idiopathic arthritis, but few evidence-based management strategies exist. Intra-articular steroid injection (IASI) is a common intervention and is associated with pain reduction and improved mandibular function. Emerging evidence, however, suggests that IASI may actually impair rather than improve mandibular growth. It is therefore time to reconsider this practice.