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Abstract






Prognostic factors for radiographic progression, radiographic damage, and disability in juvenile idiopathic arthritis.

Magni-Manzoni S1, Rossi F, Pistorio A, Temporini F, Viola S, Beluffi G, Martini A, Ravelli A.

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Abstract

OBJECTIVE:

To investigate the rate of radiographic progression and identify prognostic factors of radiographic progression, radiographic damage, and physical disability in juvenile idiopathic arthritis (JIA).

METHODS:

Ninety-four JIA patients with a median disease duration of 1.1 years were followed up prospectively for a median of 4.5 years. Bilateral wrist radiographs were obtained at baseline, at 1 year, and at the last followup visit. Radiographic damage was assessed by the carpal length (Poznanski score), and physical disability by the Childhood Health Assessment Questionnaire (C-HAQ). Yearly radiographic progression, the Poznanski score at the final visit, and the C-HAQ score at the final visit were used as outcome measures. Baseline parameters included demographic, clinical, laboratory, and radiographic data.

RESULTS:

The mean +/- SD Poznanski score was -1.2 +/- 1.3 at baseline, -1.7 +/- 1.8 at the 1-year visit, and -1.9 +/- 2.2 at the final visit (P < 0.0001). Radiographic progression was greater during the first year (mean +/- SD -0.5 +/- 1.1) than between the 1-year visit and the final visit (-0.2 +/- 1.3). The mean yearly radiographic progression during the entire study period was -0.1 +/- 0.4. Logistic regression analysis revealed that radiographic progression during the first year was the only baseline parameter that was predictive of all 3 study outcomes. The final Poznanski score was also predicted by the baseline Poznanski score, whereas female sex was protective against radiographic progression.

CONCLUSION:

We identified the prognostic factors for poorer outcome in polyarticular-course JIA. The changes in the early Poznanski score can be used to predict long-term joint damage and physical disability.

 

Juvenile idiopathic arthritis (JIA) is a heterogeneous condition whose clinical course varies widely and is difficult to predict (1). Although it was previously believed that the disease had a good to excellent outcome in most cases, recent studies have shown that a higher than expected percentage of patients may develop unremitting disease and that there is a considerable risk of developing progressive joint destruction and serious functional disability (2). Predicting outcome in JIA is crucial for its optimal clinical management. It would be desirable to be able to distinguish patients with a high likelihood of an untoward outcome so as to better manage the disease course and to institute appropriately aggressive therapy at an early stage. This has become even more important since new therapies that can be effective in the most severe and refractory forms of JIA are now available (3).

The degree of joint damage caused by the synovitis process is traditionally assessed radiographically. Radiography is an important clinical tool for the evaluation of disease progression (4) and is usually seen as the “gold standard” for measuring the disease-modifying potential of antirheumatic drugs (5). In adult patients with rheumatoid arthritis, serial plain radiographs have been largely used to measure the progression of joint damage in clinical practice, clinical research, and therapeutic trials. However, little information exists on the use of radiography in the investigation of disease outcome in children with JIA. Furthermore, the assessment of radiographic progression has never been included in controlled trials of second-line agents in JIA. This chiefly reflects the lack of established, validated radiographic scoring systems for use in subjects of pediatric ages.

It is commonly believed that the traditional scoring methods used for adult rheumatoid arthritis (6, 7), which are based on the assessment of joint space narrowing and erosions, may not be suitable for the evaluation of pediatric joint diseases. In contrast to adults, it is difficult to reliably determine cartilage loss and erosions in children by simple examination of radiographs because ossification is incomplete and joint space width varies with age (8). In 1978, Poznanski et al (9) published standards for normal carpal length in growing children, thus enabling a measurement of carpal size that is not dependent on the degree of ossification. The carpal length reflects a reduction in the joint space of the wrist, rather than erosive damage, and may therefore be a good method for identifying cartilage damage in the early phases of joint diseases. Previous studies have shown that the assessment of carpal length represents a suitable radiographic tool for investigating the efficacy of second-line drug therapy in JIA (10, 11).

The purpose of the present study was to determine the rate of radiographic progression, as measured by carpal length, in patients with polyarticular-course JIA. We also attempted to determine prognostic factors for radiographic progression, radiographic damage, and physical disability.

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