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Dr shridhar jia children and young people with arthritis.ppt 121011


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Dr shridhar jia children and young people with arthritis.ppt 121011

  1. 1. Children with Arthritis (JIA) Dr A Sridhar, Consultant Paediatrician, UHL NHS Trust, Leicester
  2. 2. Juvenile Idiopathic Arthritis (JIA) <ul><li>Most common connective tissue disease in childhood </li></ul><ul><li>The DOH Musculo-skeletal framework states that musculo-skeletal conditions are the biggest cause of disability in children . </li></ul><ul><li>In recent years, the management of children with Arthritis has changed significantly. </li></ul><ul><li>The availability of the new drugs (DMARDS, Biologicals) has lead to a marked improvement in disease outcomes </li></ul><ul><li>The emphasis is on early diagnosis and tight disease control </li></ul>
  3. 3. J.I.A. R.A. <ul><li>a disease affecting a growing developing skeleton. </li></ul><ul><li>a disease affecting a developed skeleton . </li></ul><ul><li>In children there is the capacity for regeneration, re-modelling and repair </li></ul><ul><li>This needs to be used to a maximum </li></ul><ul><li>The treatment needs to be different </li></ul>
  4. 4. JIA- Definition <ul><li>Is a group of conditions </li></ul><ul><li>in which there is chronic arthritis </li></ul><ul><li>lasting more than 6 weeks , </li></ul><ul><li>presenting </li></ul><ul><li>before 16 years of age </li></ul>
  5. 5. JIA- Criteria for Diagnosis American College of Rheumatology Revised Criteria <ul><li>Age of onset < 16 years </li></ul><ul><li>Arthritis of one or more joints </li></ul><ul><li>Duration of disease > 6 weeks </li></ul><ul><li>Other conditions which present with arthritis in childhood must be excluded </li></ul>
  6. 6. Aetiology <ul><li>Autoimmune disease in which the cause of arthritis is largely unknown </li></ul><ul><li>combination of factors </li></ul><ul><ul><li>Environment (infection, trauma, stress) </li></ul></ul><ul><ul><li>Immuno-genetic </li></ul></ul>
  7. 7. JIA Epidemiology <ul><li>Described in all races and geographic areas </li></ul><ul><li>The UK prevalence is estimated at 1:1000 under 16 years with an incidence of approximately 1:10000 </li></ul><ul><li>Females predominate 2:1 </li></ul><ul><li>Leicestershire has a population of approximately 117,600 children (Mid-2006 population estimates) </li></ul>
  8. 8. JIA- Onset Types <ul><li>Pauciarticular ( < 4 joints) </li></ul><ul><li>Polyarticular ( > 5 joints) </li></ul><ul><li>Systemic (arthritis with fever and rash) </li></ul>
  9. 9. ILAR Proposed Classification Criteria <ul><li>Juvenile Idiopathic Arthritis (JIA) </li></ul><ul><li>Systemic </li></ul><ul><li>Polyarticular: RF+ and RF- </li></ul><ul><li>Oligoarticular: persistent and extended </li></ul><ul><li>Psoriatic arthritis </li></ul><ul><li>Enthesitis-related arthritis </li></ul>
  10. 10. Presenting features of Arthritis <ul><li>Joint Pain </li></ul><ul><li>Joint Stiffness </li></ul><ul><li>Joint swelling </li></ul><ul><li>Limp </li></ul><ul><li>Restriction of movement </li></ul><ul><li>Eye symptoms </li></ul><ul><li>Systemic symptoms </li></ul>
  11. 11. Common Differential Diagnosis <ul><li>Irritable hip- Transient Synovitis </li></ul><ul><li>Septic Arthritis, Osteomyelitis </li></ul><ul><li>Infection – Viral, Bacterial, Lyme disease </li></ul><ul><li>Malignancy – leukaemia, Neuroblastoma </li></ul><ul><li>Perthe’s Disease </li></ul><ul><li>Slipped Capital Femoral Epiphysis (SCFE) </li></ul>
  12. 12. Generalised Joint and Bone pains <ul><li>Non-specific but clinically well, No joint Swelling </li></ul><ul><li>Hyper-mobility of Joints- either Syndromic or Benign Hypermobilty syndromes </li></ul><ul><li>Vitamin D deficiency </li></ul>
  13. 13. JIA Management <ul><li>No cure but treatable </li></ul><ul><li>Remissions and Relapses </li></ul><ul><li>Involves multidisciplinary team (MDT) approach </li></ul><ul><li>Relieve pain, reduce inflammation, preserve joint function, maintain normal growth and development </li></ul><ul><li>Screen for Uveitis </li></ul>
  14. 14. Medical Management <ul><li>NSAIDS – Ibuprofen, Naproxen, Piroxicam </li></ul><ul><li>DMARDS (Disease modifying anti rheumatic drugs) </li></ul><ul><li>- under Rheumatologist’s supervision </li></ul><ul><li>- Methotrexate: Orally or subcutaneously: Weekly </li></ul><ul><li>Joint steroid injections </li></ul><ul><li>Corticosteroids : Oral or IV Methyprednisolone </li></ul><ul><li>Anti- TNF agents </li></ul><ul><li>– block the immune protein TNF : Infliximab, Etarncept, Adalimumab </li></ul>
  15. 15. Physiotherapist & Occupational Therapists <ul><li>Develop exercise programs </li></ul><ul><li>Strengthen muscles & keep joints flexible </li></ul><ul><li>Encourage normal limb development </li></ul><ul><li>Maintain function and prevent deformities </li></ul><ul><li>- </li></ul>
  16. 16. JIA Prognosis <ul><li>Chronic disease which is treatable but cannot be cured </li></ul><ul><li>Characterized by remissions and Relapses </li></ul><ul><li>Overall the prognosis is much better in JIA compared to RA </li></ul>
  17. 17. JUVENILE RHEUMATOID ARTHRITIS Poor Prognostic Signs <ul><li>Pauciarticular </li></ul><ul><ul><li>Long duration of active disease </li></ul></ul><ul><ul><li>Conversion to polyarticular disease </li></ul></ul><ul><ul><li>Chronic uveitis </li></ul></ul><ul><li>Polyarticular </li></ul><ul><ul><li>Long duration of active disease </li></ul></ul><ul><ul><li>Articular erosions </li></ul></ul><ul><ul><li>RF positivity </li></ul></ul><ul><li>Systemic </li></ul><ul><ul><li>Conversion to polyarticular disease </li></ul></ul>
  18. 18. Paediatric Rheumatology Service Aims of the Service <ul><li>To provide a high quality care for children and young people with Rheumatological problems locally </li></ul><ul><li>To provide or enable them to receive the care at home </li></ul>
  19. 19. Paediatric Rheumatology Service <ul><li>Running the service:15 yrs </li></ul><ul><li>All children < 16 yrs age </li></ul><ul><li>Children between 16-18 yrs( full time education) or with other chronic medical conditions </li></ul><ul><li>Significant number of children with JIA on Methotrexate therapy </li></ul>
  20. 20. Clinical team <ul><li>Consultant Paediatricians with specialist interest in Paediatric Rheumatology </li></ul><ul><li>Adult Rheumatologist </li></ul><ul><li>Specialist Registrar </li></ul><ul><li>Clinical Nurse Specialist (CNS) </li></ul>
  21. 21. Conditions seen <ul><li>JIA and other Inflammatory Arthropathies </li></ul><ul><li>Non-inflammatory Musculo-skeletal pain syndromes </li></ul><ul><li>Childhood Vasculitis </li></ul><ul><li>Hyper-mobility syndromes </li></ul>
  22. 22. OPD clinics <ul><li>OPD Clinics; New and follow up </li></ul><ul><li>Consultant/Registrar led </li></ul><ul><li>Weekly clinics </li></ul><ul><li>Rapid access clinics </li></ul><ul><li>Annual Reviews </li></ul>
  23. 23. Children’s Day Care Unit <ul><li>Mon-Fri, 0800- 1800 hrs </li></ul><ul><li>Methotrexate info, counselling , injections, training to parents </li></ul><ul><li>Bloods sampling </li></ul><ul><li>Joint steroid injections </li></ul><ul><li>Specialist Nurse support- Close liaison with Diana team in the community </li></ul><ul><li>Methotrexate MDT meetings: </li></ul><ul><li>( 2 meetings/month): Specialist nurse, Pharmacist and Consultant </li></ul>
  24. 24. Inpatient Services <ul><li>Dedicated support by on-call team </li></ul><ul><li>Open access to Children’s assessment unit- 24x 7 </li></ul><ul><li>Multi-disciplinary team: Physiotherapy, OT, other speciality input </li></ul>
  25. 25. Support Services <ul><li>Paediatric Physiotherapist </li></ul><ul><li>Occupational Therapist (O.T) </li></ul><ul><li>Podiatrist/Orthotist </li></ul><ul><li>Paediatric Pharmacist </li></ul><ul><li>Paediatric Dietician </li></ul><ul><li>Play therapist </li></ul><ul><li>Dedicated secretarial support </li></ul>
  26. 26. Specialist Services <ul><li>Paediatric Ophthalmologist </li></ul><ul><li>Paediatric Dermatologist </li></ul><ul><li>Paediatric Orthopaedic Surgeon </li></ul><ul><li>Paediatric Radiologist: X-rays, U/S, MRI Scans </li></ul><ul><li>Musculo-Skeletal Radiologist; Monthly meetings </li></ul>
  27. 27. Transition <ul><li>Transitional Services </li></ul>