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Dry Synovitis Complicates JIA Management

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Dry Synovitis Complicates JIA Management 26 Pediatric Rheumatology R HEUMATOLOGY N EWS • June 2006 A SK THE E XPERT Dry Synovitis Complicates JIA Management uvenile idiopathic arthritis is a diagno- nor well documented in the literature, Rheumatology News: How common a perience, anti–tumor necrosis factor ther- sis of exclusion and as such can be dif- despite the fact that it is not an infrequent finding is dry synovitis with respect to cer- apy may be more successful for treating Jficult to make with certainty. The con- finding in certain types of JIA, said Dr. Os- tain subsets of JIA patients? these patients, but a prospective analysis dition is defined as the inflammation of trov, who conducted a retrospective chart Dr. Ostrov: In my review of 50 patients, should be undertaken to clarify this issue. one or more joints for at least 3 months in review of 50 JIA patients to gauge the in- 30% of polyarticular and 14% of systemic a child or adolescent in whom other caus- cidence of the condition and to deter- patients were found to have dry synovitis, RN: What are the most important man- es of joint pain have been excluded. While mine which subsets of patients are most almost exclusively in hand joints. No child agement considerations for these kids? laboratory investigations likely to present with this with oligoarticular JIA had evidence of dry Dr. Ostrov: In addition to appropriate may provide some insight, disease variation. synovitis. medication, occupational therapy should the diagnosis is essentially For purposes of the re- be an important component of treatment clinical and often not view, Dr. Ostrov developed RN: How does the finding of dry synovi- for patients with dry synovitis because straightforward, considering preliminary diagnostic crite- tis complicate diagnosis and/or manage- the contractures are so prominent. that children commonly pre- ria for dry synovitis, includ- ment? sent with musculoskeletal ing joint pain and stiffness Dr. Ostrov: Because dry synovitis may be RN: How do wet and dry synovitis differ? concerns of unknown etiol- for at least 3 months plus difficult to identify in some patients, di- Dr. Ostrov: There is virtually no literature ogy—growing pains, for ex- minimal joint effusion and agnosis of JIA may be delayed if this is the on this variant of arthritis in children. What ample, or pain resulting minimally palpable synovial main feature. Also, in patients with “wet” is needed is a multicenter prospective data- from an injury that they tissue on examination, synovitis, changes in the synovitis allow base to collect information on diagnosis don’t remember happening. morning stiffness lasting for accurate monitoring of treatment re- and treatment of these patients. Such a BY BARBARA E. A finding of swollen, bog- OSTROV, M.D. more than 1 hour, loss of sponse. Obviously, this is not the case database would enable us to compare fea- gy joints is helpful for defin- range of motion (with or when there is no such change to monitor. tures of the variants and to assess different itively diagnosing juvenile id- without contractures) of in- treatment responses. Such a database also iopathic arthritis (JIA), but such a finding volved joints detected on physical exami- RN: Are the treatment options the same would be useful in the design of research is not a diagnostic prerequisite as it does nation, and improvement in the symptoms for wet and dry synovitis? and drug therapy trials. Currently, the issue not take into consideration the possibility and physical findings with appropriate Dr. Ostrov: Although some polyarticular of dry synovitis is too much a matter of of “dry” synovitis, according to pediatric medical therapy. Based on these criteria, JIA patients may have some symptomatic speculation and anecdotal opinion. ■ rheumatologist Barbara E. Ostrov of Dr. Ostrov determined that 17% of the pa- response to NSAIDs, my patient review re- Pennsylvania State University in Hershey. tients in the review had dry synovitis. vealed that the dry synovitis did not seem DR. OSTROV is professor of pediatrics and Dry synovitis—joint inflammation with In this month’s column, Dr. Ostrov dis- to respond at all to NSAIDs. Additionally, medicine at Pennsylvania State University significant stiffness, flexion contractures, cusses the diagnostic and management it appears that dry synovitis does not re- and chief of the division of pediatric and pain but little in the way of discern- implications of dry synovitis in juvenile spond as readily to other standard JIA rheumatology at the Milton S. Hershey able swelling—is neither well described arthritis patients. therapies, such as methotrexate. In my ex- Medical Center in Hershey, Pa. Cost of Childhood-Onset SLE Children Rate JIA Pain Lower Is Thrice That of Adult Lupus Than Do Their Parents, Physicians BY FRAN LOWRY tient self-reporting, said the researchers BY DOUG BRUNK months, and the researchers reported on re- Orlando Bureau (Arthritis Rheum. 2006;55:177-83). San Diego Bureau sults of 3,184 patient-months of follow-up. The researchers examined the level The cumulative cost of medical care dur- hildren with juvenile idiopathic of agreement between children, par- he mean direct cost for treating child- ing the study period was $3,965,048, which Carthritis rate the intensity of their ents, and physicians in rating JIA pain Thood-onset systemic lupus erythe- excluded the cost of outpatient medica- pain lower than their parents or their intensity. The study group comprised matosus per patient is $14,944 a year, which tions. This translated into a mean per-pa- physicians do. They also rate their 94 children, aged 5-18 years, who at- is roughly three times higher than the cost tient monthly cost of $1,245, or $14,944 per overall sense of well-being as being tended an outpatient clinic accompa- of treating an adult with the condition, re- year. In contrast, recent estimates of the per- much higher, according to Dr. Pablo nied by both parents. sults from the first analysis of its kind patient annual cost of treating adult SLE put Garcia-Munitis, formerly of the Uni- The child, mother, and father inde- demonstrated. the figure at $4,170. versità di Genova (Italy) and now of pendently rated the intensity of the “Whether this difference in cost between A breakdown of the direct costs revealed the Hospital de Ninos “Superiora Sor child’s present pain and of pain during adults and children is due to differences in that most came from inpatient or day-pa- Maria Ludovica,” La Plata, Argentina, the previous week according to a visu- health care delivery systems, adherence to tient care (28%), followed by laboratory and his associates. al analog scale. They also completed therapies, or differences in disease severity testing (21%), inpatient or day-patient med- The finding suggests that children the discomfort scale of the Childhood remains to be determined,” wrote the re- ication (13%), dialysis (11%), and outpatient may cope with their disease better than Health Assessment Questionnaire. searchers, led by Dr. Hermine I. Brunner of clinic visits other than rheumatology out- their parents realize, or that parents Rather than being combined with the the division of rheumatology at Cincinnati patient visits (11%). tend to be oversolicitous about their visual analog scale, the questionnaire Children’s Hospital Medical Center. The researchers noted that only 3 of the children’s health problems, wrote Dr. was presented in a separate form to The researchers reviewed the clinical 199 patients required dialysis, yet it was the Garcia-Munitis and his associates. avoid possible confusion, the re- and administrative records of 119 patients fourth-largest cost entity. “Therefore, based Observing the intensity of a child’s searchers said. with childhood-onset systemic lupus ery- on previous research in adults, dialysis ex- pain plays an important role in deter- On average, the children rated their thematosus (cSLE) who were diagnosed penses contribute to the direct cost of both mining therapy for children with juve- pain and disability as consistently low- and treated at two large tertiary pediatric SLE and cSLE in similar proportions,” they nile idiopathic arthritis (JIA). Because er, and their overall well-being as bet- rheumatology centers in the United States wrote. the experience of pain is personal and ter, than did their mothers, fathers, between January 2001 and April 2004 “This finding suggests that prevention subjective, children’s self-reports are giv- and physicians. Mothers and fathers (Arthritis & Rheum. 2006;55:184-8). They and aggressive therapy of renal diseases are en preference whenever possible. Yet were similar in their mean ratings of used health-related quality of life estimates not only of utmost importance for avoiding physicians usually rely on information their child’s pain, disability, and well-be- for patients with cSLE as reported in the patient damage but also appear to be rele- obtained from the parents, most often ing. Physicians gave the worst scores of medical literature to calculate the direct vant for containing the cost of care of from the mother. There is growing all. With regard to the level of present cost per quality-adjusted life-year. These cSLE,” they noted. awareness that the sole use of parent pain, mothers and children had mod- quality of life measures were based on the The study was supported by the Robert proxy reports may fail to capture the fact erate agreement, whereas fathers and global health subscale of the Child Health Wood Johnson Foundation, the Arthritis that parents and children may differ in children and physicians and children Questionnaire. Foundation of America, and the National their perceptions of health, hence the had poor agreement. The parents and Of the 119 patients, 87% were female. Institute of Arthritis and Musculoskeletal need to understand the relationship be- physicians had moderate agreement in The mean duration of follow-up was 27 and Skin Diseases.
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