General pediatricians often initially address children's musculoskeletal (MSK) issues and play a crucial role in triaging and managing patients' rheumatologic conditions. This study assessed the ...effectiveness of a structured curriculum in enhancing pediatric residents' knowledge, MSK examination skills, and confidence during a 4-week pediatric rheumatology rotation.
Pediatric residents in their either second or third year who participated in the 4-week rheumatology rotation once across three academic years (July 2020-June 2023) were enrolled. Residents' knowledge, MSK examination skills, and confidence were assessed at pre- and post-rotation by using 25 multiple-choice questions, the Thai pediatric Gait Arms Legs Spine examination, and a questionnaire, respectively. The curriculum comprised instruction on MSK examinations, interactive lectures, case-based discussion, topic reviews, MSK radiology conference, clinical experience in rheumatology clinic and consultations, with self-guided learning with educational resources.
Fifty-eight pediatric residents (48 females, 10 males) with a mean age of 28.9 ± 0.8 years participated. Significant improvements were noted postrotation. Knowledge scores rose from 63.0 ± 12.2 to 79.7 ± 9.1 (mean difference 16.7 ± 10.3, p < 0.001). Similarly, MSK examination scores increased from 67.5 ± 14.4 to 93.6 ± 8.7 (mean difference 26.1 ± 14.6, p < 0.001). Residents also reported a marked increase in confidence across all evaluated areas, including history taking, MSK examination, arthrocentesis, and diagnosing and treating rheumatologic conditions (p < 0.001).
The 4-week structured curriculum in the pediatric rheumatology rotation significantly enhanced pediatric residents' knowledge, MSK examination skills, and confidence. These findings support the integration of pediatric rheumatology rotations into pediatric residency training programs.
Low bone mass is one of the complications of juvenile idiopathic arthritis (JIA). However, a study focusing on the low bone mass in children and adolescents with JIA in Southeast Asian countries is ...limited. This study aimed to evaluate the bone mineral density (BMD) of Thai patients with JIA and identify factors correlated with BMD. A cross-sectional study was conducted at a tertiary-care center. The BMD of the lumbar spines (BMDLS) and the total body (BMDTB) were measured by dual-energy X-ray absorptiometry. Thirty-eight patients were enrolled between July 2015 and January 2016. No patient had low BMDLS, and only 2 (5.3%) had low BMDTB. Serum 25-hydroxyvitamin D (25OHD) levels were significantly positively correlated with the BMDTB Z-score (coefficient: 0.047; 95% confidence interval = 0.011-0.082; P = .012). Our study demonstrated a very low prevalence of low bone mass. Optimization of the serum 25OHD level should be encouraged.
Children and adolescents with juvenile idiopathic arthritis (JIA) may suffer from disability and disease-related damage. This study aimed to investigate the prevalence of disability and damage, and ...identify the factors associated with articular and extra-articular damage in children and adolescents with JIA in a resource-restricted setting in Thailand.
This cross-sectional study enrolled JIA patients during June 2019-June 2021. Disability was assessed using the Child Health Assessment Questionnaire (CHAQ) and Steinbrocker classification criteria. Damage was evaluated using the Juvenile Arthritis Damage Index (JADI) and the modified-JADI (mJADI) tools.
There were 101 patients (50.5% female) with median age of 11.8 years. Median disease duration was 32.7 months. Enthesitis-related arthritis (ERA) was the most common subtype (33.7%), followed by systemic JIA (25.7%). Thirty-three (32.7%) patients had delayed diagnosis ≥ 6 months. Moderate to severe disability was found in 20 (19.8%) patients. Patients with Steinbrocker functional classification > class I were seen in 17.9%. Thirty-seven (36.6%) patients had articular damage. Extra-articular complications were observed in 24.8%. Growth failure and striae were the most common complications in 7.8%. Leg-length discrepancy was documented in 5.0%. Ocular damage was found in 1 patient with ERA. Multivariable logistic regression analysis revealed Steinbrocker functional classification > class I (aOR: 18.1, 95% CI: 3.9-84.6; p < 0.001), delayed diagnosis ≥ 6 months (aOR: 8.5, 95%CI: 2.7-27.0; p < 0.001), and ERA (aOR: 5.7, 95%CI: 1.8-18.3; p = 0.004) as independent predictors of articular damage. Systemic corticosteroids use was the independent predictor of extra-articular damage (aOR: 3.8, 95%CI: 1.3-11.1; p = 0.013).
Disability and disease-related damage was identified in one-fifth and one-third of JIA patients. Early detection and treatment are essential for preventing permanent damage.
Background
Pediatric rheumatology (PR) is a relatively new and rare subspecialty in emerging countries. This study aimed to investigate physicians' attitudes toward and real‐life clinical practice in ...PR among residency‐trained pediatricians in Thailand.
Methods
An electronic questionnaire was developed and sent via email to pediatricians from Thailand who completed their residency training between 2007 and 2015. Confidence in treating and managing children with rheumatic diseases was rated using a 5‐point Likert scale.
Results
The response rate was 281 out of 902 (31%), and the mean ± standard deviation age of respondents was 33.8 ± 2.7 years. Confidence was rated as adequate for history taking of children with rheumatic diseases (mean 2.76, 95% confidence interval CI: 2.66–2.91), but low for musculoskeletal (MSK) examination (2.42, 95% CI: 2.29–2.54), arthrocentesis (2.01, 95% CI: 1.91–2.11), and rheumatology investigation (2.49, 95% CI: 2.39–2.60). Confidence was high for diagnosis and management of Henoch‐Schönlein purpura (3.83, 95% CI: 3.74–3.92) and Kawasaki disease (3.46, 95% CI: 3.38–3.55), but low for juvenile idiopathic arthritis (JIA) (2.41, 95% CI: 2.30–2.52) and chronic systemic vasculitis (1.97, 95% CI: 1.85–2.08). Confidence to perform an MSK examination and arthrocentesis was significantly higher in respondents who had a full‐time pediatric rheumatologist working in their pediatric residency training center (P = 0.02, P = 0.01, respectively), and in those who had experienced a PR rotation (P < 0.001, P = 0.01, respectively). Most respondents agreed that more teaching in PR is essential (95.3%) and that case‐based discussion was the preferred teaching method.
Conclusion
The self‐rated confidence of pediatricians was low in MSK examination, arthrocentesis, and rheumatology investigation and therefore, teaching on PR is needed.
Background
Acute inflammatory arthritides can present as a result of immune reaction following infections. Post‐infectious arthritis and transient synovitis of the hip in children are included in ...this disease entity. The aim of this study was to describe the clinical profiles of post‐infectious arthritis and transient synovitis of the hip in Thai children.
Methods
A retrospective review was performed at a tertiary care hospital in Bangkok, Thailand from January 2005 to July 2017.
Results
Eighty‐six patients (56 boys and 30 girls) were included in this study. Mean age was 8.4 ± 4.8 years. Reactive arthritis was diagnosed in two patients (2.3%) following Salmonella spp. and Chlamydia trachomatis infections. Post‐streptococcal reactive arthritis was present in 10 patients (11.6%). Transient synovitis of the hip was found in 30 patients (34.9%). Forty‐four patients (51.2%) were clinically diagnosed with post‐infectious arthritis. Mono/oligoarthritis was the most common clinical profile (84.9%). The distribution of lower‐extremity involvement was as follows: hip, 47.6%; knee, 46.5%; and ankle joints, 30.2%. The documented preceding illness consisted mostly of upper respiratory tract symptoms (30.2%). Non‐steroidal anti‐inflammatory drugs were prescribed for 70 patients (81.4%).
Conclusion
Mono/oligoarthritis of the lower extremity was the main clinical profile. Preceding viral illness was documented in one‐third of children. Reactive arthritis was rarely seen.
Background
Musculoskeletal (MSK) complaints in children vary, ranging from benign, self-limited conditions to serious disorders. Juvenile idiopathic arthritis (JIA) is the most common rheumatic ...disease, initially presenting with MSK complaints. Delayed diagnosis and appropriate treatment have an enormous impact on the long-term outcomes and the level of disability. This study aimed to identify the features distinguishing JIA among children presenting with MSK complaints and to describe the spectrum of diseases at a large, single, tertiary center.
Methods
A retrospective chart review was performed of patients evaluated by pediatric rheumatology consultation at the Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, from July 2011 to June 2015.
Results
Of 531 patients, 285 (53.6%) had at least one MSK complaint. The mean age of the patients was 9.1 ± 4.1 years. Joint pain was the most common MSK complaint (86.3%), followed by limping (33%) and refusal to walk (19.6%). Joint swelling and limited range of motion were found in 146 (51.2%) and 115 (40.4%) patients, respectively. Seventy-three (25.6%) patients were diagnosed as JIA. The other common diagnoses included Henoch–Schönlein purpura (16.1%), reactive arthritis (14.2%), and systemic lupus erythematosus (13.7%). Morning stiffness ≥ 15 minutes odds ratio (OR) 8.217 (3.404–19.833); joint swelling on MSK examination OR 3.505 (1.754–7.004); a duration of MSK complaints of more than 6 weeks OR 2.071 (1.120–3.829); and limping OR 1.973 (1.048–3.712) were significantly associated with the ultimate diagnosis of JIA.
Conclusions
Morning stiffness ≥ 15 minutes is a strong predictor of JIA. Comprehensive history taking and an MSK examination will provide clues for making the ultimate diagnosis for children with MSK complaints.
Objectives
We evaluated the immunogenicity and safety of BNT162b2 vaccination in adolescents with systemic lupus erythematosus (adoSLE) receiving either high- or low-dose immunosuppressant (High-IS ...and Low-IS).
Methods
Patients aged 12–18 years diagnosed with SLE were enrolled. High-IS was defined as >7.5 mg/day prednisolone or with other immunosuppressant, while Low-IS was defined as only ≤7.5 mg/day of prednisolone and no immunosuppressant. Two doses of BNT162b2 vaccination were given 4 weeks apart, followed by a booster (third) dose at 4–6 months later. Anti-spike receptor binding domain (anti-RBD) IgG against Wuhan, neutralising antibody (NT) against Wuhan and Omicron variants, and cellular immune response by IFN-γ-ELISpot assay were evaluated following vaccination. Adverse events (AEs) and SLE flare were monitored.
Results
A total of 73 participants were enrolled, 40 and 33 in the High-IS and Low-IS group, respectively. At 4 weeks following the 2nd dose, overall anti-RBD IgG seropositivity was 97.3%, with no difference between the groups (p = .498). AdoSLE on High-IS had lower anti-RBD IgG (p < .001), Wuhan NT (p < .001), and IFN-γ-ELISpot (p = .022) than those on Low-IS. A 3rd dose induced significantly higher antibody responses than after the 2nd dose (p < .001) in both groups and established seroconversion against Omicron variants, with persistent lower antibody levels in High-IS group. SELENA-SLEDAI scores within 12 weeks after 2-dose vaccination was higher than before vaccination (3.1 vs 2.5; p < .036); however, the occurrence of disease flare by SELENA-SLEDAI flare index was not different after vaccination compared to before vaccination, consistent across groups. Non-severe AEs occurred similarly in both groups.
Conclusion
AdoSLE on High-IS induced lower SARS-CoV-2 vaccine immune responses than Low-IS. Vaccination can increase disease activity and requires close monitoring for disease flare.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Vaccination against coronavirus disease 2019 (COVID-19) is effective in protecting patients from severe COVID-19 infection. Disease flare-up following immunization in children with rheumatic ...disorders may result in patient reluctance to receive the vaccine. Underlying rheumatic diseases or the use of immunosuppressive drugs may influence the outcomes of COVID-19 vaccination and infection. We aimed to describe outcomes in children with rheumatic diseases following COVID-19 immunization and infection.
This retrospective study was performed at two large academic centers in Thailand. During the COVID-19 pandemic, all patients were routinely queried about COVID-19-related conditions. We included patients with rheumatic diseases aged <18 years who received at least one dose of a COVID-19 vaccine or had a history of COVID-19 infection with more than 6 months of recorded follow-up after the last vaccine dose or COVID-19 illness. Demographic information and data on clinical symptoms, disease activity, treatment, outcomes, and COVID-19 vaccination and infection were collected.
A total of 479 patients were included. Most (229; 47.81%) patients had juvenile idiopathic arthritis, followed by connective tissue diseases (189; 39.46%), vasculitis syndromes (42; 8.76%), and other rheumatic diseases (19; 3.97%). Approximately 90% of patients received at least one dose of COVID-19 vaccination, and half of the patients had COVID-19 infection. Among patients, 10.72% and 3.27% developed a flare after COVID-19 vaccination and COVID-19 illness, respectively. Flare severity after COVID immunization and infection was mainly mild to moderate. The predictor of flare after COVID-19 vaccination was the use of prednisolone ≥10 mg/day before vaccination (hazard ratio: 2.04, 95% confidence interval: 1.05-3.97,
= 0.037). Inactive disease before receiving the COVID-19 vaccination was a predictor of inactive status after a flare (hazard ratio: 2.95, 95% confidence interval: 1.04-8.40;
= 0.043). Overall, 3.36% and 1.61% of patients experienced a new onset of rheumatic disease after receiving the COVID-19 vaccine and after COVID-19 infection, respectively.
The COVID-19 vaccine is recommended for children with rheumatic disease, particularly those who are in stable condition. After COVID-19 vaccination, patients-especially those with active disease before vaccination or those receiving concurrent prednisolone doses of ≥10 mg/day-should be closely monitored.
Methylmalonic acidemia (MMA) is an inborn error of metabolism caused by either deficiency of the enzyme methylmalonyl‐CoA mutase or a defect in adenosyl‐cobalamin synthesis. Chronic kidney disease is ...its common complication and, in combination with persistent acidosis, leads to hyperuricemia. Symptomatic hyperuricemia or gout, however, has not been reported in MMA. We herein report two pediatric cases of MMA caused by MMAB mutations (cblB defect) with renal tubular acidosis, chronic kidney disease, hyperuricemia, and gout. The clinical findings of gout in these cases included recurrent first metatarsophalangeal arthritis and/or tophi. The patients responded to treatment with colchicine and allopurinol.
