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Advances in pediatric rheumatology paving the way to better care: better medications, a team approach, and empowerment optimize results.

Article Excerpt
Advances in pediatric rheumatologic disease--from new disease classification and understanding to decreased morbidity and mortality--have been significant over the past 10 years. Accompanying these advances have been declines in joint replacements, hospitalizations, and permanent disability. Now most children with rheumatologic disease attend school regularly and pursue extracurricular activities. Several factors contribute to these advances that probably will lead to continued improvement in the future.

Perhaps a central driver of improvement in the area of pediatric rheumatology has been the implementation of a team approach to patient care. This team includes the patient and his or her family, the pediatric rheumatologist and associated rheumatology personnel, the primary care physician and, when needed, other subspecialists. Depending on the patient, the pediatric rheumatology team also may include a nurse, occupational therapist, physical therapist, dietician, and psychologist. All of the team members are vital to achieving optimal health for these patients.

In this article, we discuss topics that are germane to all members of the pediatric rheumatologic disease team, especially the primary care physician. We cover advances in the areas of juvenile arthritis, medication monitoring, and evaluation of intercurrent illness. We also offer insights that the primary care physician can use to support and empower the patient to assume some responsibility for his own care in the areas of compliance, sleep, stress management, weight control, and osteoporosis.

JUVENILE ARTHRITIS

Nomenclature changes

The classification of pediatric arthritis has been garnering much attention in the past few years. Considerable discussion and debate have centered around changing the nomenclature for the disorder traditionally referred to as juvenile rheumatoid arthritis (JRA), with subtypes of systemic, polyarticular, and pauciarticular disease. Proposed alternative names include juvenile chronic arthritis (JCA) (1) and juvenile idiopathic arthritis (JIA). (2) The JCA and JIA systems include additional subtypes of psoriatic arthritis and enthesitis-associated arthritis, which overlap with the spondyloarthropathies. In the old nomenclature, these are separate.

Regardless of the classification system that is used, all the proposed systems contain 3 major patterns of JRA: systemic, polyarticular, and pauciarticular. The goal in renaming these subtypes is to gain consistency for the purposes of research studies conducted in the United States and elsewhere. Nomenclature changes will not affect the approach to diagnosis or management of juvenile arthritis.

Improved diagnosis

Of high interest among pediatric rheumatologists is research aimed at using gene microarrays to improve diagnosis and identify likely responders to treatment options. For example, systemic-onset juvenile arthritis is a disorder in which interleukin (IL)-1 has a prominent role. Gene studies using blood leukocytes and microarray technology have identified 88 genes that are associated with systemic-onset juvenile arthritis, 12 of which appear to be specific for this disorder. (3)

Improved diagnostic methods...

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