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JUVENILE IDIOPATHIC ARTHRITIS IN CHILDREN: CLINICAL
PICTURE, DIAGNOSIS AND TREATMENT OPTIMIZATION
Mallaev Shuxrat Sherqulovich (
ORCID:0009-0002-3439-4282)
associate professor of the Department of propaedeutics of children's
diseases of the Alfraganus university
Tashkent, Uzbekistan
Summary: The article presents clinical laboratory features and prognostic
criteria of juvenile rheumatoid arthritis. The clinical characteristics of the disease
and the results of laboratory analysis are important in choosing an effective treatment
method. Medicinal and surgical treatment of joints is recommended, depending on
the severity of the disease, the characteristics of the clinical flow and the results of
the functional laboratory analysis.
Keywords: juvenile rheumatoid arthritis, diagnostics, prognosis.
Relevance.
Juvenile rheumatoid arthritis (
JRA
) is a destructive inflammatory disease of
joints with unknown etiology, complex immunogenic pathogenesis, characterized by
symmetric chronic arthritis, systemic lesions of internal organs, which leads to the
disability of sick children. Improving the effectiveness of treatment for this disease is
therefore a highly topical issue in terms of both scientific and practical pediatrics.
There are many factors that trigger the disease. The most frequent are viral or
mixed bacterial-viral infection, joint injury, excessive or supercooling insolation,
prophylactic inoculations carried out against the background or immediately after the
acute respiratory infection (ARI) of a viral or bacterial nature [3,11,15,17].
It is known that it is the early years of the disease that are decisive in the
development and progression of the pathological process. In the earliest period of the
JRA, when the process is in the primary, exudative, phase, the reversibility of the
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disease is significantly higher due to the still-inconclusive autoimmune mechanisms
and the absence of a pannus, the morphological basis of the joint destruction
[4,8,9,11,12]. It has been shown that within 2-4 months of the onset of the disease,
there are morphological signs of chronic synovitis in the joints. Numerous studies of
the JRA have shown that erosion changes in joints also occur at an early stage. For
example, an X-ray examination of 90 patients with early (<1 year) Over the next
three years, it was found that changes in the joints of the brushes and the stop occurred
in 70% of cases [ 1,2,3,7 ]. According to most recent studies, 25% of patients have
erosive joint changes already in the first year of the onset of clinical symptoms of the
JRA [ 7,8,10,12 ]. Clinical dynamics - laboratory manifestations of juvenile
rheumatoid arthritis (
JRA
) - one of the widely debated difficulties of JRA
rheumatology, The relevance of which is explained by two main factors - the
subtleties of the disease in babies with different debut variants and the effectiveness
of all possible approaches of basic therapy. The results of the retrospective studies of
the ADP reflect the scientific and practical statements of reviewers on the evolution
of the disease - the number of patients with continuous development of the disease
ranges from 33% to 75%, some researchers estimate that only 10 - 20% of patients
have the most severe disability, and most infants have a favorable illness (1-4). At the
same time, the literature also shows the negative dynamics of the JRA - the
functioning of gross functional deficiency of 30% of cases and disability - in 51.5%
of patients with different debuts.
Purpose of the study. Study clinical and laboratory manifestations of juvenile
rheumatoid arthritis and determine predictive outcome criteria.
Material and methods.
Eighty-four children between the ages of 3 and 16 (average age 11) with
rheumatoid arthritis were monitored, of whom 74 (per cent) were articular and 10 (per
cent) were systemic. Of the cases examined, 47 (56 per cent) were boys and 37 (44
per cent) were girls. The patients were divided into two groups depending on the
treatment provided: 54 patients constituted the main group that received
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chronotherapy by nimesulide and 30 patients with traditional therapy Nsaids formed
a comparison group. The control group consisted of 20 practically healthy children.
The development of the disease may be preceded by trauma, bacterial and
viral infection, including ARI, preventive vaccination, insolation, psychological
trauma. The distribution of the factors causing the development of the
JRA
among
the patients we observe is shown in Table 1.
Table 1.
Triggering factors of the
JRA
Factors
Age
up to 7 years
over 7 years of age
abs.
%
abs.
%
Hypothermia
9
10.7
36
42.8
Infectious diseases
5
6.0
12
14.3
Trauma
-
-
1
1.2
Allergy
4
4.8
6
7.2
Unknown
2
2.4
8
9.5
In total:
20
23.8
64
76.2
As can be seen from the table, hypothermia has been observed as a
provocative factor for most patients of both pre-school and school age. Of the
infectious diseases, 11 had severe ARI, 3 had anamnesis from pneumonia in the last
3 months, 2 had acute intestinal infection and 1 had follicular angina. In third place,
allergies are the trigger factor: allergic to 4, allergy to 3, allergy to 2, and polynosis
to 1.
Rheumatoid activity evaluation process using index DAS 4 we carried
out considering clinical guidelines E.L.Nasonova: 1st degree of activity was
aevaluated at the values DAS 4 <2.4 units 2nd degree of activity was characterized
by values in a range of 2.4 < DAS 4 <3.7 units, respectively, 3rd degree -
with DAS 4> 3.7 units. It was revealed that the average DAS 4 values in the groups
approximately corresponded to the established boundaries ( Table 2).
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Indicators of activity of the rheumatoid process using the DAS 4 index in
the examined patients.
Indicator
1st
degree
of
activity
2nd degree
of
activity
3rd
degree
of
activity
Das4
1.37 -2.29
2.48-3.7
3.71-4.54
The calculation of the DAS 4 indicator in dynamics, even in the absence of
significant differences with the initial value, established a higher level of activity. An
intragroup analysis of DAS 4 indicators found that in the group of patients with
minimal activity, the parameters did not change significantly or tended to decrease in
most children. In patients with the 2nd degree of activity in 19 (59.3%) cases an
increase in DAS 4 was detected , in 13 (40.6%) cases there was a slight decrease or
absence of parameter changes.
Result and discussion
The polyarticular variant of the
JRA
was observed in 35 patients examined, of
which 6 were seropositive for the rheumatoid factor. In the seropositive subtype, the
start with symmetric polyarthritis was noted. The wrist and foot joints were usually
affected. Structural changes in the joints developed during the first six months of the
disease. By the end of the first year, diseases in the joints of the wrist formed ankylosis
in two patients. One patient developed destructive arthritis. According to literature, this
form of
JRA
is the early debut of adult rheumatoid arthritis.
The joint-visceral form was observed in 10 of the patients we examined and was
characterized by a high temperature reaction, which was intermittent and did not
decrease when treated with antibiotics. The fever was accompanied by a polymorphic
rash of bright pink. All groups of peripheral lymph nodes have increased. Several joints
were involved - knee, ankle, elbow, neck. All the joints were painful and swollen. There
was an increase in liver and spleen size.
Table 3.
Frequency of
JRA
x-ray criteria
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Stages
Signs
abs.
%
1
Epiphyseal osteoporosis
53
63.1
2
Joint cleft constriction, single erosion
27
32.1
3
Destruction of cartilage and bone
3
3.6
4
Fibrous and bone ankylosis
1
1.2
As can be seen from the table, half of the patients we examined had the first
stage of anatomical changes for Steinbrocker, i.e. epiphyseal osteoporosis, and in 1/3
patients we found that the joint slit was constricted and that there was single erosion.
Destruction of cartilage and bone occurred in three patients with a disease lasting
more than three years. Ankylosis formed in a sick girl with Still syndrome.
The treatment of various forms of ADR, particularly severe and
progressive, is a complex task requiring the joint efforts of the doctor, the sick child,
his parents and the family as a whole. Effective therapy leads to the achievement of
remission of the disease and improvement of the patient’s quality of life. The
emergence in recent years of new biological agents (infilksimab, ethanercept,
rituksimab, adalimumab, etc.) that have a significant impact on the course of the
disease, and the first experience with some of them offers hope for improving the
outcome of the disease.
We have developed algorithms for predicting the health of schoolchildren. In
Table 5 of Wald’s successive analysis, each topic has a numerical value with a (+) or
(-)sign. The numerical threshold for accepting a certain conclusion (with 95%
probability) is 13. It is obtained by the algebraic addition of the predictive coefficients
of each proposed topic in the table.
Already after the first two weeks of using COX-2 inhibitors, 57.4% of patients
showed an ACR20 response, 24.1% of patients showed an ACR of 50, and 3.7%
showed an ACR70. By the 8th week, the effectiveness of the drug was observed in
80% of patients, of which ACR20 response was achieved in 15%, ACR50 in 35%,
ACR70 in 30%. In addition, there was an improvement in the well-being of patients,
an increase in overall activity, a decrease in the severity of symptoms of intoxication,
and a decrease and normalization of laboratory activity indicators . In 44 patients with
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the articular form of the disease and 10 with the systemic form of Jura who completed
the treatment of COX-2 inhibitors, the dose of glucocorticosteroids was reduced. The
average daily dose of prednisone at the 8th week of COX-2 inhibitors COX-2
inhibitors was effective not only against early arthritis, but also in patients with a long
history. Given the good response to therapy, 11 children received prolonged therapy
of COX-2 inhibitors.
The results confirm the efficacy and safety of COX-2 inhibitors in the
treatment of refractory, long-lasting Jurassic. After 6 months in patients who received
COX-2 inhibitors in complex therapy, the disease activity significantly
decreased. They reliably (P <0.05) decreased the number of joints with exudation and
painful joints, decreased the Richie index and the value of the DAS4 index.
Conclusions.
1. On the basis of the complex of clinical-laboratory and instrumental and functional
methods of investigation, the clinical variant of the disease, the level of its activity
and the features of the current have been clarified. This is the basis for the
development
of
a
range
of
treatment
measures.
2. Applying a predictive approach to determining the threat of adverse outcome of the
ADP is a modern and effective way of preventing disease progression and choosing
the most appropriate therapeutic tactic option.
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