Raju P. Khubchandani *
Department of Pediatrics.*
|Like in any chronic disease prognostication is crucial to individual patient care, besides helping health planners at a macro level and guiding future research endeavors in management.
The words outcome and prognosis are not synonymous. In fact it is outcome studies which are used to guide and understand factors which can help to predict at the outset what course the patient is going to follow.
Would authorities confess the lack of quality prospective studies in Juvenile Arthritis that could help us arrive at a consensus regarding prognosticating for afflicted children? The reasons for this are manifold. Firstly the outcome studies performed use different disease classifications and differing nomenclature for the disease we now know as JIA making comparison of data unfeasible. Hopefully with the recognition of the ILAR classification this issue has been addressed. Secondly with a host or new drugs which are now available to treat the condition and the change in paradigms of management the older outcome studies have been rendered less relevant. However, we in India and similarly those in other countries where biologicals still remain a piped dream may not be able to extrapolate from those recent Western studies where these newer class of drugs have been used. Thirdly even the recent studies performed have limitations including design (prospective Vs retrospective) number of cases (limited number in the subtypes) non-uniformity of follow up duration and outcome measures studied. And last but not the least it is important to realize that outcome in Juvenile arthritis is not governed my joint status alone but also by extra-articular manifestations such as uveitis / amyloidosis / macrophage activation syndrome, etc.
An ideal outcome study would therefore be multicentric / multiethnic, prospective, with a common classification system, similar investigative arms and common treatment protocols which would measure the outcome in terms of a well defined remission, radiological progression and quality of life scores over fixed and prolonged intervals of time.
Till this utopian dream materializes we are constrained to draw from the material and studies available to us to date. Disease groups is known to be the most important guiding factor with persistent oligoarticular arthritis known to have the best outcome in terms of higher remission rates (36-84%), better functional status and lower rates of erosive damage in most of the studies though there is a wide variation in remission rates in the various studies. The extended oligoarticular subtype fare less well but again the remission rates reported in various studies are widely varied though publications which have looked at prevalence of joint erosions have reported a high percentage of erosions in this sub category (33-43%). Other groups have lower remission rates than oligoarticular disease but the variation in remission rates reported is even greater in both the polyarticular. (12.5% - 65%) and systemic (0-76%) groups.
The predictive role of individual disease features has also been studied and reported by various workers. Demographic factors, disease related issues such as onset and course, nature of joint involvement (duration / joint group / joint count / symmetry) acute phase reactants and autoantibodies (RF / ANA) have all been studied in their role as predictors of ongoing activity, functional outcome and erosive disease and these will be discussed in my presentation.
There is a marked paucity of Indian data in general and related to outcome or prognosis in particular. A PUBMED search revealed only one study which shall be touched upon during the talk. My experience with JIA is restricted to just over 100 cases most of whom have been recruited over the last 3 years since we started a organized pediatric rheumatology service in our hospital in Mumbai. Since several of these children come for outreach areas, follow up in many is not punctual / regular, nor is it standardized for want of resource on occasion. Nonetheless, I shall present some observations that may be relevant in the Indian setting.
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|Khubchandani P R.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=495|