The severity of lesions in the temporomandibular joint (TMJ) area and their association with age at onset, the various forms of juvenile rheumatoid arthritis (JRA), and certain serologic tests for rheumatoid factor (RF), antinuclear antibodies (ANA), and human leukocyte antigen (HLA)‐B27 were determined in 15‐yr‐old children. The series comprised 121 JRA children, 78 girls and 43 boys, in whom an analysis had recently been made of the relation of TMJ lesions to jaw movement and occlusal status. The mean age at onset was 7.3 yr, the girls contracting JRA earlier than the boys. Also, the girls with lesions in the TMJ area were significantly younger than those with no lesions. TMJ abnormalities were found in 50% of cases with a pauciarticular or systemic onset, but in 72% of those representing the polyarticular subtype. Flattened condyles and grave lesions were equally represented in all subgroups and in both sexes. A crossover from onset type to present diagnosis was found in 30% of the cases, mostly from pauciarticular to polyarthritis, which also increased the risk of TMJ lesions from 50 to 60%. RF, ANA, or HLA‐B27 alone did not seem to be associated with a risk of TMJ abnormalities. Maximal opening capacity is more restricted in patients with early onset or a polyarticular mode of JRA. Since the TMJ is affected in more than half of JRA children, regular measurements of maximal movements of the mandible or roentgenologic examinations of the TMJ are essential for their optimal treatment.

We established cut-off values for LDA and MDA. A reliable definition for HDA will require more patients. In the clinical setting, both the cJADAS10 and JADAS10 serve equally well both for research and quality control purposes. In the future, uniform clinical disease activity levels should be established. We also suggest revising and validating the criteria for HDA. Valid and robust cut-off values for disease activity levels can guide both clinicians and researchers and equip them for quality control.

Objectives To redefine criteria for high disease activity (HDA) in JIA, to establish HDA cut-off values for the 10-joint Juvenile Arthritis Disease Activity Score (JADAS10) and clinical JADAS10 (cJADAS10) and to describe the distribution of patients’ disease activity levels based on the JADAS cut-off values in the literature. Methods Data on 305 treatment-naïve JIA patients were collected from nine paediatric units treating JIA. The median parameters of the JADAS were proposed to be the clinical criteria for HDA. The cut-off values were assessed by using two receiver operating characteristics curve–based methods. The patients were divided into disease activity levels based on currently used JADAS cut-off values. Results We proposed new criteria for HDA. At least three of the following criteria must be satisfied in both disease courses: in oligoarthritis, two or more active joints, ESR above normal, physician global assessment (PGA) of disease activity ≥2 and parent/patient global assessment (PtGA) of well-being ≥2; in polyarthritis, six or more active joints, ESR above normal, PGA of overall disease activity ≥4 and PtGA of well-being ≥2. The HDA cut-off values for JADAS10 (cJADAS) were ≥6.7 (6.7) for oligoarticular and ≥15.3 (14.1) for polyarticular disease. The distribution of the disease activity levels based on the JADAS cut-off values in the literature varied markedly based on which cut-offs were used. Conclusion New clinically derived criteria for HDA in JIA and both JADAS and cJADAS cut-off values for HDA were proposed.

Diclofenac sodium was investigated in the treatment of juvenile rheumatoid arthritis (JRA). The pharmacokinetics of diclofenac in children aged 2-7 was assessed. Seven patients were included in a single-dose trial to determine plasma levels and renal elimination of diclofenac sodium. Venous blood samples were taken at 0, 0.5, 1, 2, 4 and 6 hours after administration of a 25 mg enteric-coated Voltaren tablet. Urine was collected before and 0-6 and 6-12 hours after tablet ingestion. Maximum concentrations ranged from 0.79 to 4.25 micrograms/ml, and were found between 0.5 and 2 hours. Renal elimination of total diclofenac ranged from 5.4 to 10.2% of the oral dose in 6 of the 7 patients. The youngest patient (2 years) had a lower elimination rate (2.25%) during the 12 hours observed. The values for children over 2 years corresponded to the range measured in adults. The pharmacokinetic study was followed by a placebo-controlled study with diclofenac sodium and acetylsalicylic acid (ASA) for 2 weeks in 45 hospitalized patients aged 3-15 years. The patients were randomly assigned to either: DS 2-3 mg/kg/day, microcrystallized ASA 50-100 mg/kg/day, or placebo matching diclofenac. Global evaluation of therapeutic efficacy showed improvement in 73% of the patients in the diclofenac group, in 50% of the ASA group and in 27% of the placebo group. A statistically significant difference between these groups was found (p less than 0.05). The sum of grades of joint tenderness decreased during the 2 weeks in 67% of patients in the diclofenac group, in 56% of the ASA group and in 36% of the placebo group.(ABSTRACT TRUNCATED AT 250 WORDS)

In 13 of the 30 patients with JCA, the sTfR concentration, which is an indicator of iron status and erythropoiesis, was elevated. The results raise the possibility that sTfR is able to distinguish iron-deficiency anaemia from anaemia of chronic disease. It should be further explored as a candidate.

ObjectivesTo validate cut-offs of the Juvenile Arthritis Disease Activity Score 10 (JADAS10) and clinical JADAS10 (cJADAS10) and to compare them with other patient cohorts.MethodsIn a national multicentre study, cross-sectional data on recent visits of 337 non-systemic patients with juvenile idiopathic arthritis (JIA) were collected from nine paediatric outpatient units. The cut-offs were tested with receiver operating characteristic curve-based methods, and too high, too low and correct classification rates (CCRs) were calculated.ResultsOur earlier presented JADAS10 cut-offs seemed feasible based on the CCRs, but the cut-off values between low disease activity (LDA) and moderate disease activity (MDA) were adjusted. When JADAS10 cut-offs for clinically inactive disease (CID) were increased to 1.5 for patients with oligoarticular disease and 2.7 for patients with polyarticular disease, as recently suggested in a large multinational register study, altogether 11 patients classified as CID by the cut-off had one active joint. We suggest JADAS10 cut-off values for oligoarticular/polyarticular disease to be in CID: 0.0–0.5/0.0–0.7, LDA: 0.6–3.8/0.8–5.1 and MDA: >3.8/5.1. Suitable cJADAS10 cut-offs are the same as JADAS10 cut-offs in oligoarticular disease. In polyarticular disease, cJADAS10 cut-offs are 0–0.7 for CID, 0.8–5.0 for LDA and >5.0 for MDA.ConclusionInternational consensus on JADAS cut-off values is needed, and such a cut-off for CID should preferably exclude patients with active joints in the CID group.

Ibuprofen levels were measured in the serum and synovial fluid of 33 children (mean age 11 years) with juvenile chronic arthritis. A total daily dose of about 40 mg of ibuprofen per kg of body weight (mean 37.1 mg/kg) was given in three portions. In serum the peak level was reached 1-2 hours after drug intake. The half-life of elimination in swum WPP 2.3k0.5 hours (mean k 1 S.D., n=12). Twelve hours after the last dose the mean serum level was about 20 jmol/l. Ibuprofen concentrations fluctuated far less In synovial M d than in serum. In synovlal fluid peak levels (mean 65 pmd/l) were reached 5-6 hwrs after drug intake. Thereafter, the levels declined slowly but 12 h w r s later were still higher than In serum.

Sir: Nesher et al recently described the first comprehensive series considering antiperinuclear factor in juvenile chronic arthritis (JCA). They found an overall positivity of 34%; in patients with the polyarticular type of the disease 16/28 patients were positive.' Our results are at variance with these data: in a group of 313 patients only three were positive, all of them children with polyarticular onset (table). Thus our results are more in line with a recently reported Czechoslovakian series (Bardfeld R, IVth Prague international pediatric rheumatology symposium, 1992).Our material consisted of 49 fresh and 264 frozen serum samples. One of the former and two of the latter were positive. As antiperinuclear factor is predominantly, if not exclusively, of the IgG class, sample preservation would seem unlikely to have influenced the results. A more plausible explanation for the discrepancy lies in the immunofluorescence system. A major confounding factor causing variability in antiperinuclear factor results is the variation in substrate sensitivity, between different donors, of the buccal cells that contain the antigen. This drawback has barred antiperinuclear factor from coming into general use despite the long history of the test.2 We used a recently described improved technique that includes detergent treatment of the cells, which is reported to minimise, albeit not to eliminate, donor differences.3 We tested the serum samples at a standard dilution of 1:5,4 which is also the titre we recorded for the WHO rheumatoid factor reference preparation that has been proposed by Feltkamp et al as the reference standard for antiperinuclear factor, too.5 Sixty per cent of serum samples from adult patients with rheumatoid arthritis tested in parallel by this technique were positive (manuscripts in preparation).In conclusion, antiperinuclear factor seems to be a specific but insensitive marker for the JCA subset with polyarticular onset that resembles adult rheumatoid arthritis. It contributes to the evidence for a basic difference between JCA in general and adult rheumatoid arthritis. The need for a common reference standard in future studies is obvious.