Jra Edit Kuliah
-
Upload
winda-hidayati -
Category
Documents
-
view
229 -
download
16
Transcript of Jra Edit Kuliah
-
8/12/2019 Jra Edit Kuliah
1/37
Zakiudin Munasir :
HERCULE POIROT IN :
JUVENILE RHEUMATOID ARTHRITIS
-
8/12/2019 Jra Edit Kuliah
2/37
Causes bone and joint pain in
children 43 medical conditions:
1. Trauma
2. Infection 3. Malignancy
4. Metabolic
5. Autoimmune 6. Growing pain
-
8/12/2019 Jra Edit Kuliah
3/37
Synonym:
Juvenile IdiopathicArthritis (JIA)
One of the most
frequent chronicillnesses in children
Short-termdisabilities
Long-term disabilitis
Juvenile
RheumatoidArthritis (JRA)
-
8/12/2019 Jra Edit Kuliah
4/37
A chronic arthritis that persists for a minimum of 6consecutive weeks in one or more joints, commencing
before the age of 16 years and after active exclusionother causes. (Cassidy et al.,1989:Ansell,1990)
Definition
High remittent fever with one or more of the following-rash, hepatomegaly, splenomegaly, generalizedlymphadenopathy, serositis, usually pericarditis.
Arthritis may be absent at the onset, but myalgia orarthralgia are ussualy present
Systemic disease
JUVENILE CHRONIC (RHEUMATOID) ARTHRITIS
-
8/12/2019 Jra Edit Kuliah
5/37
5 or more joints develop in theonset periodusually
insidiously and symmetrically
Further divided by thepresence of IgM rheumatoid
factor
Polyarthritic onset:
-
8/12/2019 Jra Edit Kuliah
6/37
Most common mode with 4 orfewer joints involved
Particularly knees and ankles
Young children with positiveantinuclear antibodies who are atrisk from chronic iridocyclitis, andolder boys (aged 9 upwards) who
frequently carry thehistocompatible leucocyte antigen(HLA) B27
Pauci-articular onset:
-
8/12/2019 Jra Edit Kuliah
7/37
Include:
Juvenile psoriatic arthritis
Arthritis of inflammatory bowel
diseaseReiters syndrome
While some are as yet
unclassified.
Polyarthritic onset:
-
8/12/2019 Jra Edit Kuliah
8/37
Classification:
By mode of onset during the first sixmonths(Cassidy et al.,1989:Prieur et al., 1990)
-
8/12/2019 Jra Edit Kuliah
9/37
Criteria for Classification of
Juvenile Rheumatoid Arthritis
1. Age at onset < 16 yr
2. Arthritis (swelling or effusion, or presence of two or more of the
following signs : limitation of range of motion, tenderness or pain
on motion, and increased heat) in one or more joints
3. Duration of disease 6 wk or longer
4. Onset type defined by type of disease in first 6 mo:
a. Polyarthritis : > 5 inflammed joints
b. Oligoarthritis (pauciarticular disease) : < 5 inflammed jointsc. Systemic-onset : arthritis with characteristic fever
5. Exclusion of other forms of juvenile arthritis
Modified from Cassidy JT, Levinson JE, Bass JC, et al :A study of classification criteria for a diagnosis ofjuvenile rheumatoid arthritis, 1986
-
8/12/2019 Jra Edit Kuliah
10/37
-
8/12/2019 Jra Edit Kuliah
11/37
-
8/12/2019 Jra Edit Kuliah
12/37
-
8/12/2019 Jra Edit Kuliah
13/37
-
8/12/2019 Jra Edit Kuliah
14/37
-
8/12/2019 Jra Edit Kuliah
15/37
-
8/12/2019 Jra Edit Kuliah
16/37
-
8/12/2019 Jra Edit Kuliah
17/37
-
8/12/2019 Jra Edit Kuliah
18/37
-
8/12/2019 Jra Edit Kuliah
19/37
Treatment approach of
rheumatic diseases
-
8/12/2019 Jra Edit Kuliah
20/37
American College of
Rheumatology Guideline
The goalsof osteoarthritis (OA)management are :
To control pain and other symptoms,
Minimize disability, and
Educate the patient about the diseaseand its therapy
-
8/12/2019 Jra Edit Kuliah
21/37
Multidisciplineapproach
Non-pharmacologic
treatment
Pharmacologic
treatment
Surgery
-
8/12/2019 Jra Edit Kuliah
22/37
THERAPEUTICS PRINCIPLES
Nonsteroidal antiinflammatory drugs COX2 inhibitors
Steroids (systemic onset or uveitis)
Analgesics
Antiinflammatorymedications
Physical therapy
Ocupational therapy
Psychologic support
Exercise
Rehabilitationtechniques
Immunosuppressants
Biologic agentsAdvance therapy
-
8/12/2019 Jra Edit Kuliah
23/37
PHARMACOLOGIC THERAPY
Acetaminophen
Acetyl salicylic acidAnalgesics
Naproxen
Ibuprofen
Diclofenac
NSAIDThe main therapy
for rheumaticdisease
Only for systemic or uveitisCorticosteroid
-
8/12/2019 Jra Edit Kuliah
24/37
PHARMACOLOGIC THERAPY
Methotrexate, salazopyrin, hydroxychloroquine,
Other cytotoxics/immuno-suppressive drugs(Azathioprine, cyclophosphamide, cyclosporine,mycophenolate mofetil)
Disease modifyingantirheumatic
drugs
(DMARDs) :
Biphosphonate
Calcitonin
Antiosteo-porotic
Etanercept, infliximab
Biologic agents(biologicDMARDs)
-
8/12/2019 Jra Edit Kuliah
25/37
Table: Clinical Outcome-by Onset and Course Subtypes
Onset Type (N) Course Subtype
(n)
Profile Outcome
Polyarthritis
(78)
RF seropositive
(16)
Female
Older age
Hand-wrist
Involvement
Erosions
Nodules
Unremitting
Poor
ANA seropositive(38)
FemaleYoung age
Good
Seronegative (24) Variable Good
-
8/12/2019 Jra Edit Kuliah
26/37
ANA, anti nuclear antibodies; RF, rheumatoid factors
Cassidy JT, Levinson JE, et al: A sudy of classification criteria for a diagnosis of juvenile rheumatoidarthritis. Arthritis Rheum 29: 274-278, 1986
Table: Clinical Outcome-by Onset Type and Course Subtypes (cont.)
Onset Type (N) Course Subtype (n) Profile Outcome
Oligoarthritis
(121)
ANA seropositive
(66)
Female
Young ageChronic
uveitis
Excellent
(except eyes)
RF seropositive (8) Polyarthritis
Erosions
Unremitting
Poor
HLA-B27 positive
(120)
Male
Older age
Good
Seronegative (35) Variable Excellent
Systemicdisease (51)
Oligoarthritis (30) Variable Good
Polyarthritis (21) Erosions poor
-
8/12/2019 Jra Edit Kuliah
27/37
-
8/12/2019 Jra Edit Kuliah
28/37
-
8/12/2019 Jra Edit Kuliah
29/37
-
8/12/2019 Jra Edit Kuliah
30/37
-
8/12/2019 Jra Edit Kuliah
31/37
4343
Endoscopically Detected Bleeding UlcerEndoscopically Detected Bleeding Ulcer
-
8/12/2019 Jra Edit Kuliah
32/37
When pain strikes, it's natural for child to
want to sit still
But it's important to maintain a regular
exercise program
Muscles must be kept strong and healthy
so they can help support and protect joints
Regular exercise also helps to maintain
range of motion.
-
8/12/2019 Jra Edit Kuliah
33/37
GROWINGPAIN
-
8/12/2019 Jra Edit Kuliah
34/37
Positive connotation :
Most parents accept it as a benign condition
Negative connotation :
This diagnosis has been too frequently applied to children whoactually have a serious rheumatic or malignant disease
Most occur in preschool- to school-agedchildren
The pathophysiology is unknown
Growing pains
G i P i (B i N t l
-
8/12/2019 Jra Edit Kuliah
35/37
Growing Pains (Benign Nocturnal
Pains of Childhood)Age at onset 4 to 12 years
Sex ratio Probably equal, slightly more girls insome series
Symptoms Deep aching, cramping pain in thigh orcalf, usually in the evening or during the
night; never present in the morning;
bilateral; responds to massage and
analgesia
Signs Physical examination results are normal
Investigations Laboratory and radiographic studies (ifdone) have normal results
Modified from Cassidy JT, Petty RE, Laxer RM, Lindsley, ed. Textbook of Pediatric Rheumatology, 2005
-
8/12/2019 Jra Edit Kuliah
36/37
V
Children who have unusual
symptoms or abnormal
findings on examinationshould notbe diagnosed
as having growing pains
-
8/12/2019 Jra Edit Kuliah
37/37
THANK YOU