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Dear Colleagues;
Greetings! The new team that has taken over the Rheumatology Chapter of the IAP. We
have taken some time to settle down and hope that we can now regularly communicate
with you. A few points that I would like to emphasize are
1. We would like to go green and thus confirm that all further newsletters will be
electronic as this will conserve paper, help you to file the newsletters if you like
and will be significantly low cost.
2. If you would like to be in touch with the RCIAP please ensure that you e mail your
id and your telephone number to Dr. Rashna Dass , Secretary at
[email protected] or to me, Dr. Sujata Sawhney at
3. NO FURTHER PAPER COMMUNICATION WILL BE DONE SO WE URGE YOU TO
PLEASE RESPOND AND HELP TO MAKE THE CHAPTER VIBRANT AND ACTIVE
4. Our newsletters will be thematic and the first one helps Paediatricians to decide
when a patient should be referred to a Paediatric Rheumatologist.
5. Your suggestions are welcome and we will be delighted to take questions/cases/
pictures that you may want to share with us
6. Once again may I request for your cooperation and help us to take the chapter
forward.
7. This news letter:
� Helps you to understand why a child with arthritis needs to be
seen by a Paediatric Rheumatologist and also decide when a
Pediatric Rheumatologist should be involved in the care of such
children
� Gives you details about the forth coming conference at Nagpur
� Gives you details about the short term course on Paediatric
Rheumatology on offer at Mumbai
Happy Reading
Dr Sujata Sawhney
Dr Rashna Dass
(Editorial Board)
1. Importance of early diagnosis of juvenile idiopathic arthritis
(JIA)
Joint pains in children are a
common problem faced by clinicians all over
the world. About 10-20 % of school going
children have some form of musculoskeletal
pain. Rheumatic fever accounts for about
100-150 cases per one million cases and
Juvenile idiopathic arthritis (JIA) for about
16-150 cases per million cases. Practising
Paediatricians are more tuned to think of
tuberculosis, acute bacterial infections,
acute rheumatic fever or growing pains as a
common differential diagnosis of joint pain
in children, particularly in our country with a
huge burden of infectious diseases. Thus JIA
may not even figure in the initial diagnosis
of a child with joint pain.
Rheumatic diseases, and in
particular JIA form an important cause of
lifetime childhood disability which may be
articular or extra-articular in nature. Some
of the more serious complications
associated with JIA are as follows:
1. Articular and peri-articular:
a. Joint deformity
b. Hypoplasia of the temporo-
mandibular joints leading to
restricted mouth opening
c. Ankylosis and narrowing of cervical
spine & joint subluxation and risk
of paraparesis / paraplegia
d. Hip joint erosions and need for
total hip replacement in the
adolescent period
e. Growth failure – short stature
f. Disproportionate growth of limbs-
leg length discrepancy
g. Sacroiliiatis
h. Disuse atrophy
i. Coxa valga deformity
2. Extra-articular:
a. Chronic silent uveitis and
subsequent irreversible blindness
b. Aortic regurgitation
c. Pulmonary fibrosis
d. Vasculitis
e. Carpal tunnel syndrome
f. Sgoren’s syndrome
g. Felty’s sundrome
h. Polyserositis
i. Fulminant hepatic failure
j. Laryngeal stricture secondary to
cricoarytenoid arthritis
k. Amylodosis
l. Macrophage activation
syndrome
A frequent misconception has been that
most of the childhood arthritis would
disappear by childhood. This has been
proved otherwise by various studies
wherein it was demonstrated that most
cases of JIA still had some form of active
disease even after 10 years of follow up. It
was found that 30-70% of cases of
pauciarticular onset, 40-50%of polyarticular
onset and 25-58% of systemic onset still had
active disease at or near puberty. The longer
the follow up, the worse was the functional
state.
Prognosis after proper treatment in
individual subtypes are fairly distinct.
Overall, eighty percent of those with
pauciarticular disease will remain without
-1-
major difficulty at the end of 15 years.
Fifteen percent of the pauciarticular JIA
develop a polyarticular course with severe
joint deformity. But silent uveitis remains a
major problem in this subtype. In the
seronegative polyarticular variety only
about 10-15% have functional disability at
the end of 10-15 years. In contrast the sero-
positive poyarticular variety has a more
severe course in spite of adequate therapy
and a majority continue to have active
disease at 15 years of follow up. Of those
with systemic onset JIA, 50% will remit
without recurrence. Four percent of the
children with systemic onset JIA die from
infection or amyloidosis.
Thus, one can see that the above
statistics bring forth the following
important points to mind while treating
children with JIA:
1. Proper diagnosis and early
aggressive intervention can
minimize both short term and long
term morbidity associated with
these conditions
2. Preserve normal physical, social
and emotional growth and
development
3. Achieve remission of disease
4. Laboratory findings may be minimal
and hence an examination by a
skilled worker is a must.
One must also remember that
Paediatric Rheumatologists are
specially trained for:
1. Differential diagnosis in children
and adolescents
2. Efficient use of diagnostic tests
3. Selection of most appropriate
therapy
4. Monitoring for long term
effectiveness of therapy and
appearance of side effects
associated with therapy
5. Achieve favourable outcomes
6. Coordination for multi-specialty
care
7. Deal with the social and
psychological aspects of
chronically ill children and their
families which need support.
Most of the Paediatric
rheumatologists in India are located at
centres where facilities for diagnosis and
multi-specialty care are available. Such care
and expertise may not be available to many
of us practising in the different parts of this
vast country. Therefore we must put in
efforts to involve a Paediatric
Rheumatologist at an early stage for better
and holistic management of such
disadvantaged children. By doing so we will
also be able to establish a good follow up
system for the affected children.
-2-
2. Guidelines for early referral of arthritis cases to a Paediatric
Rheumatologist (Adapted from the ACR guidelines 1997):
Children and adolescents with the
following joint diseases may benefit from
early referral to a Paediatric
Rheumatologist:
1. Patients with unclear diagnoses:
a. Prolonged fever
b. Loss of function:
i. Inability to attend school
ii. Regression in physical skills
c. Normal laboratory findings
but local or generalized pain
and / or swelling
d. Abnormal laboratory findings
but symptoms and / or
examination do not fit the
clinical criteria for a specific
rheumatic disease
e. Complaints not consistent
with laboratory findings or
physical examination
f. Unexplained physical findings
such as rash, fever, anemia,
weakness, weight loss, fatigue
or anorexia along with
arthritis
g. Unexplained musculoskeletal
pain
h. Suspicion of an associated
autoimmune diseases
2. Diagnostic evaluation and long
term management of:
a. Juvenile idiopathic arthritis
b. Spondyloarthropathies:
i. Ankylosing spondylitis
ii. Reiter’s syndrome
iii. Psoraitic arthritis
iv. Arthritis associated with
inflammatory bowel
disease
v. Lyme disease with arthritis
vi. Chronic recurrent
multifocal osteomyelitis
vii. Post-infectious arthritis
viii. Relapsing polychondritis
3. Confirmation of diagnosis and
formulation / participation in a
treatment plan:
a. Apophysitis
b. Reactive arthritis
c. Osteochondroses
d. Growing pains
e. Iritis / Uveitis
f. Acute Rheumatic fever
g. Erythromelalgia
h. Raynaud’s disease
i. Reflex sympathetic dystrophy
j. Cold induced injury
k. Pain syndromes
l. Osteoporosis
m. Over use syndromes;
hypermobility syndromes
4. Diagnostic or treatment
evaluation, provide for proper
physiotherapy regimens
5. Provide second opinion or
confirmatory evaluation when
requested in certain cases where
primary physicians request expert
opinion for families requiring
subspecialty input to cope with
disease process, accept treatment
plan, allay anxiety and provide
education.
-3-
VII NATIONAL CONFERENCE OF PEDIATRIC RHEUMATOLOGY
7TH AND 8TH NOVEMBER 2009
NAGPUR, INDIA
Hosted by
Indian Academy of Pediatrics, Nagpur Branch and IAP Rheumatology
Chapter
Highlights:
� Eminent International and National Faculty
� Arthritis for Primary Pediatrician
� Standard Treatment Protocols
� Newer Diagnostic and Therapeutic Options � Clinical Challenges in Pediatric Rheumatology
� Interactive Practice Oriented Sessions
For Further Details Contact:
Dr.Nandini Babhulkar, Sushrut Hospital & Research Centre, Ramdaspeth,
Nagpur-440010, M.S, India
E mail: [email protected]
Mobile: 9730111000.
-4-
Indian Academy of Pediatrics (Rheumatology Chapter) announces
“REACH AND TEACH”
A 40 hour intensive course in pediatric rheumatology
17-21st
September 09
Principal Sponsor and Host: Hargobind Foundation (www.hargobind.com)
Co host: Pediatric Rheumatology Unit, Jaslok Hospital and Research Center, Mumbai.
WHAT: The chapter envisages training about twenty physicians (pediatricians and adult rheumatologists)
strongly desirous of pursuing/developing the sub specialty of pediatric rheumatology in Tier 1 cities.
HOW: This will be done through a 5 day program (8 hours a day) of lectures / case discussions/ panel
discussions/ slide shows/ and videos with emphasis on practical day to day problems in clinical practice.
WHERE: At the Jaslok hospital and Research Center, Mumbai.
BY WHOM: A multidisciplinary faculty comprising of invited international and national experts in pediatric
rheumatology, ophthalmology, orthopedics, radiology, pathology and physiotherapy.
EVALUATION AND CREDIT: Candidates attending the course will undertake a pre and post test. They will
receive certificates at the end of the course.
COST: Rs 10000 for members of the Rheumatology Chapter (proof needed) and Rs 12500 for non members.
Candidates are expected to make their own travel and lodging arrangements in Mumbai. Two full scholarships
and two half scholarships are available for candidates needing financial aid. The course fee includes pre
course material, course instruction, breakfast and lunches on day of instruction and a banquet dinner. The
costs have been subsidized owing to an educational grant from Hargobind Foundation.
HOW TO APPLY AND CRITERIA FOR SELECTION: Doctors desirous of attending the course will write a 250
word statement of purpose and optionally have at least two colleague pediatricians support their cause. They
would attach a brief resume highlighting any achievements or activities in pediatric rheumatology. Attach a
demand draft for the appropriate amount stating- Jaslok Hospital and Research Center. Those applying for a
scholarship may attach an added plea/justification for the same (confidentiality assured).All correspondence
by email except drafts which may be mailed to address below.
LAST DATE FOR APPLICATION: 1st
June 2009 (Since the Newsletter is going out late due to unavoidable
reasons, as a special concession only the RCIAP Members may apply for this Course upto 10th
June, 2009.)
LAST DATE FOR WITHDRAWAL: 1st July 2009 (no refunds after this date). Candidates not selected or those
who choose to withdraw will have their drafts returned after this date.
CONTACT DETAILS: Course Coordinator Dr Raju Khubchandani .
Associates: Dr Chetna Khemani, Dr. Vijay Viswanathan and Dr. Rachana Hasija
Contact email: [email protected]
Drafts to be mailed to: Dr. Raju Khubchandani, 31, Kailas Darshan, Nana Chowk, Mumbai -400007
-5-
LIFE MEMBERSHIP FORM OF “RHEUMATOLOGY CHAPTER OF IAP”
(Only for Life Members of Central IAP)
1. Membership No. of Central IAP:……………………………………………………………………………
2. Name:….………………..…………..…………..…………..…………..…………..…………..………………….
3. Corresponding Address: …………..…………..…………..…………..…………..…………..…………..
…………..…………..…………..…………..…………..…………..…………..…………..…………..……………
4. Permanent Address: …………..…………..…………..…………..…………..…………..………………..
…………..…………..…………..…………..…………..…………..…………..…………..…………..……………
5. Phone No.(s): …………..…………..………….. Mobile(s): …………..…………..…………………..
6. Email (COMPULSORY): …………..…………..…………..……………...…………..…………..…………
7. Professional Attachment: …………..…………..…………..…………..…………..…………………….
8. Academic Qualification: …………..…………..…………..…………..…………..…………..…………..
9. Date of Birth: …………..…………..…………..…………..…………..…………..…………..………………
Date: Signature:
Present fees of Life Membership is Rs. 1000/-. To be paid in DD in favour of
“Pediatric Rheumatology Chapter of IAP”, payable at Shillong