High Anxiety Among Siblings of Kids with Arthritis


CME NUGGETS

ED SUSMAN

Mr. Susman is a freelance medical writer based in Florida, USA. He travels worldwide to report from medical conferences, writing regularly for wire services, internet websites, and medical journals such as the Journal of the National Cancer Institute and AIDS.

For comments, edwardsusman@cs.com


ORLANDO, Florida – The brothers and sisters of children who have been diagnosed with juvenile idiopathic arthritis may also be at risk of psychological problems – particularly anxiety – even if these siblings do not have the rheumatological disease, researchers reported here.

At the annual meeting of the Rheumatology Nurses Society, Maria Cusano-Sanzo, RN, DNP-RN, as a 2016 doctoral student at Sacred Heart University, Trumbull, Connecticut, reported that the siblings of children with arthritis “scored approximately 10.6 points higher on the Spence Children’s Anxiety Scale than children without arthritis in the family which is highly significantly significant.”

The Spence scale is a screening tool, and a 10-point difference may be clinically meaningful as to whether these children would be referred to specialist for treating anxiety.

Dr. Cusano-Sanzo reported that significant increases in scores were found among girl siblings (P=0.01) and among children under 10 years of age (P=0.05).

“This suggests that, as a group, siblings of children with juvenile idiopathic arthritis may be at higher risk of experiencing anxiety than non-clinical children,” she said. “Pediatric chronic illness can have a tremendous impact on children and their parents. Education and support is typically focused on the child and parents of those newly diagnosed with diabetes, cancer, renal failure, asthma, arthritis and other illnesses of childhood, often leaving siblings out of this important aspect.”

She recruited 27 children for the project, 12 girls and 15 boys, ll between the ages of 8 years and 15 years of age. The children completed the 44-item Spence questionnaire. Their parents completed a demographic survey. Ten of the children were age 8-10; 6 were ages 11-12; 11 were ages 13-15.

Dr. Cusano-Sanzo said that her study implies that “practice policy changes should be made to incorporate siblings in the education of disease states not only for juvenile idiopathic arthritis but other chronic diseases as well.”

She inferred that by addressing anxiety, clinicians might avoid negative outcomes, improve patient and family outcomes and improve family satisfaction. “the nurse should share the findings of this study to encourage parents to make sure that the unaffected child does not feel left out or uninformed and should provide the family with educational material for the sibling without arthritis.

“The implications for nursing education as a result of this study echo the importance of teaching family-centered care,” Dr. Cusano-Sanzo said.

Look in the mouth

In another study at the meeting, attended by more than 250 specialist nurses and allied health care professionals, researchers urged clinicians who are caring for children diagnosed with juvenile idiopathic arthritis to routinely check their patients’ teeth and gums for evidence of periodontal disease.

Of 15 children in a pilot study, Nancy Delnay, RN, Akron Children’s Hospital in Ohio, said that 10 of the children had signs of disease and presence of high risk bacteria existed in 4 of the patients.

Ten children had localized red gingiva, indicating the start of periodontal disease; 5 children experienced gum bleeding when brushing their teeth – a per se indication of periodontal disease, she said. Six children reported gum bleeding when they flossed their teeth, also a sign of periodontal disease.

“The presence of bacteria associated with an inflammatory process such as periodontal disease emphasizes the importance of inclusion of oral health examinations in these children,” she said.

Among her patients, she isolated high risk pathogens Aggregabacter actinomycetemcomitans, Porphyromonas gingivalis; tannerella forsythia and Treponema denticola. She also found presence of six other species of moderate risk pathogens and one low risk pathogens in the mouths of the children.

As part of a clinical examination, Delnay said that nurses and doctors routinely look into the mouths of children to check for sores associated with the disease and with medications being taken for the disease. But the routine check of the gum to see if there is periodontal disease is not part of a present protocol, and not part of electronic medical record keeping.

The convenience sample of patients ages 5-21 shows that there is an obvious high prevalence of periodontal disease or the early manifestations of the gum disease, Delnay said. “We cannot at this point say that the presence of periodontal disease is higher in the children than in the general population, but we are in the early planning stages of a larger study,” she said.

“We found evidence of early periodontal disease in our youngest patients and more advanced periodontal disease in the older patients,” she said.

Delnay said that current guidelines call for dental examination twice a year. However, she said that ophthalmologic examinations for children with juvenile idiopathic arthritis are set for every 3 months. She suggests that these children may have to see a dentist more often.

Delnay noted that inflammatory diseases such as arthritis and periodontitis are associated with risks of heart disease so getting a handle on periodontal disease early in life would benefit these patients.

“Results of this study will guide further research in the role of oral microbiota and juvenile idiopathic arthritis,” she said. “Ultimately such knowledge may lead to early intervention and prevention of inflammatory conditions.”

Arteritis treatment

Patients diagnosed with potentially deadly giant cell arteritis may achieve relief from the disease with the biologic agent tocilizumab (Actemra).

After 52 weeks, 59 percent of patients on tocilizumab weekly who tapered steroids after 26 weeks remained in remission from the disease compared with 33.3 percent of patients treated with steroids over the 52-week period (P=0.003), reported John Stone, MD, director of clinical rheumatology at Massachusetts General Hospital and professor of medicine at Harvard Medical School, Boston.

High Anxiety Among Siblings of Kids with Arthritis 2In his poster presentation, Dr. Stone also illustrated that treatment with tocilizumab – an agent that has been used in rheumatoid arthritis for several years – was superior to steroids in when delivered every other week. He reported that 55.1 percent of patients on the every 2 week course of treatment with tocilizumab remained in remission after 52 weeks compared with steroids alone (P=0.0292),

“Tocilizumab plus a 26-week prednisone taper was superior to both short-course and long-course prednisone tapers for the achievement of sustained remission at 52 weeks,” he reported. “The addition of tocilizumab to prednisone also led to a substantial reduction in the cumulative prednisone doses required to control giant cell arteritis.”

Patients on the 26-week short-course of prednisone had a median cumulative dose of 3296 mg; patients on the 52-week prednisone course had a cumulative dose of 3818 mg of the steroids; patients on both treatment arms containing tocilizumab had 1862 mg of prednisone.

Dr. Stone suggested that the treatment of giant cell arteritis with tocilizumab “revealed no new safety concerns. The benefit-risk profile of tocilizumab in giant cell arteritis constitutes a major advancement in the treatment. For more than 65 years, no true steroid-sparing therapy in giant cell arteritis has been proven.”

In the Phase III study, the researchers assigned 60 patients to a 26-week course of tapered prednisone and after 52 weeks, 14 percent of those patients remained in remission; they assigned 61 patients to a 52-week course of tapered prednisone and after 52 weeks, 17.6 percent of them were in remission; they assigned 100 patients to tocilizumab 162 mg weekly subcutaneous injections and after 52 weeks, 56 percent were in remission; they assigned 49 percent patients to tocilizumab 162 mg every 2 weeks and after 52 weeks 53.1 percent of these patients remained in remission.

The average age of the 251 patients in the study was 69; and about 75 percent of the patients were women; 975 of the treatment population were Caucasians; about half the patients in the trial were newly diagnosed with giant cell arteritis. The others had relapsing disease, the researchers reported.

The researchers also reported that treatment with tocilizumab was associated with improvement in patients outcomes, especially in the physical component summary of the Short-Form 36 Survey.

In the GiACTA trial, Dr. Stone reported that 4 percent of patients on the short-course of prednisone experienced a serious infection; 11 percent of patients on the long-course of prednisone experienced serious infections; 7 percent of patients on the once weekly tocilizumab experienced at least one serious infections and 4.1 percent of patients on the every 2 week dosing schedule of tocilizumab experienced at least one serious infection.

September 2017 Health and Lifestyle

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