ILAR Classification Criteria for Juvenile Idiopathic Arthritis (JIA)

Juvenile idiopathic arthritis is a heterogeneous group of diseases characterised by arthritis of unknown origin with onset before age of 16 years.

International League of Associations for Rheumatology (ILAR) classification of juvenile idiopathic arthritis (JIA)

JIA can be diagnosed if age at onset is under 16 years, disease duration is 6 weeks or greater, and other known conditions are excluded.

• Systemic-onset JIA: Systemic arthritis is diagnosed if there is arthritis in 1 or more joints with, or preceded by, fever of at least 2 weeks' duration. Signs or symptoms must have been documented daily for at least 3 days and accompanied by 1 or more of the following: evanescent rash, generalised lymphadenopathy, hepato/splenomegaly, serositis. (Exclusions are A, B, C, and D from the exclusion list below.)
• Persistent or extended oligoarthritis: Oligoarthritis is diagnosed if there is arthritis affecting 1 to 4 joints during the first 6 months. Persistent oligoarthritis affects up to 4 joints throughout the course of the disease, and extended oligoarthritis affects more than 4 joints after the first 6 months of disease. (Exclusions are A, B, C, D, and E from the exclusion list below.)
• RF-negative polyarthritis: Polyarthritis (RF-negative) is diagnosed if there is rheumatoid factor (RF)-negative arthritis affecting 5 or more joints during the first 6 months of disease. (Exclusions are A, B, C, D, and E from the exclusion list below.)
• RF–positive polyarthritis: Polyarthritis (RF-positive) is diagnosed if there is RF-positive arthritis affecting 5 or more joints during the first 6 months of disease. Two or more RF tests (taken at least 3 months apart) are positive during the first 6 months of disease. (Exclusions are A, B, C, and E from the exclusion list below.)
• Psoriatic JIA: Psoriatic arthritis is diagnosed if there is arthritis and psoriasis, or arthritis and at least 2 of the following: dactylitis, nail pitting, onycholysis, and/or family history of psoriasis (in a first-degree relative). (Exclusions are B, C, D, and E from the exclusion list below.)
• Enthesitis-related arthritis: Enthesitis-related arthritis is diagnosed if there is arthritis and/or enthesitis with at least 2 of the following: presence or history of sacroiliac joint tenderness with or without inflammatory lumbosacral pain; presence of HLA B27 antigen; onset of arthritis in a male over 6 years of age; acute (symptomatic) anterior uveitis; history of ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with inflammatory bowel disease, Reiter's syndrome, or acute anterior uveitis in a first-degree relative. (Exclusions are A, D, and E from the exclusion list below.)
• Undifferentiated: Undifferentiated arthritis is diagnosed if there is arthritis that does not fulfil criteria in any of the above categories or that fulfils criteria for 2 or more of the above categories.

Exclusions:

A. Psoriasis or history of psoriasis in patients or first-degree relatives.
B. Arthritis in HLA B27 positive males beginning after the age of 6 years.
C. Ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with inflammatory bowel disease, Reiter's syndrome, acute anterior uveitis, or history of  1 of these disorders in first-degree relatives.
D. Presence of IgM rheumatoid factor on at least 2 occasions at least 3 months apart.
E. Presence of systemic JIA in patients.

References:

1. Merino R, de Inocencio J, Garcia-Consuegra J. Evaluation of Revised International League of Associations for Rheumatology Classification Criteria for Juvenile Idiopathic Arthritis in Spanish Children (Edmonton 2001). J Rheumatol 2005;32:559-61. [Medline]
2. Petty RE, Southwood TR, Manners P, et al. International League of Associations for Rheumatology. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol. 2004;31:390-392. [Medline]
3. Prakken B, Albani S, Martini A. Juvenile idiopathic arthritis. Lancet. 2011;377(9783):2138-2149. [Medline]

Clinical Criteria for the Diagnosis of Acute Bacterial Sinusitis

Acute bacterial sinusitis in children is diagnosed on the basis of the history, with the use of the criteria. Imaging studies (plain-film radiography, computed tomography [CT], magnetic resonance imaging [MRI], and ultrasonography) show signs of sinus inflammation but are not recommended in patients with uncomplicated infection, given the low specificity of these studies.

Clinical Criteria for the Diagnosis of Acute Bacterial Sinusitis

Persistent symptoms

• Nasal congestion, rhinorrhea, or cough
• >/=10 Days’ duration without improvement

Severe symptoms

• Temperature >/=38.5°C for 3–4 days
• Purulent rhinorrhea for 3–4 days

Worsening symptoms

• Return of symptoms after initial resolution
• New or recurrent fever, increase in rhinorrhea, or increase in cough 

References:

1. DeMuri GP, Wald ER. Clinical practice. Acute bacterial sinusitis in children. N Engl J Med. 2012 Sep 20;367(12):1128-34. [Medline]
2. DeMuri GP, Wald ER. Acute sinusitis: clinical manifestations and treatment approaches. Pediatr Ann. 2010 Jan;39(1):34-40. [Medline]

Diagnostic Criteria for Difficult-to-Control Asthma

The difficult-to-control asthma can be defined as that which is inadequately or poorly controlled despite an appropriate therapeutic strategy that is adjusted to clinical severity.

Diagnostic Criteria for Difficult-to-Control Asthma

A diagnosis of difficult-to-control asthma is established when, once false difficult-to-control asthma has been ruled out, 2 major criteria or 1 major and 2 minor criteria are met. Criteria are modified in part from the proposal of the American Thoracic Society Workshop on Refractory Asthma

Major criteria
– Use of oral corticosteroids continuously or for more than 6 months in the last year
– Continuous use of inhaled corticosteroids at high doses (budesonide or equivalent >1200 ug/day or fluticasone >880 ug/day) alongside another antiasthmatic drug, usually a long-acting B2-adrenergic (LABA)

Minor criteria
– Daily requirement for short-acting B2-adrenergic (SABA) rescue medication
– FEV1 less than 80% of theoretical value or greater than 20% variability of PEF
– One or more visits to the emergency department in the last year
– Three or more courses of oral corticosteroids in the last year
– Prior episode of life-threatening asthma
– Rapid deterioration of lung function

*FEV1 indicates forced expiratory volume in the first second; PEF, peak expiratory flow.




References:

1. López-Viña A, Agüero-Balbín R, Aller-Alvarez JL, Bazús-González T, Cosio BG, de Diego-Damiá A, Martínez-Moragón E, Pereira-Vega A, Plaza-Moral V, Rodríguez-Trigo G, Villa-Asensi JR; Area de Asma-SEPAR. Guidelines for the diagnosis and management of difficult-to-control asthma. Arch Bronconeumol. 2005 Sep;41(9):513-23. [Medline]
2. Le AV, Simon RA. The Difficult-to-Control Asthmatic: A Systematic Approach. Allergy Asthma Clin Immunol. 2006 Sep 15;2(3):109-16. [Medline

Typical Laboratory Abnormalities in Alcoholic Liver Disease (ALD)

Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis.

Typical Laboratory Abnormalities in ALD

Serum enzymes

• AST >>> ALT: Both usually <300 IU/L
• Alkaline phosphatase (ALP) and g-glutamyl transpeptidase (GGT): Both usually elevated to a variable degree

Metabolic alterations

• Hyperglycemia
• Hypertrygleridemia
• Hyperuricemia
• Electrolyte abnormalities: low potassium, magnesium and phosphorus

Tests of liver function

• Serum albumin, prothrombin time, and serum bilirubin usually normal until significant liver injury present

Hematological abnormalities

• Mild anemia common (usually macrocytic)
• Platelets (normal to markedly decreased)
• Elevated white blood cell count: Leukemoid reactions associated with alcoholic hepatitis

Abbreviations: AST, aspartate aminotransferase;  ALT, alanine aminotransferase

References:

1. O'Shea RS, Dasarathy S, McCullough AJ. Alcoholic liver disease. Am J Gastroenterol. 2010 Jan;105(1):14-32. [Medline]
2. McCullough AJ, O'Connor JF. Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology. Am J Gastroenterol. 1998 Nov;93(11):2022-36.[Medline]

Medical Management of Kidney Stones: AUA Guideline

Purpose

The purpose of this guideline is to provide a clinical framework for the diagnosis, prevention and follow-up of adult patients with kidney stones based on the best available published literature.

Materials and Methods

The primary source of evidence for this guideline was the systematic review conducted by the Agency for Healthcare Research and Quality on recurrent nephrolithiasis in adults. To augment and broaden the body of evidence in the AHRQ report, the AUA conducted supplementary searches for articles published from 2007 through 2012 that were systematically reviewed using a methodology developed a priori. In total, these sources yielded 46 studies that were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as Clinical Principles and Expert Opinions.

Results

Guideline statements were created to inform clinicians regarding the use of a screening evaluation for first-time and recurrent stone formers, the appropriate initiation of a metabolic evaluation in select patients and recommendations for the initiation and follow-up of medication and/or dietary measures in specific patients.

Conclusions

A variety of medications and dietary measures have been evaluated with greater or less rigor for their efficacy in reducing recurrence rates in stone formers. The guideline statements offered in this document provide a simple, evidence-based approach to identify high-risk or interested stone-forming patients for whom medical and dietary therapy based on metabolic testing and close follow-up is likely to be effective in reducing stone recurrence.