Delineating the role of multiple intraarticular corticosteroid injections in the management of juvenile idiopathic arthritis in the biologic era.

OBJECTIVE: To investigate the outcome and predicting factors of multiple intraarticular corticosteroid (IAC) injections in children with juvenile idiopathic arthritis (JIA). METHODS: The clinical charts of patients who received their first IAC injection in ≥3 joints between January 2002 and December 2011 were reviewed. The corticosteroid used was triamcinolone hexacetonide for large joints and methylprednisolone acetate for small or difficult to access joints. In each patient, the followup period after IAC injection was censored in case of synovitis flare or at the last visit with continued remission. Predictors included sex, age at disease onset, JIA category, antinuclear antibody (ANA) status, age and disease duration, disease course, general anesthesia, number and type of injected joints, acute-phase reactants, and concomitant systemic medications. RESULTS: A total of 220 patients who had 1,096 joints injected were included. Following IAC therapy, 66.4% of patients had synovitis flare after a median of 0.5 years, whereas 33.6% of patients had sustained remission after a median of 0.9 years. The cumulative probability of survival without synovitis flare was 50.0%, 31.5%, and 19.5% at 1, 2, and 3 years, respectively. On Cox regression analysis, positive C-reactive protein value, negative ANA, lack of concomitant methotrexate administration, and a polyarticular (versus an oligoarticular) disease course were the strongest predictors for synovitis flare. CONCLUSION: Multiple IAC injection therapy induced sustained remission of joint synovitis in a substantial proportion of patients. A controlled trial comparing multiple IAC injection therapy and methotrexate versus methotrexate and a tumor necrosis factor antagonist is worthy of consideration.

Retrospective investigation of prognostic indicators for adult horses with infection of a synovial structure.

OBJECTIVE: To investigate predictors of survival and athletic function in adult horses with infection of a synovial structure. HYPOTHESES: Increasing duration from contamination to referral, bone or tendon involvement and positive microbial culture decreases short-term survival. Synovitis and/or sepsis at 5 days post-admission and involvement of Staphylococcus spp. decreases long-term athletic function. DESIGN: Retrospective study. METHODS: Records over 4 years of adult horses with synovial sepsis were reviewed. A two-tailed Fisher's exact test, Mann-Whitney U test or t-test was used to examine whether variables were predictive of short-term survival and long-term athletic function. RESULTS: During the study period 75 horses underwent treatment for infection of 93 synovial structures. Short-term survival was 84% (63/75) and 54% (30/56) of horses returned to athletic function. Of the variables measured at admission, duration from contamination to referral did not affect survival, whereas evidence of bone or tendon involvement decreased survival and athletic function. Of the variables available during treatment, abnormal synovial fluid at 4-6 days post-admission and positive microbial culture reduced athletic function. Staphylococcal infection was associated with persistent sepsis. CONCLUSIONS: Of the variables available at presentation, only evidence of bone or tendon involvement negatively affected survival and athletic function. During treatment of synovial sepsis, analysis of synovial fluid at 4-6 days and bacterial culture results have prognostic value.

Virulence of Mycoplasma synoviae strains in experimentally infected broiler chickens.

Seven field isolates of German origin and the type strain WVU 1853 of Mycoplasma synoviae (MS) were experimentally investigated for their virulence in mycoplasma-free broiler chickens. Two groups of birds were inoculated at 6 days of age with each isolate, one group into the thoracic air sac and the other group intravenously and all surviving birds were examined at necropsy 17 days post inoculation (pi). Groups of negative control birds received sterile Frey's broth medium by intravenous and intra-air sac inoculation, respectively. Variation in virulence was evaluated on the basis of significant differences in incidence, severity and extend of MS-induced airsacculitis and synovitis as well as isolation rates of MS especially from parenchymous organs. All the strains tested were pathogenic but varied in their virulence for broiler chickens. Based on differences of the virulence, the isolates were classified to the categories: (1.) highly virulent, (2.) virulent, (3.) moderately virulent and (4.) slightly virulent. (1) Strains WVU 1853 and 246-91 induced a systemic disease associated with multiple synovitis and bilateral airsacculitis (2) Strains 93-92 and 151-77 induced bilateral airsacculitis similar to WVU 1853 and 246-91 but rarely a systemic disease after exposure by intra-thoracic airsac inoculation. (3) In comparison, strains 27-79, 76-93 and 513-83 caused less frequently airsacculitis and even if, then only at the side of intra-airsac exposure. (4) Strain 91-93 has been found to differ significantly from all the other isolates in its capacity to produce disease independently from the inoculation route. After intravenous inoculation, findings gave no indications for strains with selective tropism to the epithelial membranes of the lower respiratory tract or to those of the joints, tendon sheaths and bursae. However, the presented data of the experiments suggest that the MS strains tested differ in their potential capacity to invade systemically and produce acute septicaemia.