Bibliography February 2001- AIHARA Y, KATAKURA S, IMAGAWA T, MITSUDA T, YOKOTA S: Transient remission of intractable systemic-type of juvenile rheumatoid arthritis after chickenpox in a 2-year-old boy. Pediatr.Int. 2001, 43:95-97.
Organism:Department of Pediatrics, Yokohama City University, School of Medicine, Yokohama, Japan yaihara1@urahpyokohama-cuacjp
Internet : PM:11208011 - AL MATAR MJ, CABRAL DA, PETTY RE: Isolated tuberculous monoarthritis mimicking oligoarticular juvenile rheumatoid arthritis. Rinsho Ganka 2001, 28:204-206.
Organism:Dr. R.E. Petty, Division of Rheumatology, Department of Pediatrics, University of British Columbia, 4480 Oak Street, Vancouver, BC V6H 3V4
Abstract: Isolated monoarthritis caused by Mycobacterium tuberculosis in the absence of clinical pulmonary disease is extremely rare in North America. After decades of consistent declines in incidence, a remarkable resurgence of tuberculosis (TB) is occurring in North America. It must always be considered in the differential diagnosis of chronic monoarthritis if devastating sequelae are to be avoided. We describe 2 cases of tuberculous arthritis in young children presenting with monoarthritis of the knee. The presumptive diagnosis in each case was oligoarticular onset juvenile rheumatoid arthritis (JRA). Each had an atypical course for JRA, with lack of response to intraarticular corticosteroid. The diagnosis of TB arthritis was made only with synovial biopsy - BANKS S, OSTROV BE: Clinical images: Hip joint remodeling in systemic-onset juvenile rheumatoid arthritis. Arthritis And Rheumatism 2000, 43:2856
Organism:S. Banks, Geisinger Medical Center, Danville, PA - BROBERG K, TOKSVIG-LARSEN S, LINDSTRAND A, MERTENS F: Trisomy 7 accumulates with age in solid tumors and non-neoplastic synovia. Genes Chromosomes and Cancer 2001, 30:310-315.
Organism:K. Broberg, Department of Clinical Genetics, Lund University Hospital, SE-221-85 Lund
Abstract: Trisomy 7 is a common finding in benign and malignant solid tumors, in several non-neoplastic lesions (for example, osteoarthritis and rheumatoid arthritis), and in apparently normal tissues as well, suggesting that the occurrence of +7 might be associated with factors other than the disease process itself. To find out whether the frequency of + 7 varies with a patient's age, we cytogenetically analyzed short-term-cultured synovial samples from elderly persons without signs of arthritis and from young patients affected by juvenile chronic arthritis (JCA). In normal synovia, gain of a chromosome 7 was present as a clonal change in five of 10 cases and in single cells in four of the five remaining cases. In synovia from patients with JCA, cells with +7 were detected in only one of nine cases, representing the oldest patient in the series. Furthermore, we reviewed the cytogenetic literature on tumors of the brain, breast, colon, kidney, lung, skin, thyroid, and upper aerodigestive tract. In the majority (six of eight) of these tumor types, the frequency of cases displaying a clone with +7 as the sole aberration increased with age. Taken together, the results presented here suggest that the acquisition of trisomy 7 in some neoplastic and non-neoplastic tissues might be associated with age rather than with disease. The finding of a completely different frequency distribution in two of the tumor types (tumors of the brain and the thyroid gland), however, emphasizes the heterogeneity of +7 and indicates that other, possibly tissue-specific, factors might influence the occurrence of this mutation. (c) 2001 Wiley-Liss, Inc
Internet : karin.broberg@klingen.lu.se - CLAUS R, BITTORF T, WALZEL H, BROCK J, UHDE R, MEISKE D, SCHULZ U, HOBUSCH D, SCHUMACHER K, WITT M, BARTEL F, HAUSMANN S: High concentration of soluble HLA-DR in the synovial fluid: Generation and significance in "rheumatoid-like" inflammatory joint diseases. Cellular Immunology 2000, 206:85-100.
Organism:R. Claus, Institute of Immunology, University of Rostock, Schillingallee 70, 18057 Rostock
Abstract: In the search for its role in inflammatory joint diseases, soluble HLA-DR (sHLA-DR) was quantitated in 72 synovial fluids (SF) by a newly established immunoenzyme assay. Unlike other soluble receptors which accumulated only moderately (sCD25, sCD4) or negligibly (sHLA class I, sCD8) in the SF, SF sHLA-DR levels exceeded serum levels by up to 3 orders of magnitude and varied disease dependently from "control" values (traumatic synovitis and osteoarthritis: 9.9 +/- 6.1 ng/ml). Clear-cut different SF sHLA-DR values in HLA-DR-associated "rheumatoid-like" (136.5 +/- 130.0 ng/ml) vs HLA-B27-associated "spondylarthropathy-like" arthritic forms (28.4 +/- 29.1 ng/ml) were most significant comparing oligoarticular juvenile chronic arthritis type I (147.6 +/-112.6 ng/ml) and type II (3.3 +/- 1.1 ng/ml), thus offering a new classification marker. Also ex vivo, large amounts of sHLA-DR were released spontaneously by SF mononuclear cells and found to be related to the T-cell activation state. SF sHLA-DR may be shed in large complexes or micelles, as it eluted mainly at >450 kDa on gel filtration. Western blotting revealed that the majority of SF sHLA-DR consisted of full-length alpha- and beta-chains. Minor fractions of smaller sized antigens seemed to be generated by proteolytic cleavage rather than by alternative splicing, since only minute amounts of HLA-DRB mRNA lacking the transmembrane exon could be amplified by RT-PCR. Distinct forms of high-dose sHLA-DR, able to provoke rather than to suppress T-cell responses, are discussed as contributing to some HLA-DR disease association. (c) 2000 Academic Press
Internet : renate.claus@med.uni-rostock.de - DE BOECK H, SCHEERLINCK T, OTTEN J: The cinca syndrome: A rare cause of chronic arthritis and multisystem inflammatory disorders. Acta Orthopaedica Belgica 2000, 66:433-437.
Organism:H. De Boeck, Department of Pediatric, Orthopaedics A.Z.-V.U.B., Laarbeekdaan 101, B-1090 Brussels
Abstract: Chronic infantile neurological cutaneous articular (CINCA) syndrome is a rare disorder with neonatal onset characterised by a chronic progressive inflammatory process with skin rash, articular and central nervous system involvement. This primary systemic inflammatory disorder should be distinguished from juvenile rheumatoid arthritis (JRA). Although the articular findings are characteristic features of CINCA syndrome, there is a certain degree of variability in the articular involvements which are not always symmetrical nor is the degree of severity uniform. The etiology of CINCA syndrome remains unknown. No single treatment has been found to be effective. This syndrome is known in the American medical literature as infantile onset multisystem inflammatory disease (IOMID) - EDIVA A, HOZA J, NE c, POSPIS c, BARTUN c, VENCOVSKY J: Immunological investigation in children with juvenile chronic arthritis. Medical Science Monitor 2001, 7:99-104.
Organism:A. S(caron)ediva, Institute of Immunology, University Hospital Motol, Prague
Abstract: Background: Immunological investigation is a part of the complex view on a child with juvenile chronic arthritis (JCA). We analyzed the data of a cohort of children with JCA in order to determine the real contribution of this investigation to their diagnosis and therapy. Material and methods: We included the investigation of humoral immunity and autoantibodies of 78 children with JCA. 18 children completed investigation of both humoral and cellular immunity of paired peripheral blood (PB) and synovial fluid (SF). Humoral immunity consisted from immunoglobulins, complement, circulating immune complexes, rheumatoid factors, soluble HLA I. molecules and antinuclear and antineutrophil cytoplasmic antibodies. Cellular immunity included cytometric studies of CD3, CD4, CD8, CD16/CD56, CD19, CD20, 23, CD3 HLA DR+, CD45 RA, CD45 RO, alpha/beta and gamma/delta T cells. To observe the status of Th1/Th2 balance in children with JCA, the cytokines IL-4, IFN gamma, TNF alpha and IL-6 were measured in the tissue culture of the synovial cells. Results: The parameters of humoral immunity in serum showed wide variability. We could not confirm particular changes specific for the forms or stage of the disease. ANCA were positive in 21 out of 78 children with JCA, 3 times both in PB and SF. More typical pattern could be followed in the comparison of PB and SF, with immunoglobulins and complement always found lower in SF than in PB. The cellular immunity was represented by the activation of lymphocytes mainly in SF, reverse ratio of CD45 RA and RO cells in PB and SF with marked predominance of memory T cells in the joint. High levels of sHLA in SF are the nonspecific marker of activation, the same is true for high levels of TNF alpha and IL 6 in SF cell culture supernatant. Conclusion: The described changes in immunological parameters of humoral and cellular immunity are not specific for JCA. In the individual cases they can contribute to the diagnosis and monitoring of the disease. The investigation of sHLA molecules and cytokine profile should be restricted only for research
Internet : anna.sediva@lfmotol.cuni.cz - FREDRIKSEN B, MENGSHOEL AM: The effect of static traction and orthoses in the treatment of knee contractures in preschool children with juvenile chronic arthritis: A single-subject design. Arthritis Care and Research 2000, 13:352-359.
Organism:B. Fredriksen, Physiotherapy Department, National Hospital, 0027 Oslo
Abstract: Objective. External applied devices are sometimes used in the treatment of persistent knee contractures in juvenile chronic arthritis (JCA). This study examined the effect of static night traction and orthoses on passive and active extension range of motion (ROM) in preschool children with JCA. Method. A single-subject design was used, comparing the outcome of periods without intervention (A) with that of periods with intervention in the form of traction and orthoses (B). Five patients, 3 girls and 2 boys, participated. Active and passive extension ROM was measured weekly. The data were examined by visual inspection of trend, slope, and mean level in each period. Results. Greater improvement in both active and passive extension ROM was seen in the B periods than in the A periods. The intervention was not observed to have any negative effects on the children. Conclusion. Static night traction may be a useful supplement to physiotherapy and medication to reduce knee flexion contractures in small children with JCA. The effect of the orthoses was difficult to evaluate because they were used for an insufficient time - HAQUE MA, BARI MA, SAHA GK, ALI MA, HOQUE SA, ABDULLAH ABM, CHOUDHURY AI, ALAM MN: Prospective, nonblind trial of methotrexate on seronegative spondyloarthropathy. Journal of Institute of Postgraduate Medicine and Research 1999, 14:56-63.
Organism:M.A. Bari, Department of Medicine, BSMMU, Dhaka
Abstract: This study was designed to see the efficacy of methotrexate (MTX) in patients with seronegative spondyloarthropathies viz ankylosing spondylitis (AS), juvenile chronic arthritis (JCA) and Reiter's syndrome (ReS) / Reactive arthritis (RA). Thirty two patients were randomly selected and methotrexate was given orally to each patient. 6 (18.7%) and 11 (34.3%) cases showed complete and partial improvement respectively. Individual therapeutic response with MTX were 38.9% in ankylosing spondylitis, 70.0% in JCA and 75% in RS/ReA respectively. The improvement was significant (P<.001) - HELDERS PJM, NIEUWENHUIS MK, VAN DER NJ, KRAMER PPG, KUIS W, BUCHANAN TS: Displacement response of juvenile arthritic wrists during grasp. Arthritis Care and Research 2000, 13:375-381.
Organism:Dr. P.J.M. Helders, University Medical Center, Children's Hospital, Dept. Pediatric Physical Therapy, P.O. Box 85090, 3508 AB Utrecht
Abstract: Objective. To analyze the displacement response of juvenile arthritic wrists during grasp in order to diagnose early ligamental laxity and facilitate early splinting. Methods. X-rays of the wrists, made under standardized conditions, of 30 children with juvenile chronic arthritis (mean age 10.4 years, range 4.5-16.9) were analyzed after being digitalized. Osseous landmarks were identified, and coordinates were calculated from measured angles and lengths with an accuracy of 0.01'. Lunate and carpal-ulnar distance were obtained according to Youm, and ulnar variance according to Hafner. Results. Overall, an increase in ulnar-lunate displacement and carpal narrowing and a decrease in ulnar variance were found. However, not all wrists responded to the same extent. Radial displacement of the lunate, though slight, was found in 2 wrists and the amount of ulnar displacement varied substantially (3.1% to 22.5%). The variance in amount of displacement could suggest that juvenile wrists do not respond to increased compressive forces to the same extent. Conclusion. The changes found are similar to those found in the healthy wrist. Furthermore, our findings suggest that the juvenile wrist acts in accordance with the generally accepted explanation for the development of malalignment in adult wrists. It seems that laxity of ligaments can be diagnosed early by the force grip maneuver during x-ray. It would have a significant impact on the moment of orthotic intervention as well as the design of the orthotic device. Further study along this line seems justified - NGUYEN QD, HUMPHREY RL, DUNN JP, HUMAYUN MS: Elevated vitreous concentration of monoclonal immunoglobulin manifesting as schlieren in juvenile rheumatoid arthritis-associated uveitis. Arch.Ophthalmol. 2001, 119:293-296.
Organism:Maumenee Building, Room 738, Wilmer Ophthalmological Institute, the Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, Md 21287, USA mhumayun@jhmiedu
Abstract: We report the clinical findings and analysis of the immunoglobulin (Ig) composition of the vitreous of a 10-year-old girl with juvenile rheumatoid arthritis-associated uveitis. The vitreous had a schlieren appearance at the time of pars plana lensectomy and vitrectomy. Analysis of the vitreous fluid revealed marked elevation of IgG, IgM, IgA, and albumin levels relative to vitreous fluids from control patients without uveitis. The immunoglobulin coefficients were also elevated for the IgG and IgM classes of immunoglobulins. Immunofixation electrophoresis of the vitreous fluid revealed 2 distinct bands of restricted electrophoretic mobility. These studies suggest that there may be local (intraocular) production of immunoglobulins as an immunologic response in ocular inflammatory diseases such as juvenile rheumatoid arthritis-associated uveitis and that this immunologic response may be monoclonal (possibly biclonal or oligoclonal) in nature
Internet : PM:11176997 - OREN B, SEHGAL A, SIMON JW, LEE J, BLOCKER RJ, BIGLAN AW, ZOBAL-RATNER J: The prevalence of uveitis in juvenile rheumatoid arthritis. J.AAPOS. 2001, 5:2-4.
Organism:Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York
Abstract: BACKGROUND: Because asymptomatic uveitis has been an important cause of visual loss in children with juvenile rheumatoid arthritis, periodic ophthalmologic screenings of such patients have been recommended. Recently, some authors have found a decreased prevalence of uveitis in children with juvenile rheumatoid arthritis. Methods: We studied a total of 76 patients (63 girls and 13 boys, aged 1 to 16 years), referred to 3 pediatric ophthalmology practices between March 1976 and October 1999. Follow-up examinations were performed at intervals of 3 to 6 months according to current guidelines, during the following 6 months to 23 years (mean, 55 months). Results: Uveitis developed in 10 children (13%). Of these 10 children, 2 were symptomatic (blurred vision, discomfort) and 7 were diagnosed with uveitis at the initial visit. Only 1 patient had asymptomatic uveitis after initial negative findings on screening examination. Final visual acuity for all the compliant children in the uveitis group was better than 20/30. Discussion: The prevalence of uveitis in our study is similar to rates found by other recent authors. This decrease may reflect a tendency for systemic medications to prevent the development of ocular inflammation. We believe that screening guidelines should be reevaluated, especially for asymptomatic children with negative findings on initial examinations
Internet : PM:11182663 - PAIKOS P, FOTOPOULOU M, PAPATHANASSIOU M, CHOREFTAKI P, SPYROPOULOS G: Cataract surgery in children with uveitis. Journal of Pediatric Ophthalmology and Strabismus 2001, 38:16-20.
Organism:Dr. P. Paikos, Ophthalmology Dept., Agia Sofia Children's Hospital, Goudi, 11527 Athens
Abstract: Purpose: To report the technique and postoperative results of cataract surgery in children with uveitis. Method: Between 1988 and 1998, nine children (age range: 2.5-11 years) who developed secondary uveitic cataract and underwent cataract extraction were studied retrospectively. Seven children had juvenile rheumatoid arthritis and two had chronic anterior uveitis of unknown etiology. The surgical technique was lensectomy and wide anterior vitrectomy with limbal approach, lysis of anterior synechiae and in some cases, peripheral iridectomy. Postoperative aphakia was corrected with soft contact lenses in all patients. Follow-up ranged from 6 months to 6 years. Results: Postoperatively, visual acuity in all patients improved and final visual acuity ranged from 20/70 to 20/25. Significant intraoperative complications did not occcur in any patient. One boy with juvenile rheumatoid arthritis developed cystoid macular edema 1 month postoperatively, which was successfully managed. He also developed hypertonia 1 year later, which was also successfully managed. Seven of the nine children had fewer and milder relapses of uveitis after surgery. Conclusion: Cataract surgery, using the lensectomy-vitrectomy technique in children with uveitis, is a safe technique with a relatively small percentage of postoperative complications and good functional results - PUNNONE K, KAIPIAINEN-SEPPANEN O, RIITTINEN L, TUOMISTO T, HONGISTO T, PENTTILA I: Evaluation of iron status in anemic patients with rheumatoid arthritis using an automated immunoturbidimetric assay for transferrin receptor. Clinical Chemistry and Laboratory Medicine 2000, 38:1297-1300.
Organism:Dr. K. Punnonen, Department of Clinical Chemistry, Kuopio University Hospital, PL 1777, 70211 Kuopio
Abstract: We have evaluated a newly introduced immunoturbidimetric transferrin receptor assay (IdeA TfR-IT, Orion Diagnostica, Finland) in healthy subjects and in a study population consisting of patients with rheumatoid arthritis and juvenile chronic arthritis. The IdeA TfR-IT assay was found to provide reproducible results which were in good agreement with the ELISA assays from Orion Diagnostica (IDeA-ELISA, correlation RSUB2=0.8,n=102) and R&D systems (Quantikine TfR ELISA assay, correlation RSUB2=0.95, n=39). The analysis of the patient samples suggested that, on the basis of serum transferrin receptor and ferritin concentrations, in approximately one third of patients with rheumatoid arthritis anemia is due to the depletion of iron stores. Apparently, in all patients with rheumatoid arthritis iron deficiency must be considered as a potential cause of the anemia. Now, that assays which are suitable for automated analyzers have become available for the measurement of serum transferrin receptor, this analyte has the potential to become a part of the routine evaluation of iron status
Internet : kari.punnonen@kuh.fi - SIKORA A, BROZIK H, CHLEBNA-SOKOL D, KARDAS-SOBANTKA D, BIERNACKA M, SMOLEWSKA E, POLAKOWSKA E: Vaccination against virus hepatitis B in children with connective tissue diseases Part I. Safety of vaccination against hepatitis type B in children with chronic juvenile arthritis and other connective tissue diseases. Przeglad Pediatryczny 2000, 30:292-297.
Organism:A. Sikora, Klinika Propedeutyki Pediatrii, Inst. Pediatrii AM w Lodzi, ul. Sporna 36/50, 91-738 Lodz
Abstract: The aim of the study was evaluation of the safety of vaccination against virus hepatitis B with Engerix-B vaccine in children with chronic juvenile arthritis (34 cases) and other connective tissue diseases (4 cases). The study comprised 38 patients (29 girls and 9 boys) aged 3-20 years at various stages of activity of the inflammatory process. Vaccination was conducted according to the scheme 0-1-6. In 5 children during vaccination exacerbation of the disease was seen, but only in 1 case it could be connected with vaccination. The results of the study show that vaccination against active viral hepatitis B in this group of patients was in the majority of cases safe - SIMONINI G, CERINIC MM, CIMAZ R, ANICHINI M, CESARETTI S, ZOPPI M, GENERINI S, FALCINI F: Evidence for immune activation against oxidized lipoproteins in inactive phases of juvenile chronic arthritis. Rinsho Ganka 2001, 28:198-203.
Organism:Dr. F. Falcini, Department of Pediatrics, Via Luca Giordano 13, 50132 Firenze
Abstract: Objective. Oxidative stress contributes to joint inflammation and damage in rheumatoid arthritis. In a mobile inflamed joint, exercise induced multiple cycles of hypoxia-reperfusion injury may lead to the creation of a redox environment in which oxido-reductase systems, by NADPH mechanisms, produce highly reactive chemical species (i.e., oxygen free radicals). We investigated 2 endproducts of lipid peroxidation, malonildialdehyde (MDA) and diene conjugates (DC), and the formation of antibodies against oxidized low density lipoproteins (Ab oxLDL) in juvenile chronic arthritis (JCA), and assessed the role of oxidative phenomena in different phases and subsets of this disease. Methods. To assess the role of oxidative stress in JCA, we measured the endproducts of lipid peroxidation, MDA and DC, by the increase of absorbance at 586 nm and 234 nm, respectively, and the levels of Ab oxLDL by ELISA in the sera of 58 patients with JCA and 21 healthy controls. Due to cross-reactivity between Ab oxLDL and anticardiolipin antibodies (aCL), the sera were also tested by a standard ELISA for IgG-aCL. The patients were divided into 3 subsets: 29 with pauciarticular (pauci), 15 with polyarticular (poly), and 14 with systemic (sys) onset disease, and then were subdivided, according to different variables appropriate to each subset, reflecting active and inactive disease, into 30 active (14 pauci, 8 poly, 8 sys) and 28 inactive (15 pauci, 7 poly, 6 sys). Results. Levels of Ab oxLDL were significantly increased in the whole group of patients (566.6 +/- 263.0 vs 206.6 +/- 136.3 mU/ml; p < 0.001) and in each of the type of onset (pauci 660.8 +/- 272.1, p < 0.001; poly 341.3 +/- 134.7, p < 0.01; sys 497.8 +/- 114.8, p < 0.001) compared to controls, Ab oxLDL were higher in the inactive than in the active group (743.5 +/- 231.9 and 404.4 +/- 169.9; p < 0.001). MDA and DC levels were not increased significantly in patients' sera. No patient was positive for IgG-aCL, Conclusion. These findings suggest that MDA and DC cannot be considered major markers of oxidative stress in JCA and that the Ab oxLDL may represent a delayed sign of oxidative stress previously induced by the inflammatory process in patients with JCA
Internet : falcini@cesit1.unifi.it - TSE S, LUBELSKY S, GORDON M, AL MAYOUF SM, BABYN PS, LAXER RM, SILVERMAN ED, SCHNEIDER R, FELDMAN BM: The arthritis of inflammatory childhood myositis syndromes. Rinsho Ganka 2001, 28:192-197.
Organism:Dr. B.M. Feldman, Division of Rheumatology, Hospital for Sick Children, 555 University Arenue, Toronto, Ont. M5G 1X8
Abstract: Objective. Arthritis has been an associated finding in juvenile dermatomyositis (JDM), but its prevalence, course, and response to therapy has not been well described. We investigated the frequency, course, and clinical and radiographic features in a large cohort of patients with JDM. Methods. The charts of 94 patients with idiopathic myositis (1984-99) were reviewed: 80 JDM, 3 juvenile polymyositis (JPM), 5 amyopathic JDM, and 6 overlap myositis syndromes. Compiled data included demographics, clinical features, a detailed description of the arthritis, investigations (radiographs, autoantibodies), course, and response to therapy. All radiographs were independently reviewed by a single radiologist. Results. Sixty-one percent (95% CI 50-72%) of patients with JDM had arthritis. The arthritis was reported a median 4.5 mo (range -73.6 to 76.6 mo) after the JDM onset. When compared to patients with no arthritis, the occurrence of arthritis was not significantly related to sex, race, positive antinuclear antibody or rheumatoid factor, calcinosis, nodules, vasculitis, or Raynaud's phenomenon. The initial involvement was pauciarticular in 67% and polyarticular in 33%. In the pauci group, asymptomatic knee effusions were the predominant finding (n = 19, 58%), and in 18 patients may have been the result of steroid therapy. Two patients evolved from a pauci onset to a polyarticular course. All responded to therapy (corticosteroids; 47 were taking other medications) with remission of the arthritis within a median of 2.0 mo (range 0.1-64.5 mo). However, the arthritis recurred in 39% as the corticosteroids were tapered. Four patients with JDM eventually required corticosteroid wrist injections, with resolution of the arthritis. The arthritis was nonerosive in all cases. No patient with JPM had arthritis. Three of 5 patients with amyopathic JDM and 4 of 6 with overlap myositis syndrome had a nonerosive polyarthritis. Conclusion. Nonerosive arthritis involving the knees, wrists, elbows, and fingers is a frequent manifestation of JDM and other idiopathic childhood myositis. The arthritis is seen early in the course of JDM and often responds to treatment. However, the arthritis may recur with tapering of corticosteroids despite remission of the JDM. In a significant proportion of JDM cases, arthritis is the major sequela and may warrant further medical therapy or intraarticular corticosteroid injections
Internet : brian.feldman@sickkids.on.ca