Validation of nasal tracheal aspiration in children with lung disease.

BACKGROUND: Nasal tracheal aspiration (NTA) is a frequently used diagnostic method to assess of infections in the lower airways. However, the validity of the method has not previously been compared to bronchoalveolar lavage (BAL) in non-intubated children with a lung disease. We hypothesised that NTA performed by health professionals using the nares vocal cord distance to be placed at the entrance of the trachea, will result in same finding of bacteria in the lower airways as the gold standard of BAL. METHODS: In a prospective study, 173 paired samples of NTA and BAL were obtained between June 2016 to August 2018. Samples were collected from all patients undergoing bronchoscopy with spontaneous breathing during general anaesthesia. This study compares the microbiological results from the cultures obtained by investigating complete concordance i.e. identical pathogenic bacteria and coherence i.e. absence or presence of pathogenic bacteria growth between NTA and BAL. RESULTS: Samples were collected in 164 patients, 158 children between 21 days and 18 years of age and six young adults still treated at the paediatric department. The overall similarity (complete agreement) was found in 49% [41-56], sensitivity was 35% [27-45], specificity was 66% [55-76], positive predictive value was 36% [27-46] and negative predictive value was 64% [54-64] concerning complete pathogenic bacteria concordance. If we only considered coherence growth of pathogenic bacteria, similarity was 71% [63-79], sensitivity was 74% [64-81], specificity was 66% [55-76], positive predictive value was 75% [65-82] and negative predictive value was 65% [54-75]. Patients with cystic fibrosis showed a similarity of 88% [73-95], a sensitivity of 92% [76-99], a specificity of 71% [36-95], a positive predictive value of 92% [76-99] and a negative predictive value of 71% [36-95] concerning coherence growth of pathogenic bacteria. CONCLUSION: The study indicates that NTA compared to BAL as the gold standard is not clinically useful to assess positive findings of specific bacteria in the lower airway tract. Statistically significantly increased sensitivity and positive predictive value were found in cystic fibrosis patients concerning coherence growth. The clinical usage of NTA remains important as negative findings are of clinical value. However, BAL continues to be preferred as a significantly superior diagnostic tool.

A Comparison of Radiographic Joint Space Width Measurements Versus Ultrasonographic Assessment of Cartilage Thickness in Children with Juvenile Idiopathic Arthritis.

OBJECTIVE: Joint space narrowing (JSN) is a measurable outcome of tissue degeneration in arthritis. JSN is usually assessed by conventional radiography. Ultrasonographic (US) measurement of joint cartilage thickness has been validated in healthy children, and US measurement of the distal femoral cartilage has been validated in a group of patients with juvenile idiopathic arthritis (JIA). Our aim was to compare the measures of cartilage thickness of the proximal cartilage site in the second metacarpophalangeal (MCP), second proximal interphalangeal (PIP), and knee joints as assessed by US to joint space width (JSW) as measured by computerized radiography in children with JIA. METHODS: The study included 74 children with JIA aged 5-15 years (median 11.3 yrs). MCP and PIP joints were assessed at one midline spot. Knee joints were assessed at the medial and lateral femoral condylar areas. Only the proximal cartilage site in the joints was assessed by US, whereas the complete JSW was assessed by radiography. RESULTS: We assessed 136 second MCP, 138 second PIP, and 146 knee joints. We found a high level of agreement between US and radiographic measures of cartilage thickness and JSW: r = 0.82-0.86 (second MCP), r = 0.50-0.55 (second PIP), and r = 0.52-0.81 (knee); p < 0.001 for all 8 assessed sites. CONCLUSION: US measurements of cartilage thickness of the proximal site of the second MCP, second PIP, and knee joints correlated well with radiographic JSW measurements in the finger and knee joints of children with JIA. However, US does not measure the distal cartilage, which may limit its use in the assessment of JSN.

Joint cartilage thickness and automated determination of bone age and bone health in juvenile idiopathic arthritis.

BACKGROUND: BoneXpert is an automated method to calculate bone maturation and bone health index (BHI) in children with juvenile idiopathic arthritis (JIA). Cartilage thickness can also be seen as an indicator for bone health and arthritis damage. The objective of this study was to evaluate the relation between cartilage thickness, bone maturation and bone health in patients with JIA. METHODS: Patients with JIA diagnosed according ILAR criteria included in a previous ultrasonography (US) study were eligible if hand radiographs were taken at the same time as the US examination. Of the 95 patients 67 met the inclusion criteria. RESULTS: Decreased cartilage thickness was seen in 27% of the examined joints. Decreased BHI was seen in half of the JIA patient, and delayed bone maturation was seen in 33% of patients. A combination of decreased BHI and bone age was seen in 1 out of 5 JIA patients. Decreased cartilage thickness in the knee, wrist and MCP joint was negatively correlated with delayed bone maturation but not with bone health index. CONCLUSION: Delayed bone maturation and decreased BHI were not related to a thinner cartilage, but a thicker cartilage. No relation with JADAS 10 was found. The rheumatologist should remain aware of delayed bone maturation and BHI in JIA patients with cartilage changes, even in the biologic era.

Decreased cartilage thickness in juvenile idiopathic arthritis assessed by ultrasonography.

OBJECTIVE: Juvenile idiopathic arthritis (JIA) may result in disability, which is caused primarily by degeneration of the osteocartilaginous structures, due to the synovial inflammatory process. It is essential to closely monitor structural damage during the disease course. We aimed to compare ultrasound (US) measurements of joint cartilage thickness in 5 joints in children with JIA to our findings in an age- and sex-related healthy cohort regarding disease duration, joint activity, JIA subtype, age, and sex. METHODS: We clinically examined joint activity in 95 patients with JIA and collected parent and physician global assessments. Joint cartilage thickness was assessed by greyscale US in knee, ankle, wrist, metacarpophalangeal, and proximal interphalangeal (PIP) joints. Measurements were compared to reference values of a healthy cohort from a previous study. Medical records were reviewed for JIA subtype, treatment, and disease duration. RESULTS: Joint cartilage thickness was decreased in the knee, wrist, and second PIP joint in children with JIA compared with the healthy cohort (p < 0.001 for all). Patients with oligoarticular JIA had thicker cartilage than patients with polyarticular and systemic JIA. We also found decreased joint cartilage thickness in joints not previously affected by arthritis in children with JIA compared to the same joint in the healthy cohort. We found decreasing cartilage thickness with age and thicker cartilage in boys than in girls. CONCLUSION: Children with JIA have reduced cartilage thickness compared with children who do not have JIA, and children with polyarticular and systemic JIA have thinner cartilage than children with oligoarticular JIA.

Ultrasonographic measurements of joint cartilage thickness in healthy children: age- and sex-related standard reference values.

OBJECTIVE: Loss of joint cartilage may be an early feature of chronic inflammatory joint diseases like juvenile idiopathic arthritis (JIA). Conventional radiography usually detects only late changes such as joint space narrowing and bone erosion rather than early inflammatory changes. Joint cartilage is easily visualized with high-frequency ultrasonography (US), but age- and gender-related normal standard reference values should be established before US measurement of cartilage thickness becomes standard procedure in the clinic. METHODS: A cross-sectional study of bilateral grey-scale US cartilage thickness of the knee, ankle, wrist, and second metacarpophalangeal (MCP) and second proximal interphalangeal (PIP) joints was performed in 394 (215 boys/179 girls) healthy Danish Caucasian children aged between 7 and 16 years. RESULTS: Cartilage thickness differed significantly between sexes (p < 0.001 for all joints), boys having thicker cartilage than girls. Cartilage thickness clearly decreased with increasing age in both sexes. A formula for calculating sex-specific cartilage thickness at different ages in childhood is suggested. No difference between the right and left side of the investigated joints was observed. CONCLUSION: Using US, we established age- and sex-related normal reference intervals for cartilage thickness of the knee, ankle, wrist, and MCP and PIP joints in 7- to 16-year-old children, and designed a formula for calculating hyaline cartilage thickness in all age groups throughout childhood.

Inter -and intraobserver variation of ultrasonographic cartilage thickness assessments in small and large joints in healthy children.

BACKGROUND: There is an increasing interest among pediatric rheumatologist for using ultrasonography (US) in the daily clinical examination of children with juvenile idiopathic arthritis (JIA). Loss of joint cartilage may be an early feature of destructive disease in JIA. However, US still needs validation before it can be used as a diagnostic bedside tool in a pediatric setting. This study aims to assess the inter- and intraobserver reliability of US measurements of cartilage thickness in the joints of healthy children. METHODS: 740 joints of 74 healthy Caucasian children (27 girls/47 boys), aged 11.3 (7.11 - 16) years were examined with bilateral US in 5 preselected joints to assess the interobserver variability. In 17 of these children (6 girls/11 boys), aged 10.1(7.11-11.1) years, 170 joints was examined in an intraobserver sub study, with a 2 week interval between the first and second examination. RESULTS: In this study we found a good inter- and intraobserver agreement expressed as a coefficient of variation (CV) less than 10% in the knee (CV = 9.5%interobserver and 5.9%intraobservserI, 9.3%intraobserverII respectively for the two intraobserver measurements) and fairly good for the MCP joints (CV = 11.9%interobserver, 12.9%intraobserverI and 11.9%intraobsevrerII). In the ankle and PIP joints the inter- and intraobserver agreement was within an acceptable limit (CV<20%) but not for the wrist joint (CV>26%). We found no difference in cartilage thickness between the left and right extremity in the investigated joints. CONCLUSION: We found a good inter -and intraobserver agreement when measuring cartilage thickness with US. The inter- and intraobserver variation seemed not to be related to joint size. These findings suggest that positioning of the joint and the transducer is of major importance for reproducible US measurements. We found no difference in joint cartilage thickness between the left and right extremity in any of the examined joint of the healthy children. This is an important finding giving the opportunity of using the non-affected extremity as a reference when assessing articular joint cartilage damage in JIA.

Ultrasound measurement of joint cartilage thickness in large and small joints in healthy children: a clinical pilot study assessing observer variability.

BACKGROUND: Loss of joint cartilage is a feature of destructive disease in JIA. The cartilage of most joints can be visualized with ultrasonography (US). Our present study focuses on discriminant validity of US in children. We studied reproducibility between and within a skilled and a non-skilled investigator of US assessment of cartilage thickness in small and large joints in healthy children. METHODS AND RESULTS: In 11 healthy children (5 girls/6 boys), aged 9.6 years (9.3-10 years), 110 joints were examined. Cartilage thickness of the right and left hip, knee, ankle, 2nd metacarpophalangeal (MCP), and 2nd proximal interphalangeal (PIP) joint independently. The joints were examined twice, two days apart by a skilled and a non-skilled investigator. Mean cartilage thickness in the five joints was: hip 2.59 +/- 0.41, knee 3.67 +/- 0.64, ankle 1.08 +/- 0.31, MCP 1.52 +/- 0.27 and PIP 0.73 +/- 0.15 mm. We found the same mean differences in CTh of 0.6 mm in the inter-observer part with regard of the PIP joint. Within investigators (intra-observer), the smallest mean difference of CTh was found in the MCP joint with -0.004 (skilled) and 0.013 mm (non-skilled). CONCLUSION: We found the level of agreement between observers within a 95% Confidence Interval in assessment of cartilage thickness in hip-, knee-, ankle-, MCP-, and PIP joints in healthy children. Observer variability seems not to relate to joint size but to the positioning of the joints and the transducer. These factors seem to be of major importance for reproducible US measurements. The smallest difference in measurement of cartilage thickness between observers was found in the PIP joint, and within observers in the MCP joint and it seems that using EULAR standard US guidelines is feasible for a pediatric setting. The use of US in children is promising. Studies on larger groups of children are needed to confirm the validation and variability of US in children as well as determining the smallest detectable difference of US measures.