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ORIGINAL ARTICLE High frequency power doppler ultrasonography in oligoarticular juvenile idiopathic arthritis: Correlation with disease severity Hala Abd Elhady Saleh Hassan, Amal Mostafa Ibrahim El Ganzouri, Sahar Fathi Ahmed * , Sally Mohamed Abd Elhady Sayed Rheumatology and Rehabilitation Department, Ain Shams University, Cairo, Egypt Received 30 September 2014; accepted 6 November 2014 Available online 12 December 2014 KEYWORDS Juvenile idiopathic arthritis; High resolution power Doppler ultrasonography; Disease severity score; Juvenile arthritis functional- ity scale Abstract Aim of the work: Juvenile idiopathic arthritis (JIA) is the most common chronic rheu- matic disease in children and is a leading cause of acquired disability in the pediatric age. We aimed to detect subclinical synovitis in children with oligoarticular JIA using high frequency power Doppler ultrasonography (US) and correlate US scores with clinical disease severity. Patients and methods: High frequency power Doppler ultrasonography was done for both knees and ankles of 20 oligoarticular JIA patients. Assessment of clinical disease severity by articular index scores and functional assessment by the modified juvenile arthritis functionality scale (JAFS) were calculated for all patients. Results: We found 24 clinically active knees and 20 clinically active ankles. On comparison between clinical and ultrasonography activity, we found 13 clinically inactive joints, but they were active joints by ultrasonography. There was a highly significant difference (p < 0.001) between clin- ical and US activity as regards the number of affected joints. There was a highly significant (p < 0.01) positive correlation between clinical disease severity scores and all US scores except clinical score of range of motion (ROM); that did not show a significant positive correlation with US score of effusion (p > 0.05). Conclusions: High frequency power Doppler US may be useful in detecting subclinical synovitis of joints in JIA patients with clinically defined inactive joints. Also, it can indicate the degree of disease severity in JIA patients. So, high frequency power Doppler US can be used in standard clin- ical practice for monitoring JIA patients for better assessment and management of the disease. Ó 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases. 1. Introduction The term juvenile idiopathic arthritis (JIA) encompasses a clin- ically heterogeneous group of disorders characterized by arthritis that begins before 16 years of age, persists for more than 6 weeks and is of unknown cause [1]. JIA is the most * Corresponding author at: Rheumatology and Rehabilitation Department, Ain Shams University, Cairo 11566, Egypt. Tel./fax: +20 226830729. E-mail address: [email protected] (S.F. Ahmed). Peer review under responsibility of Egyptian Society of Rheumatic Diseases. The Egyptian Rheumatologist (2015) 37, 125–131 HOSTED BY Egyptian Society of Rheumatic Diseases The Egyptian Rheumatologist www.rheumatology.eg.net www.elsevier.com/locate/ejr http://dx.doi.org/10.1016/j.ejr.2014.11.003 1110-1164 Ó 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases.

Transcript of High frequency power doppler ultrasonography in ... · High frequency power doppler ultrasonography...

Page 1: High frequency power doppler ultrasonography in ... · High frequency power doppler ultrasonography in oligoarticular juvenile idiopathic arthritis: Correlation with disease severity

The Egyptian Rheumatologist (2015) 37, 125–131

HO ST E D BYEgyptian Society of Rheumatic Diseases

The Egyptian Rheumatologist

www.rheumatology.eg.netwww.elsevier.com/locate/ejr

ORIGINAL ARTICLE

High frequency power doppler ultrasonography

in oligoarticular juvenile idiopathic arthritis:

Correlation with disease severity

* Corresponding author at: Rheumatology and Rehabilitation

Department, Ain Shams University, Cairo 11566, Egypt. Tel./fax:

+20 226830729.

E-mail address: [email protected] (S.F. Ahmed).

Peer review under responsibility of Egyptian Society of Rheumatic

Diseases.

http://dx.doi.org/10.1016/j.ejr.2014.11.0031110-1164 � 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases.

Hala Abd Elhady Saleh Hassan, Amal Mostafa Ibrahim El Ganzouri,

Sahar Fathi Ahmed *, Sally Mohamed Abd Elhady Sayed

Rheumatology and Rehabilitation Department, Ain Shams University, Cairo, Egypt

Received 30 September 2014; accepted 6 November 2014Available online 12 December 2014

KEYWORDS

Juvenile idiopathic arthritis;

High resolution power

Doppler ultrasonography;

Disease severity score;

Juvenile arthritis functional-

ity scale

Abstract Aim of the work: Juvenile idiopathic arthritis (JIA) is the most common chronic rheu-

matic disease in children and is a leading cause of acquired disability in the pediatric age. We aimed

to detect subclinical synovitis in children with oligoarticular JIA using high frequency power

Doppler ultrasonography (US) and correlate US scores with clinical disease severity.

Patients and methods: High frequency power Doppler ultrasonography was done for both knees

and ankles of 20 oligoarticular JIA patients. Assessment of clinical disease severity by articular

index scores and functional assessment by the modified juvenile arthritis functionality scale (JAFS)

were calculated for all patients.

Results: We found 24 clinically active knees and 20 clinically active ankles. On comparison

between clinical and ultrasonography activity, we found 13 clinically inactive joints, but they were

active joints by ultrasonography. There was a highly significant difference (p< 0.001) between clin-

ical and US activity as regards the number of affected joints. There was a highly significant

(p< 0.01) positive correlation between clinical disease severity scores and all US scores except

clinical score of range of motion (ROM); that did not show a significant positive correlation with

US score of effusion (p> 0.05).

Conclusions: High frequency power Doppler US may be useful in detecting subclinical synovitis

of joints in JIA patients with clinically defined inactive joints. Also, it can indicate the degree of

disease severity in JIA patients. So, high frequency power Doppler US can be used in standard clin-

ical practice for monitoring JIA patients for better assessment and management of the disease.� 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases.

1. Introduction

The term juvenile idiopathic arthritis (JIA) encompasses a clin-

ically heterogeneous group of disorders characterized byarthritis that begins before 16 years of age, persists for morethan 6 weeks and is of unknown cause [1]. JIA is the most

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126 H.A.E.S. Hassan et al.

common chronic rheumatic disease in children and is a leadingcause of acquired disability in the pediatric age. It is an impor-tant cause of short and long-term disability [1]. The persistence

of synovial inflammation may cause cartilage and bone dam-age and, ultimately, lead to permanent alterations in jointstructures and serious impairment of physical function [2].

The International League of Associations for Rheumatol-ogy (ILAR) has subclassified the disease entity into seven dis-tinct categories, based on the number of affected joints and the

presence of particular extraarticular manifestations. They aresystemic, oligoarticular (persistent and extended), polyarticu-lar (rheumatoid factor negative), polyarticular (rheumatoidfactor positive), psoriatic, enthesitis-related and undifferenti-

ated [3].Musculoskeletal ultrasound (MSUS) has emerged as an

indispensable tool for physicians involved in musculoskeletal

medicine, and lately it has become more attractive to pediatricrheumatologists as well. Two important aspects have resultedin increased interest in using MSUS in JIA: firstly, the evolu-

tion of high frequency linear transducers that depict superficialmusculoskeletal structures with unsurpassed resolution. Sec-ondly, the need for imaging techniques that can detect the

slightest traces of soft tissue inflammation. So far, only fewstudies have investigated power Doppler assessments of chil-dren with JIA [4–9].

In general, US has gained an important position in rheuma-

tologists’ clinical practice. This is due to its intrinsic character-istics, such as low costs, rapidity and lack of radiation [10]. Forthese reasons, US could be a valuable tool in the assessment of

JIA, as it is a simple examination that can offer a significantamount of information on a large number of joints in a rela-tively short time and with minimal discomfort to the patient.

It is easy to perform on children of all ages, because agitationof the patient is rarely a problem [11,12].

Ultrasound may demonstrate a greater sensitivity in identify-

ing joint synovitis than clinical examination alone. This is ofmajor importance, as clinical classification and therapeutic strat-egy in JIA are guided by the number of joints involved [1]. So, InJIA, US assessment of disease activity may be more informative

than clinical examination [13]. Ultrasound images are analyzedin real time, and the information that is acquired can be useddirectly to adjust the clinical assessment, which can be particu-

larly useful if there are few verbal complaints, e.g., in infants[14]. Subclinical synovitis is frequently detected by US, particu-larly in the handsand feet [15].Theprognostic significanceof such

subclinical inflammation still needs to be determined [11].The aim of this study was to detect subclinical synovitis

(hypertrophied vascular synovium) in children with oligoartic-ular JIA using high frequency Doppler US as a new imaging

microvascular sensitive method of disease prediction, then cor-relate the US scores with clinical disease severity.

2. Patients and methods

Twenty patients with oligoarticular JIA were selected fromthose presenting to the Pediatric Rheumatology outpatient

clinics of the Ain Shams University Hospitals. Those patientswere all fulfilling the ILAR classification. They presented witharthritis of 4 or fewer joints during the first 6 months of dis-

ease. Patients were further classified as either persistent (if nomore than four joints are affected during the disease course)or extended (if, after the initial 6 month period, the total num-

ber of affected joints exceeds four) [3]. The included patientshad arthritis in knees and/or ankles.

We excluded patients with age more than 16 years old,

other six types of JIA according to ILAR, systemic connectivetissue disease: systemic lupus erythematosus, vasculitis, grow-ing pain, trauma of joints or bones, infective arthritis, reactive

arthritis, hemophilic arthropathy, tumor of joints or bones,avascular necrosis, Perthes’ disease and osteochondritis. Thestudy protocol was in accordance with Helsinki declaration

of human rights, and was approved by the local Ethics Com-mittee. The written informed consent from all the patients’parents was obtained.

All patients were subjected to the following:

1. Full history taking and thorough physical examinationincluding detailed musculoskeletal examination.

2. Assessment of disease severity by articular index (severityscore) according to Kakati et al. [16]: Both knees andankles of all patients were assessed for swelling, tender-

ness/pain on motion and restricted motion. Clinically activearthritis was defined as swelling or limitation of movementwith either pain upon movement or tenderness. Swelling

was scored as 0 = none; 1 = mild, definite swelling butwith no blurring of normal skeletal outlines; 2 = moderate,definite obscuring of skeletal landmarks; 3 = severe, nodiscernible skeletal landmarks; Tenderness and/or pain on

motion was scored as 0 = none; 1 = mild, patient com-plains on joint movement or palpation; 2 = moderate,patient withdraws or changes facial expression on move-

ment or palpation; 3 = severe, patient responds severelyto movement or palpation); Restricted motion was scoredas 0 = full range; 1 = 1–25% limitation; 2 = 26–50% lim-

itation; 3 = 51–75% limitation; 4 = 76–100% limitation.In overall, severity score is calculated to each joint as thesum of the severity ratings obtained for the scores of pain

on motion/tenderness, swelling and limited range ofmotion; severity score to each joint ranged from 0 to 10and to all joints from 0 to 40.

3. Functional assessment: The parent is asked to assess a

child’s functional ability by completing the modified juve-nile arthritis functionality scale (JAFS) [17]. It is a 5-itemquestionnaire (for lower limbs only) in which the ability

of the child to perform each task is scored as follows:0 = without difficulty, 1 = with difficulty and 2 = unableto do. It is ranged from 0 to 10.

4. High frequency ultrasonographic and power Doppler assess-ment: By 12 MHz probe Esaote MyLab in Al Demerdashhospital, is performed on both knees and ankles of allpatients, which are scanned for the presence of synovial

hyperplasia, joint effusion, and power Doppler (PD) signal.All of the US findings were interpreted using both longitu-dinal and transverse planes [18]. Synovial hyperplasia was

graded as follows: 0 = < 2 mm, 1 = 2–5 mm, 2 = 6–8 mm, and 3 => 8 mm. Joint effusion was graded as fol-lows: 0 = absent, 1 =< 5 mm, 2 = 5–10 mm, and

3 = > 10 mm.Power Doppler signal was graded as fol-lows: 0 = absent, 1 = presence of single/vessel dots,2 = presence of confluent vessel dots in less than half of

the synovial area, and 3 = presence of confluent vessel dotsin more than half of the synovial area. Ultrasound activejoint scores ranged from 1 to 9, except if 1 was for PDalone, then it was considered to be inactive [13]. Ultrasound

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Table 1 Evaluation of articular index scores in the 20 oligoarticular Juvenile idiopathic arthritis patients (n= 20).

Articular index scores Knees Ankles

Range Mean ± SD Range Mean ± SD

Tenderness 0–2 0.58 ± 0.6 0–2 0.58 ± 0.8

Swelling 0–1 0.35 ± 0.5 0–1 0.18 ± 0.4

Limited ROM 0–2 0.15 ± 0.4 0–2 0.50 ± 0.8

Total severity 0–5 1.08 ± 1.1 0–5 1.25 ± 1.6

ROM: range of motion.

Ultrasonography in oligoarticular juvenile idiopathic arthritis 127

score for synovial hyperplasia, joint effusion and PD signalwas calculated as the sum of severity rating obtained ineach joint as a total US score which ranged from 0 to 9

to each joint. The maximum score for all joints is 36.5. Laboratory investigations: Complete blood count, erythro-

cyte sedimentation rate and C-reactive protein were done

for all patients.

Statistical analysis: IBM SPSS statistical software package(SPSS 15.0.1 for windows; SPSS Inc, Chicago, IL, 2001) wasused for data analysis. Data were expressed as range (mini-mum–maximum), mean and standard deviation (SD) for

quantitative parametric data, and median was used for quanti-tative non parametric data. Nominal data were expressed asfrequency and percentage. Comparison between two indepen-

dent groups of numerical parametric data was done using Stu-dent’s t-test and Mann–Whitney test for non parametric data.Pearson Chi-Square test was used to examine the relationship

between two qualitative variables. Spearman correlation coef-ficient test was done to study the correlation between twoquantitative variables. Probability of error at <0.05 was con-

sidered significant and highly significant at <0.001.

Figure 1 Longitudinal ultrasonographic view of the right knee show

with oligoarticular juvenile idiopathic arthritis (JIA).

3. Results

This study included 20 patients diagnosed as oligoarticular JIA(10 males and 10 females). The patients’ age ranged from 8 to15 years, with a mean of 12.5 ± 2.1 years. The disease dura-tion ranged from 2 to 8 years; with a mean of 5.5 ± 1.9 years.

As regards medical treatment, there were 19 patients (95%)on non steroidal anti inflammatory drugs (oral ibuprofen), 16patients (80%) on methotrexate injection and 4 patients (20%)

on low dose corticosteroids.The number of affected joints in 1st 6 months of the disease

ranged from 1 to 4 joints, with a mean of 2.7 ± 1 joints. The

number of affected joints along the course of the disease ran-ged from 2 to 6 joints with a mean of 3.8 ± 1.6 joints. Accord-ing to the type of oligoarticular JIA (whether extended or

persistent), there were 5 patients (25%) with the extended typeand 15 patients (75%) with the persistent type.

Our study included 40 knee joints and 40 ankle joints. Asregards clinically active joints count, we found 24/40 (60%) clin-

ical active knees and 20/40 (50%) clinical active ankles. Eachaffected joint of both knees and ankles was assessed for swelling,tenderness/pain on motion and restricted motion, and total

ing moderate (6.6 mm) synovial hyperplasia in a 13 years old girl

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128 H.A.E.S. Hassan et al.

severity score (Table 1). Functional disease assessment by mod-ified JAFS ranged from 1 to 10 with a mean of 3.8 ± 2.3.

As regards ultrasonography assessment, there were 29/40

(72.5%) ultrasonography active knees and 22/40 (55%) activeankles (See Figs. 1–3). On comparison between clinical andultrasonography activity, we found 13/80 (16.25%) clinically

inactive joints (9 knees and 4 ankles), but they were active jointsby ultrasonography. Also, there were 6/80 (7.5%) clinically

Figure 2 Longitudinal ultrasonographic view of the left knee showing

juvenile idiopathic arthritis (JIA).

Figure 3 Ultrasonography showing grade 2 power Doppler signal in

(JIA).

active joints (1 knee and 5 ankles), but they were inactive jointsby ultrasonography while there were 38/80 (47.5%) clinicallyandultrasonographically active joints. Therewas a highly signif-

icant difference (p < 0.001) between clinical and US activity asregards the number of affected joints (Table 2). The mean ofsynovial hyperplasia score, effusion score and PD signal score

is shown in Table 3. There was an absence of Baker’s cyst clini-cally and by PDUS in all JIA patients.

moderate (8 mm) effusion in an 8 years old boy with oligoarticular

a 12 years old girl with oligoarticular juvenile idiopathic arthritis

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Table 2 Comparison between clinical and ultrasonography

activity in the knees and ankles of the oligoarticular juvenile

idiopathic arthritis patients.

Joints (n = 80) knees & ankles Clinical

Active Inactive p Sig.

Ultrasonography Active No. 38 13 <0.001 HS

(%) (47.5) (16.25)

Total 51

Inactive No. 6 23 <0.001 HS

(%) (7.5) (28.75)

Total 29

Sig: significance, HS: highly significant.

Table 3 Description of ultrasonographic scores in the knees

and ankles of the oligoarticular juvenile idiopathic arthritis

patients.

US scores Knees Ankles

Range Mean ± SD Range Mean ± SD

Synovial hyperplasia 0–3 1.18 ± 1.01 0–3 1.03 ± 1.1

Effusion 0–2 0.78 ± 0.8 0–2 0.35 ± 0.6

PD signal 0–3 0.83 ± 0.9 0–3 0.73 ± 1.01

US: ultrasonographic, PD: power Doppler.

Ultrasonography in oligoarticular juvenile idiopathic arthritis 129

There was a high significant (p< 0.001) positive correla-tion between all clinical scores (except ROM) and all US scores

(Table 4). On the other hand, there was no significant correla-tion between all US scores and functional assessment score(p> 0.05).

As regards laboratory investigation, we found that themean of hemoglobin was 11.1 ± 1.1 g/dl. The mean of whiteblood cells was 8.8 ± 1.2 · 1000/ll and the mean of platelets

was 390.0 ± 87.8 · 1000/ll. Also, the mean of 1st hour eryth-rocyte sedimentation rate was 28.6 ± 21.7 mm/h and the meanof C-reactive protein was 2.2 ± 3.9 mg/dl.

Table 4 Correlation between clinical severity and ultrasonograph

idiopathic arthritis patients.

Clinical severity (articular index scores) Tenderness r

p

Sig

Swelling r

p

Sig

Limited ROM r

p

Sig

Total score r

p

Sig

ROM: range of motion, r: correlation coefficient, Sig: significance, NS: n

4. Discussion

Juvenile idiopathic arthritis (JIA) is defined as persistent arthri-tis for more than 6 weeks with an onset before 16 years and no

other identifiable cause. Several JIA subtypes are distinguishedbased on symptoms in the first 6 months. The prognosis variesacross subtypes and according to the number of affected joints

[19]. The most common sites of involvement in JIA are theknees, ankles, feet, and hands. Therefore, the clinical joint eval-uation is of prime importance for diagnosing JIA, monitoringdisease activity, and predicting the outcome [20].

Imaging in JIA is crucial for diagnosis of the disease, assess-ing its severity and prognosis, monitoring disease progressionand treatment response, and evaluating complications associ-

ated with the disease or its therapy [21].There was equal male to female ratio in our study. This was

in agreement with Haslam et al. [22] study, which was done on

17 oligoarticular JIA patients. The number of female/male intheir study was 9–8.While in another study on Egyptian JIApatients, the F:M of the oligoarticular subtype was 26:5 [23].

In our study, the number range of joints affected in 1st6 months was the same as in Haslam et al. [22] study. In anEgyptian study on JIA, oligoarticular subtype was also morefrequent (39%) compared to the other subtypes [24]. In

another study, the oligoarticular subtypes (33.3%) were com-parable with the other subtypes [25]. These results indicate thatoligoarticular subtype is common, that’s why we did our study

on this subtype.We had more persistent than extended type of JIA patients

in our study. Similarly, another study had more persistent olig-

oarticular JIA patients (62.5%), despite they did their study onall subtypes of JIA [26]. Also, Magni-Manzoni et al. [27] whostudied on all subtypes of JIA, found 18 patients with persis-

tent and 12 with extended oligoarthritis.In our study, knees were more affected than ankles. Also,

Haslam et al. [22] revealed that knees were the most commonlyaffected joint in oligoarticular JIA patients. Moreover, knees

and ankles are the most commonly affected in JIA patients,and 50% of patients at presentation have mono arthritis; usu-ally in the knee [28].

ic scores of the knees and ankles in the oligoarticular juvenile

Ultrasonographic scores

Synovial hyperplasia Effusion Power Doppler

0.51 0.56 0.54

<0.001 <0.001 <0.001

. HS HS HS

0.68 0.74 0.72

<0.001 <0.001 <0.001

. HS HS HS

0.35 0.17 0.35

0.002 <0.13 0.002

. S NS S

0.61 0.60 0.66

<0.001 <0.001 <0.001

. HS HS HS

on significant, HS: high significant.

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130 H.A.E.S. Hassan et al.

In the present study, we used three scoring systems; articu-lar index score, functional score (modified JAFS) and ultraso-nography scoring to assess the clinical disease severity, the

related disability, and the extent of synovitis, effusion and vas-cularization respectively in JIA patients.

The mean values of tenderness, swelling, limited ROM and

total severity scores in our study indicate that most of jointswere of mild to moderate range of clinical severity. While themeans of these scores in the study done by Magni-Manzoni

et al. [29] were higher; indicating that most of joints were ofsevere scores. This discrepancy may be due to that their studywas done for all peripheral joints, not only knees and anklesbut also for all subsets of 31 JIA patients.

Functional assessment by modified JAFS in our study wasin agreement with Haslam et al. [22] who studied oligoarticularJIA patients, where the mean of their functional score was 4.1.

These results revealed that most patients were mild to moder-ate functionally impaired. Also, Cassidy and Petty, [28]reported that serious functional disability is uncommon.

As regards the semiquantitative grading of ultrasonographyin our oligoarticular JIA patients, the mean of synovial hyper-plasia, effusion and PD vascularization scores indicate that

most of the joints were of mild (grade 1) to moderate (grade2) range. This was in agreement with Kakati et al. [16]. Onthe contrary to our results, Collado and coworkers [30] revealedthat grade 2 or 3 vascularization was strongly associated with

JIA. Also, Magni-Manzoni et al. [29] found that the mean val-ues of synovial hyperplasia score, effusion score and PD scorewere higher than our scores which indicates severe joint affec-

tion in their study. This difference may be due to that theirstudy was done on all peripheral joints in all JIA subtypes.

Similar to our results, other studies found a significant differ-

ence between clinical and US activity of the joints [16,22]. Also,Janow et al. [13] examined knees and ankles of 19 JIA patients.They found 5 joints active on physical examination and inactive

on US, all were ankle joints. This may be due to the technical dif-ficulties associated with ultrasonographic evaluation of the anklestructures. Other studies showed that US variables significantlycorrelated with clinical measures of joint swelling, but not with

tenderness and restricted motion [16,29,31]. This was similar toour study except for insignificant correlation between tendernessand US variables. This discrepancy may be due to that other

peripheral joints were included in their study.Ultrasound may be useful in detecting the changes in olig-

oarticular JIA such as synovial thickening, effusion and vascu-

larity. The detection of a greater amount of fluid and/or anincrease in the synovial membrane may be considered indica-tive of active disease. Also, PD signal is a sign of increasedsynovial vascularization, and is considered a more reliable

indicator of active synovitis [11,32,33].However, the present study was not exempted from several

limitations. The most remarkable limitation is that we did not

collect US data from healthy children. As detection of synovialhyperplasia in children is more challenging than in adults asthe synovial tissue is often difficult to distinguish from the

hypoechoic cartilage of epiphyses. Also, sonographic referencevalues have not been established for most pediatric joints atdifferent stages in development, and there is no consensus

regarding what constitutes ‘‘normal’’ Doppler findings at thesingle-joint in children, which represents a limit to US exami-nation in healthy children [11].

In conclusion, high frequency power Doppler US may beuseful in detecting ongoing synovial pathology in oligoarticu-lar JIA patients with clinically defined inactive disease, which

could predict an early flare of synovitis. High frequency Dopp-ler US can indicate the degree of disease severity in JIApatients. Ultrasound examination is not an alternative to clin-

ical examination; however, it should be regarded as a comple-mentary tool. So, it can be used in standard clinical practicefor monitoring JIA patients for better assessment and manage-

ment of the disease.

Conflict of interest

None.

Acknowledgement

The authors would like to thank Dr. Hossam Mousa Sakr,

Assistant Professor of Radiodiagnosis, Faculty of Medicine,Ain Shams University, for technical support.

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