DISPENSARY OBSERVATION AND PREVENTION
Despite the relatively low prevalence of juvenile chronic arthritis and rheumatoid arthritis in adults, this group of patients should be monitored especially carefully due to the extremely high risk of disability and often poor prognosis (in any case, in the sense of recovery). At present, the experience of specialists in the field of this pathology is increasingly convincing that therapy of the active phase influences the prognosis of the disease to a small extent, and the management tactics during complete or partial clinical laboratory remission are decisive in the prognosis.
As already mentioned in previous chapters, in modern conditions, strict verification of diagnosis, careful selection of pathogenetically substantiated therapy is of particular importance: with subsequent monitoring of its effectiveness, monitoring of this group of patients trained narrow specialists. All this can be fully implemented only in specialized centers that have at their disposal modern methods of immunological examination and relevant specialists.
In pediatrics, this problem is solved somewhat easier because of the relatively small number of patients. For example, in Leningrad for the last 10 years, the diagnosis of UHA is verified only in the conditions of the cardio-rheumatological Center, which also carries out follow-up dispensary observation. In therapeutic practice, such an approach is currently impossible due to the small capacity of the existing Centers. The creation of district and interdistrict offices, in which patients with RA can be observed, can be considered promising . An example is the work of such an office in the Vyborg district of Leningrad.
Such a situation does not exclude the need to monitor patients with YUHA district pediatricians and cardio-rheumatologists, and RA patients with district physicians and rheumatologists, however, the choice of patient management scheme should be determined in a specialized institution.
Below is the scheme of dispensary observation of patients with YUHA, developed and well-behaved by the ^ – Commander in Leningrad. The presented scheme is focused mainly on observation in polyclinic conditions of children in the inactive phase of the disease and the state of partial clinical and laboratory remission.
Some of the provisions of the scheme need to be elaborated, this mainly concerns the ways of recovery. One of the basic principles of correct management of a patient with UHA is the constant, long-term (months and years) use of basic therapy. The selection of the therapy itself (drugs and doses) is carried out in a specialized cardio-rheumatological Center, which also determines the subsequent change in the tactics of drug therapy.
In polyclinic conditions, the tactics of managing patients receiving basic therapy are particularly difficult with: joining intercurrent diseases. In all such cases, antibiotic therapy is prescribed, and it is better to use broad-spectrum antibiotics — semi-synthetic penicillins and others — outside of intercurrent diseases in continuous anti-bacterial therapy, including prevention with bicillin, even when receiving hormonal and cytostatic drugs , patients do not need. When non-hormonal anti-inflammatory drugs are used as basic therapy, their dose is increased by 1.5 times, and return to the initial dose is carried out 3-5 days after the temperature is normalized. If immunoregulatory drugs are used as basic therapy,they are canceled from the first day of the occurrence of intercurrent disease. Immediately after the temperature is normalized, anti-inflammatory therapy is prescribed in the full therapeutic dose. 7–10 days after normalization of temperature, they return to immunoregulatory drugs, simultaneously reducing the dose of anti-inflammatory drugs by half. In the absence of signs of exacerbation of the underlying disease, anti-inflammatory drugs are canceled after 7–10 days (the total duration of anti-inflammatory therapy, therefore, is 2–3 weeks). Hormonal therapy, if the child receives it, is carried out in the same dose, however, in the presence of hormone dependence, an increase in the dose of 1.5-2 times is necessary, returning to the initial dose is carried out after the temperature is normalized against the background of anti-inflammatory drugs in 3-5 days .In cases of severe intercurrent diseases, the patient is hospitalized even without signs of exacerbation of the main process. An important step in the rehabilitation of patients with juvenile chronic arthritis is a properly organized regime of fi
zic loads. At present, it is well known that only active movements in the affected joints prevent functional disturbances, therefore the restriction of the motor regime has not been shown for this group of patients.
It is shown that patients are referred to a sanatorium, where physiotherapeutic, mud therapy procedures and physical therapy can be provided. In the USSR, there are specialized sanatoria, the most famous of which are sanatoriums in the cities. Lipetsk and Evpatoria. However, you must consider the following
general fact. Children with YUHA react poorly to changing climatic conditions and therefore the most optimal is the creation of conditions
rehabilitation in local specialized sanatoriums. Finally, I would like to emphasize that this group of patients is strictly contraindicated for parenteral antigenic loads (vaccinations, biological tests, the introduction of gamma-globulin, transfusion of albumin, plasma, blood, etc.). The introduction of these drugs can be carried out only according to vital indications. The rules for the transfer to the adult network of patients with UHA do not differ from the rules for the transfer of patients with rheumatism (see the scheme of the episode in the manual “Rheumatism in children and adults”); , portability, duration of use, side effectsit.).
One of the least developed problems in pediatric cardiac rheumatology is the problem of primary prophylaxis, which is primarily associated with the identification of a risk group for the occurrence of YUHA (in any case, there is no such group officially registered with a cardiac rheumatologist). At the same time, this Bonpoc is increasingly relevant, given the true increase in the number of patients with YUHA. In practical terms, the solution to this issue is to isolate children with manifestations of immunological disregulation.
Currently, it is possible to note the following ways to isolate the most “threatened” groups of children:
1. Since the peculiarities of immunological regulation are largely genetically determined, children with collagen diseases should be taken into account.
2. Immunological failure can be detected.
for inadequate antigenic response: a) children with manifestations of general reactions to vaccinations, administration of gamma globulins and other protein preparations, especially in cases where these reactions are accompanied by prolonged
erythrocyte sedimentation rate and other indicators of the inflammatory response; b) children giving systemic reactions to food, household and
other allergens, drugs. In terms of keeping this group of children in polyclinic conditions
They can be recommended regular monitoring by a pediatrician and a cardio-rheumatologist (at least 2 times a year), the maximum limitation of antigenic effects (as well as for patients with YUHA), systematic laboratory monitoring after past diseases, and also an immunological examination for the presence of rheumatoid factor , HLA-typing. One of the most important issues in the process of dispensation of sulfur is the mental and social rehabilitation of patients. In both children and adults, the most difficult problem is the problem of vocational guidance. The question of choosing a profession in children and the possibility of continuing work in a specialty in adults should be decided, undoubtedly, individually, depending on the form of the disease,functional disorders of the musculoskeletal system and the state of the internal organs. However, here it is necessary to take into account the need to preserve movements in the affected joints during labor activity. In this regard, one can refer to the experience of advanced sanatoriums, where occupational therapy is widely used to restore the function of the affected joints, for example, when small joints of the hands are affected — knitting, weaving, sewing, and other types of small handicraft works. Similar approaches are beginning to be used in children’s sanatoriums. Unfortunately, these issues have so far received little attention.where to restore the function of the affected joints, occupational therapy is widely used, for example, in case of damage to the small joints of the hands – knitting, weaving, sewing and other types of small handicraft works. Similar approaches are beginning to be used in children’s sanatoriums. Unfortunately, these issues have so far received little attention.where to restore the function of the affected joints, occupational therapy is widely used, for example, in case of damage to the small joints of the hands – knitting, weaving, sewing and other types of small handicraft works. Similar approaches are beginning to be used in children’s sanatoriums. Unfortunately, these issues have so far received little attention.
In children, the choice of a specialty can be guided by the following approximate list of working specialties (Table 16), developed at the Leningrad Scientific Research Institute of Occupational Health and Occupational Diseases. This list applies only to patients with UHA without significant dysfunction of the musculoskeletal apparatus. For all other groups of patients, the issue of professional orientation is decided individually, preferably after consulting with specialists. In conclusion, attention should be paid to the fact that, attaching great importance to the issues of rehabilitation of patients with roar with mahoid arthritis, the USSR Ministry of Health orders all treatment of this category of patients in an outpatient setting is free of charge.