Pediat. Radiol. 2, 51--60 (1974) 9 by Springer-Verlag 1974

Radiological Assessment of Fifty Patients with Juvenile Rheumatoid Arthritis" Correlation with Clinical and Laboratory Abnormalities K. M. Goel, S. P. Rawson, and R. A. Shanks Department of Radiology, Royal Hospital for Sick Children, Glasgow, Great Britain

Abstract. The radiological status of fifty patients with rheumatoid arthritis was re-evaluated in a follow-up study ranging from 1--30 years. A skeletal survey was compared with the radiographs taken at the onset of the disease and changes were graded according to severity (0--IV). -- A significant correlation was found between those showing moderate or severe radiological changes and those in w h o m the age of onset was less than 6 years. A similar correlation was seen with increasing duration of disease activity, intermittent or continuous course (as opposed to monocyclic.

Goel and Shanks [4]) poor functional status, physical deformity, splenomegaly, lymphadenopathy and serological abnormalities. -- Patients in the group treated by steroids showed a higher incidence of moderate or severe rediological changes. -- N o association, either positive or negative, was observed between the radiological grade and rheumatoid rash, increased B1C/B1A globulins or the sex of the patient. Key words: Juvenile rheumatoid arthritis, lymphadenopathy, splenomegaly, rheumatoid rash, immunoglobulins, Rose-Waaler test.

Introduction

was possible even after many years. The radiographs were examined for the following features and the incidence of these is shown in Fig. 1. Soft tissue swelling was noted when there was either an effusion into the joint or thickening of the tendons and ligaments around the joint. Periartic-

While much has been written on the clinical aspects of juvenile rheumatoid arthritis (JRA) there have been relatively few reports of its radiological manifestations, and in particular on their reappraisal on long term foliow-up. The purpose of the present study is to report on the radiological appearances in fifty patients with J R A and their relationship to clinical and laboratory parameters, both at onset of the disease and at follow-up.

Maleria/ and Methods This study is based upon fifty patients selected at random from a follow-up Study of a hundred patients with J R A admitted to the Royal Hospital for Sick Children, Glasgow between 1948 and

424038" 36343230p. 28-

g 2B~ a4~ 22 i ;2ot

1972 [4].

~ 18-

Of the fifty patients reviewed, twenty were male and thirty female. The mean age at onset of the patients whose films were analysed was 7.1 years (range: 1 yr. 3/12--12 yrs. 7/12). The duration of observation varied from 1 to 30 years with a mean of 8.5 years. Radiographs were available in childhood in all but three cases. In all cases follow-up radiographs (i. e. a skeletal survey) were available, these having been taken during the second half of 1972 and the beginning of 1973. As a result radiological re-evaluation of previously examined joints

~ 1s141210" s84ac

4*

A - Periarticu]ar

i

osteoporosis

B - Soft tissue swelling C - Narrowing of joint space B - Cortical erosion

iiii~ii:i iiiiiiiiiii iiiii!!! Uiiii~i iiiii!iii! i!i!iiil iiiiiiiiil iiiiiiii iiiiiiii!! iiiiiiil

i

E - Overgrowth of epiphysis P - Bony ankylosis G - Sub]uxation

I - Subch0ndral cyst J

-

Vertical elongation of

vertebral

K - Osteophyte formation L - Periosteal new bone formation

iiiiiiiii~il liC)!~i~!:iliC

A g C D E F G H I J K

L

Fig. 1. Showing incidence of radiological findings.

body

52

K.M. Goel et al. : RadiologicalAssessment of Patients with Juvenile Rheumatoid Arthritis

ular osteoporosis was indicated by a localised decrease of bone density around a joint. No attempt was made to measure joint spaces because of variation in radiographic techniques, but narrowing of a joint space was assessed subjectively. Overgrowth of epiphyses was also assessed subjectively but this was made easier by comparison with the adjacent diaphysis. Vertical elongation of a vertebral body was assessed in a similar manner. Articular erosions a n d subchondral cysts were diagnosed when localised areas of bone destruction were seen, either at the margin of a bone (articular erosions) or deep to the margin as evidenced by subchondral cysts. Subluxation was noted by the loss of alignment at a ioint and this occurred in varying degrees of severity. Lastly bony ankylosis was indicated by a complete loss of a joint space due to fusion of the two articular surfaces. On the basis of these findings the fifty cases were grouped into five grades: Grade 0 (none)

No abnormality o n the radiographs

Grade I (doubtful)

Soft tissue swelling, periarticular osteoporosis and periosteal newbone formation.

Grade II (mild)

Grade I plus narrowing of joint space, overgrowth of epiphysis, vertical elongation of vertebral bodies.

Grade III -- Grade II plus articular erosions, (moderate) subchondral cysts. Grade IV -- Grade III plus subluxation, subarticular sclerosis, osteophytes, (severe) bony anklyosis. To test the association of certain clinical and laboratory features with radiological grade, the data was analysed by the chi square test (X 3) at one degree of freedom. As the results in both sexes showed no

significant differences ( X Z = I . 0 7 ; P=0.30), they were combined for the purposes of analysis. The patients were grouped into monocyclic, intermittent or continuous courseas defined by us previously [4]. Results

Table 1 presents the radiological grades of our patients at the onset of disease and at follow-up while Table 2 shows the changes in the radiological grade as assessed at the follow-up examination in comparison to the grade at the onset of disease. In one third of patients the radiological changes at follow-up were of a moderate or severe category (radiological grades tli or IV) and in two thirds the x-rays were either normal or showed only mild changes (radiological grades 0 or II). The radiological progression of disease was observed in twenty eight patients after an average interval of 8.6 years (range 1--30 years) from the first to the last films (Table 2). In eight patients the changes led to their transfer to a lower grade while in eleven patients there was no change in the radiological grading after an average interval of 8.9 (range 4--14 years) and 6.5 (range la/4--20 years) respectively. The latter group includes eight cases in whom the x-rays remained normal during the period of follow-up. The current radiological status of three patients not x-rayed at the onset of disease is of grade II in one, and of grade 0 in two patients. None of our patients at follow-up belonged to the doubtful (grade I) radiological status. It would appear from Table 2 that the relationship between progression, regression and no change in the radiological grade to the time interval after the onset of disease is unpredictable. However, a significantly positive association was observed between the radiological grade and the duration of disease activity as shown in Table 3. The severity of the radiological grade increased in parallel with the increasing duration of the disease activity. Bony ankylosis, destruction of articular cartilage, narrowing of joint space and periarticular osteoporosis were consistently present in patients in whom the

Table 1. Radiologica] Grading at onset and a/fo/]ow-up No. of patients None (0)

Doubtful (I)

At onset 47a) 15 11 At follow-up 50 17 0 a) X-rays of 3 patients were not available for comparison.

Mild ( I I )

Moderate(111) Severe(IV)

13 16

8 7

0 10

K. M. Goel et al. : Radiological Assessment of Patients with Juvenile Rheumatoid Arthritis d u r a t i o n of disease was m o r e than 5 years. B o n y ankylosis a n d destruction of cartilage was n o t a feature in patients w i t h d u r a t i o n of diesase of less t h a n 5 years. Relation to A g e at O n s e t T h e r e was a significant relationship b e t w e e n the radiological g r a d e and the age at onset (Table 4). F u r t h e r m o r e , o n analysing the f r e q u e n c y of

Table 2, Distribution of patients according to radiological grade at onset and at follow-up

Radiological grade

Progression of disease 0--II o-iii

I --II i -iii I -IV II-iii II-IV III-IV Regression of disease I --0 II--0 111--0 IIl-ll

No change 0 --0 II-n 111-111 Current grade of three patients not x-rayed at onset of disease II o

No. of Time interval of patients radiological survey from onset (yrs) 6 1

6 2 1 3 5 4 2 3 2

2--589 (3.6)a) 5~ (5.7) 1--24 (9.1) 4-11 (7.5) 10 (10) 2}-13 (11,7) 5}-30 (11.2) 7{--16 (10.5)

1

4 - 5 (4.5) 4-15 (10.3) 12}-14 (13) 8 (8)

8 2 1

1}-20 (7.7) 4-16 (lO) 2 (2)

1

789 (7.5)

2

2-18 (lO)

joint i n v o l v e m e n t it was n o t e d that the b i g g e r joints w e r e m o r e c o m m o n l y i n v o l v e d in patients in w h o m the onset of disease was u n d e r 6 years of age (Table 5). T h e incidence of i n v o l v e m e n t of the small joints of h a n d was the same w h a t e v e r the age of onset. T h e changes of b o n y ankylosis and destruct i o n of articular cartilage w e r e m o r e frequently present in the early onset g r o u p , otherwise the type of changes were similar in the t w o age g r o u p s . Figures 2--8 s h o w radiological changes (severe: grade I V ) of t w o patients aged 10 and 16 years in w h o m juvenile r h e u m a t o i d arthritis b e g a n at the age of 21/2 and 3 years respectively. Relation to Sex, Splenomegaly, L y m p h a d e n o p a t h y and R h e u m a t o i d Rash A striking association was f o u n d b e t w e e n the radiological grade and the presence of s p e n o m e g a l y or l y m p h a d e n o p a t h y as s h o w n in Table 6. N o significant associations either positive or negative w e r e

Table 4. Relation of radiological grade to age at onset Age at onset

No. of Radiological grade patients None or Moderate mild or severe (0 or II) (III or IV)

6 years or under 6 years or over

23 27

11 22

12 5

Total

50

33

17

X 2 = 6.26 (Significant);

0.01 < P < 0.025

Table 5. Joint involvement in relation to age at onset Joints

No. of Age at onset patients Less than More than 6 years 6 years

Cervical spine Temporo-mandibular Shoulders Elbows Wrists Proximal phalangeal and metacarpophalangeal Hips Sacro-iliac Dorsolumbar Knees Ankles Tarsal and metatarsophalangeal No joint involvement

13 2 3 13 20

8 1 3 10 15

5 1 0 3 5

31 14 2 5 18 15

16 11 1 4 14 12

15 3 1 1 4 3

14 17

9 6

5 11

50 a) Number in parenthesis denotes the mean time interval Table 3. Relation of radiological grade *o duration of disease activity Total duration of active disease

53

No. of Radiological grade patients None or Moderate mild or severe (0 or II) (III or IV)

Less than 2 years 2--5 years More than 5 years

22 13 15

20 9 4

2 4 11

Total

50

33

17

X 2 = 11.41 (Significant; 0.005 < P < 0.001)

54

K . M . G o d et al. : Radiological Assessment of Patients with Juvenile Rheumatoid Arthritis

observed between the degree of radiological changes and the rheumatoid rash or sex of the patients. Relation to Course of Disease From Table 7 it is evident that patients with a_ monocyclic course did comparatively better than those with an intermittent or continuous course. Of 16 patients with a monocyclic course the radiographs were normal at follow-up in 10 patients, and of the remaining 6 periarticular osteoporosis was present in 5, and destruction of cartilage and narrowing of joint space in one patient. By contrast, patients with an intermittent or continuous course frequently Fig. 2. X-ray of the cervical spine showing bony ankylosis of the apophyseal joints from Cz--C6 in a 10 year old boy whose arthritis began at 2 years and 6 months of age.

~ig. 8

Fig. 4

Fig. 3. X-ray of the hand in a 10 year old boy whose arthritis began at the age of 3 years. Erosions at the bases of the second to fifth metacarpals and in the carpal bones. There is also soft tissue swelling at the PIP joints of the second and fifth fingers Fig. 4. X-ray of the hand of the same patient as in Fig. 3 at the age of 16 years. Complete bony ankylosis of the interearpaljoints and of the second and fifth carpo-metacarpal joints with medial subluxation at the wrist joint and deformity of the distal radio-ulnar joint. Flexion deformity at the PIP joint of the fifth finger and bony ankylosis of the PIP joint of the second finger

K. M. Goel et al. : Radiological Assessment of Patients with Juvenile Rheumatoid Arthritis

55

Table 6. Relation of radiological grade to splenomegaly, lymphadenopathy and rheumatoid rash No. of patients

Radiological grade None or mild (0 or II)

With splenomegaly Without splenomegaly With lymphadenopathy Without lymphadenopathy With rheumatoid rash Without rheumatoid rash (S) -- Significant

12 38 15 35 9 41

4 29 6 27 5 28

Chi square test (X 'a)

Moderate or severe (III or IV) 8 9 9 8 4 13

X 2 = 7.50 (S); 0.005 < P < 0.01 X2

6.45 (S); 0.01 < P < 0.025

X ~ = 0.53 (NS); 0.4 < P < 0.5

(NS) = Not significant

Fig. 5. X-ray of pelvis of the same patient as in Fig. 2 at the age of 10 years. Flattening and articular erosions of both femoral heads with marginal lipping of the acetabular borders from advanced juvenile rheumatoid arthritis. Note also the erosions at the superior margin of the left femoral neck appearing as "cysts". Sacro-iliac joints appear normal.

Fig. 6. X-ray of the knee of the same patient as in Fig. 3. Severe overgrowth of epiphyses and narrowing of the lateral aspect of the joint space

s h o w e d c h a n g e s of b o n y a n k y l o s i s , d e s t r u c t i o n of cartilage, n a r r o w i n g of j o i n t space, cyst f o r m a t i o n , e n l a r g e m e n t of e p i p h y s e s a n d p e r i a r t i c u ] a r o s t e o p o r o s i s . T h e f i n d i n g s i n t h r e e different c o u r s e s of disease m a y w e l l b e r e l a t e d t o t h e d u r a t i o n a n d f r e q u e n c y of p e r i o d s of activity.

R e l a t i o n to C u r r e n t F u n c t i o n a l Status The association between the radiological grade a n d t h e c u r r e n t f u n c t i o n a l status of o u r fifty p a t i e n t s is s h o w n in T a b l e 8. T h e i n c i d e n c e of m o d e r a t e o r e s v e r e c h a n g e s o n r a d i o l o g i c a l s u r v e y was h i g h e r i n p a t i e n t s w i t h m o d e r a t e l i m i t a t i o n s of f u n c t i o n o r

56

K . M . Goel el al. : Radiological Assessment of Patients with Juvenile Rheumatoid Arthritis

Fig. 7

Fig. 8

Figs. 7 and 8. X-ray of the foot of the same patient as in Figs. 3, 4 & 6. Complete bony ankylosis of intertarsal and metatarsotarsal joints and there is subluxation of all the metatarsophalangeat joints. Osteoporosis of the bones of the foot is also present

Table 7. Relation of radiological grade to course of disease

Table 8. Relation of radiological grade to functional stalus

Course of disease

No. of Radiological grade patients None or Moderate mild or severe (0 or II) (III or IV)

Current functional status

No. of Radiological grade patients None or Moderate mild or severe (0 or II) (III or IV)

Monocyclic Intermittent Continuous

16 33 1

15 18 0

1 15 1

Total

50

33

17

Helpless Chair/Bed existence Moderate limitation Slight limitation No limitation

None 1 9 8 32

None 0 2 2 29

Total

50

33

X ~ ~ 7.53 (Significant) 0.005 < P < 0.01

1 7 6 3 17

x 2 = 22.73 (Significant) P < 0.0005 w i t h a c h a i r / b e d existence. H o w e v e r , t h e r a d i o g r a p h s of p a t i e n t s w i t h s l i g h t o r n o l i m i t a t i o n of f u n c t i o n w e r e e i t h e r n o r m a l ( g r a d e 0) o r s h o w e d o n l y m i l d ( g r a d e II) changes. I t seems t h a t t h e f u n c tional impairment was proportional to the degree of s t r u c t u r a l d a m a g e , o r i n o t h e r w o r d s , to t h e e x t e n t o f disease r a d i o l o g i c a l l y .

Relation to Physical Deformities A s e x p e c t e d t h e p h y s i c a l d e f o r m i t i e s at f o l l o w - u p w e r e s i g n i f i c a n t l y r e l a t e d t o t h e e x t e n t of r a d i o l o g i c a l c h a n g e s as s h o w n i n T a b l e 9.

K. M. Goel el al. : RadiologicaI Assessment of Patients with Juvenile Rheumatoid Arthritis

57

Relation to L a b o r a t o r y F i n d i n g s

Discussion

Patients w i t h increased i m m u n o g l o b u l i n s ( I g G , I g M and I g A ) or a positive R o s e - W a a l e r test (titre 1 : 6 4 or more) s h o w e d a significantly h i g h e r incidence of either m o d e r a t e or severe radiological changes (Table 10) a l t h o u g h n o characteristic p a t t e r n of joint i n v o l v e m e n t or type of changes was noted. N o significant association was o b s e r v e d b e t w e e n the radiological g r a d e and increased B1C/B1A globulins.

I n the present study a significant association has been o b s e r v e d b e t w e e n the radiological grade a n d the age at onset, d u r a t i o n of disease activity, course of disease, functional status, physical deformities, splenomegaly, l y m p h a d e n o p a t h y , increased i m m u n o globulins ( I g G , I g M and I g A ) and a positive R o s e Waaler test. O u r data w o u l d suggest that radiog r a p h s at the onset of disease c a n n o t be used to fortell the eventual o u t c o m e , a l t h o u g h the numerical assessment of radiological abnormalities on serial x-rays m a y be of p r o g n o s t i c value in so far as t h e y s h o w regression, p r o g r e s s i o n or n o change. H o w ever, the d e m o n s t r a t i o n that m o d e r a t e or severe grade radiologicat abnormalities w e r e associated with certain clinical and l a b o r a t o r y parameters suggests that changes can to s o m e extent be predicted. Sairanen [10] r e p o r t e d that radiological changes in children, except soft tissue changes, appear late or sometimes do n o t o c c u r at all. H o w -

Relation to Steroid T h e r a p y A n interesting o b s e r v a t i o n was that the m o d e r a t e or severe radiological changes were m o r e f r e q u e n t in patients treated w i t h steroids at s o m e time d u r i n g the course of their disease w h e n c o m p a r e d w i t h the n o n - s t e r o i d g r o u p (Table 11). T h e changes persistently present in the steroid g r o u p w e r e : b o n y ankylosis, destruction of articular cartilage, n a r r o w i n g of joint space a n d periarticular o s t e o p o rosis. Table 9. Relalion of radiological grade lo physical deformilies

Table 11. Relation of treatment to radiological grade

Deformities at follow-up

No. of Radiological grade patients None or Moderate mild or severe (0 or II) (III or IV)

Treatment

No. of Radiological grade patients None or Moderate mild or severe (0 or II) (III or IV)

With deformities Without deformities

23 27

9 24

14 3

Steroids No steroids

14 36

6 27

8 9

Total

50

33

17

Total

50

33

17

X 2 = 13.70 (Significant)

P < 00.005

X 2 = 4.64 (Significant);

0.025 < P < 0.05

Table 10. Relation of radiological grade lo immunoglobulins, B1C/B1A globulin and Rose-Waaler test No. of patients

Radiological grade None or mild (0 or 1I)

IgG increased IgG normal IgM increased IgM normal IgA increased IgA normal B1C/B1A globulin increased normal Rose-Waaler test positive negative (S) = Significant

Chi square test (X 2)

Moderate or severe (III or IV)

19 3] 24 26 7 43

6 27 12 21 2 31

13 4 12 5 5 12

X 2 -- 5.26 (S); 0.01 < P < 0.025

10 40

5 28

5 12

X ~ = 1.42 (NS); 0.2 < P < 0.3

3 43

0 29

3 14

X 2 = 3.85 (S); 0.025 < P < 0.05

(NS) = Not significant

X ~ = 6.18 (S); 0.01 < P < 0.25

X 2 = 5.08 (S); 0.01 < P < 0.025

58

K.M. Goel et al. : Radiological Assessment of Patients with Juvenile Rheumatoid Arthritis

ever, in our series there were eight patients (16 percent) in w h o m radiological changes did not occur even after an observation period ranging from l*/a year to 20 years (mean 7.7 years). As noted by Sievers [12] the radiological grade in our patients increased with the increasing duration of active disease. The prognosis was relatively better when the total duration of active disease was less than two years. This corresponds with the monocyclic course of J R A as most of these were without clinical or radiological residua. The only patient in our series with subcutaneous nodules showed narrowing of the apophyseal joints in the upper cervical spine with sclerosis of the articular margins of the laminae, destruction of articular cartilage in the small joints of fingers and, in the carpal bones, alteration in bone calcium distribution in the wrist, early subchondral bone destruction in the hamate, demineralisation with alteration in bone calcium distribution in the ankles and feet (radiological grade III). Other authors have similarly reported a significant dependence between the nodules and the radiological changes [12, 13]. Sievers [12] also reported a highly significant relationship between radiologica] grade and seropositivity in adult rheumatoid arthritis patients. Our three patients with a positive Rose-Waaler test (titre 1 : 64 or more) showed moderate or severe grade changes. Bluestone et al. [2] reported a poor functional status and an increased incidence of hip joint involvement in patients with increased immunoglobulins (IgG, IgM and IgA). These authors, however, did not comment upon the overall radiological status of their patients. Similarly, H o u b a and Bardfeld [7] found increased immunoglobulin levels in the sera of patients with J R A but made no reference to the radiological changes in their patients. However, our patients with increased immunoglobulins showed a poor radiologieal status although no particular joint was involved in these patients [5]. G o r d o n et al. [6] reported more severe articular destruction in patients with splenomegaly and lymphadenopathy. We, too, have noted a higher incidence of moderate or severe grade radiological changes, including articular destruction, in patients with splenomegaly or lymphadenopathy. T w o patients in this study had sacro-iliac joint involvement attributed to rheumatoid disease rather than ankylosing spondylitis. This is supported by the fact that each has peripheral joint involvement

and neither of them showed radiological evidence of ankylosing spondylitis. Carter [3] reported a significant association between seropositivity and abnormal sacro-iliac joints in her series. However, the Rose-Waaler test in our two patients was negative. It is our impression, and that of others [1, 9], that children in the corticosteroid group had a poor remission rate and functional status and a higher incidence of infection as compared to those in the non-steroid group. Schlesinger and his colleagues [11] on the contrary, suggested the value of the early use of steroid therapy both in preventing disability and cutting short the disease. However, most would agree that patients who do not respond to a conservative regime will usually be given corticosteroid therapy, particularly those with constitutional manifestations. Fourteen of our patients treated with steroids at some stage of their disease showed a greater incidence of moderate or severe radiological changes at follow-up. This cannot, of course, be directly attributed to steroid therapy and is more likely to be caused by the severity of the disease. The Joint Committee of the Medical Research Council and Nuffield Foundation on the clinical trials of Cortisone, A . C . T . H . , and other therapeutic measures in chronic rheumatic diseases [8] reported that the effectiveness of prednisolone in suppressing erosions may diminish after years of administration. However, it would seem reasonable to conclude that patients in w h o m the disease begins before the sixth birthday and in those with splenomegaly, lymphadenopathy, a long duration of disease, with intermittent or continuous course, increased immunoglobulins or a positive Rose-Waaler test will do less well in terms of radiological abnormalities and consequently in terms of physical deformity and p o o r functional status. Acknowledgements. We express our thanks to our colleagues for allowing us to study the patients under their care and to Mr. David A. McLaren M. A., of the Department of Statistics in the University of Glasgow, for considerable assistence in the analysis of our data. We would also like to record our appreciation of the extra work undertaken by our Radiographers, and not least of the willing consent of our patients to return for reassessment. References

1. Anselt, B. M., Bywaters~ E, G. L.: Prognosis in Still's disease. Bull. rheum. Dis. 9, 189 (1959) 2. Bluestone, R., Goldberg, L. S., Katz, R. M., Marchesano, J. M., Calabro, J. J. : Juvenile rheumatoid arthritis :

K. M. Goel eta/.: Radiological Assessment o~ Patients with Juvenile Rheumatoid Arthritis

3. 4. 5.

6. 7. 8.

A seroiogic survey of 200 consecutive patients. J. Pediat. 77, 98 (1970) Carter, M. E. : Sacro-iliitis in Still's disease. Ann. rheum. Dis. 21, 105 (1962) Goel, K. M., Shanks, R. A.: A folio\v-up study of 100 patients with juvenile rheumatoid arthritis. Ann. rheum. Dis. (in press) Goel, K. M.; Logan, R. W., Barnard, W. P,, Shanks, R. A.: The serum immunoglobulin and BiC/B1A globulin concentrations in juvenile rheumatoid arthritis. Ann. rheum. Dis. (in press) Gordon, D, A., Stein, J. L., Be11, D. A., Broder, I.: The extraarticular features of rheumatoid arthritis. Arthr. and Rheum. 13, 319 (1970) Houba, V., Bardfeld, R.: Serum immunoglobulins in juvenile rheumatoid arthritis. Ann. rheum. Dis. 28, 55 (1969) Joint Committee of the Medical Research Council and Nuffield Foundation on Clinical Trials of Cortisone, A.C.T.H. and other Therapeutic Measures in Chronic Rheumatic Deseases.: Ann. rheum. Dis. 19, 331 (1960)

59

9. Lindbjerg, I. F, : Juvenile rheumatoid arthritis : A ~ollowup of 75 cases. Arch. Dis. Childh. 39, 576 (1964) 10. Sairanen, E.: On rheumatoid arthritis in children. A clinico-roentgenologicalstudy. Acta rheum, scand. Suppl. 1, 33 (1958) 11. Schlesinger, B. E., Forsyth, C. C., White, R. H. R., Smellie, J. M., Stroud, C. E.: Observations on the clinical course and treatment of one hundred cases of Still's disease. Arch. Dis, Childh. 36, 65 (1961) 12. Sievers, K. : The rheumatoid factor in definite rheumatoid arthritis. Acta rheum, scand. Suppl. 9, 20 (1965) ]3. Thould, A. K., Simon, G.: Assessment of radiological changes in the hands and feet in rheumatoid arthritis. Their correlation with prognosis. Ann. rheum, Dis. 25, 220 (1966)

S. P. Rawson, M. D. Department of Radiology Royal Hospital for Sick Children Glasgow, Great Britain