Prevalent vertebral fractures among children initiating glucocorticoid therapy for the treatment of rheumatic disorders

OBJECTIVE

Vertebral fractures are an under-recognized problem in children with inflammatory disorders. We studied spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid therapy.

METHODS

Children were categorized as follows: juvenile dermatomyositis (n = 30), juvenile idiopathic arthritis (n = 28), systemic lupus erythematosus and related conditions (n = 26), systemic arthritis (n = 22), systemic vasculitis (n = 16), and other conditions (n = 12). Thoracolumbar spine radiograph and dual x-ray absorptiometry for lumbar spine (L-spine) areal bone mineral density (BMD) were performed within 30 days of glucocorticoid initiation. Genant semiquantitative grading was used for vertebral morphometry. Second metacarpal morphometry was carried out on a hand radiograph. Clinical factors including disease and physical activity, calcium and vitamin D intake, cumulative glucocorticoid dose, underlying diagnosis, L-spine BMD Z score, and back pain were analyzed for association with vertebral fracture.

RESULTS

Thirteen vertebral fractures were noted in 9 children (7%). Of these, 6 patients had a single vertebral fracture and 3 had 2-3 fractures. Fractures were clustered in the mid-thoracic region (69%). Three vertebral fractures (23%) were moderate (grade 2); the others were mild (grade 1). For the entire cohort, mean +/- SD L-spine BMD Z score was significantly different from zero (-0.55 +/- 1.2, P < 0.001) despite a mean height Z score that was similar to the healthy average (0.02 +/- 1.0, P = 0.825). Back pain was highly associated with increased odds for fracture (odds ratio 10.6 [95% confidence interval 2.1-53.8], P = 0.004).

CONCLUSION

In pediatric rheumatic conditions, vertebral fractures can be present prior to prolonged glucocorticoid exposure.

Autoantibodies in childhood opsoclonus-myoclonus syndrome

Opsoclonus-myoclonus syndrome or Dancing Eye Syndrome (OMS/DES) is a rare neurological disorder of children, which associates with neuroblastoma (NB) in approximately 50% of cases. We examined sera from five patients with (OMS-NB(+)) and five without NB (OMS-NB(-)) for autoantibodies. OMS-NB(-) IgG bound to the surface of a NB cell line, whereas IgG from OMS-NB(+) and from NB patients without OMS/DES bound only to permeabilised cells. Both OMS-NB(+) and OMS-NB(-) reduced proliferation of NB cells. We also present a case report of a child with OMS/DES without NB who made a complete recovery without treatment. Serum antibodies at presentation bound to the surface and decreased NB cell proliferation but had decreased 9 weeks later when the child was asymptomatic. These results demonstrate that sera from some OMS/DES patients contain IgG antibodies that are potentially pathogenic.

IgG subclass distribution of autoantibodies in pediatric opsoclonus–myoclonus syndrome

Opsoclonus-myoclonus syndrome (OMS) in children is a rare disorder including a severe eye movement disturbance, myoclonia, ataxia and often developmental retardation. Both OMS forms, idiopathic or neuroblastoma-associated (paraneoplastic), have been suspected to be autoimmune. Recently, autoantibodies have been found in OMS sera. We here show that autoantibodies in OMS, both intracellular and surface binding, belong mainly to the IgG3 subclass, although the total serum IgG3 level is normal. These results support the autoimmune hypothesis and point to a protein autoantigen as antigenic target.

Outcome of interventions to identify family history and risk management for women with breast cancer in the ambulatory setting

6121

Background: In 2002, Kansas City Cancer Center (KCCC) performed a quality improvement (QI) project to evaluate how breast cancer patients were being assessed for family history and cancer risk management. A self-administered family history questionnaire was developed to improve the thoroughness of family history collected and education of clinicians was completed to improve the recognition of risk factors based on ASCO guidelines. Methods: Chart audits on 210 women with breast cancer at KCCC, were completed in the second quarter of 2005. All patients were under the age of 65, not undergoing chemotherapy. A risk management tool was developed. Scoring criteria for 2002 was replicated in 2005 as listed in the table . Results: In 2002, 171 pts (89%) had level 1 or 2 family history assessed compared to 207 pts (99%) in 2005, p<0.0001. In 2002, 47% had 3 generations assessed compared to 84% in 2005, p<0.0001. In 2002 and 2005, some risk factor management occurred in both groups, and was equal, 78% and 80% respectively (p=ns). Of those that had risk management 33% had level 1 in 2002 compared to 3% in 2005 (p<0.0001) a 91% reduction in identifying risk without subsequent management. In 2002, 58% had level 2, compared to 71% in 2005 (p=0.02) a 23% improvement in identification & management of risk. In 2002, 9% had level 3 compared to 26% in 2005 (p<0.0001) a 183% improvement in patients with a detailed risk assessment and/or genetic referral. Conclusions: By improving the assessment of family history and education of providers, women with breast cancer are receiving more information to reduce their risk for recurrence and complications. Patients who were identified as high risk for BRCA1 or BRCA2 mutations were referred to either a nurse practitioner or genetic counselor.

[Table: see text]

No significant financial relationships to disclose.

A collaborative demonstration project: Depression screening in patient with cancer

18556

Background: A demonstration project testing the feasibly of implementing a depression screening work flow algorithm was initiated by the anti-depression committee at one of six ambulatory care sites in the Kansas City Cancer Center (KCCC) system. The object of the study was to develop a process of work flow that would assist in identifying patients with depression and facilitate appropriate interventions by providers. Methods: A flow chart was developed illustrating critical decision-making points in the screening for depression by physicians and nurse practitioners (NP). The population included half radiation therapy and the other half chemotherapy. Patients completed the PHQ-2 a two question prescreen to assess initial symptoms of depression, including feeling depressed, down or hopeless and/ or little interest or pleasure in activities. A positive response to one of these 2 questions prompted the administration of the PHQ-9 a validated depression screening instrument. The PHQ-9 scoring criteria was used to assist the physician and NP with taking the appropriate action such as the initiation of antidepressant therapy and/or referral to mental health provider, follow up for subsequent appointments and/or reassessment. Results: Seventy-one patients were tracked to evaluate the process of recognition and management of depression from April 2004 to January 2005. Of the 71 patients 37% (N = 26) scored positive on at least one question on the two question prescreen. Of the 26 patients scoring positive 27% (N = 7) of these patients had less than 3 follow up visits while 73 % (N = 19) had greater than 3 follow-up visits by the KCCC providers. Of the patients that answered positively to one of the two prescreen questions 69% (N = 18) completed the full PHQ-9 and their scores were recorded. Conclusions: The development of a new model in a community-based oncology practice allows for integrating clinically proven techniques for diagnosing and treating depression. It will allow for the committee to make recommendations for changes in the process before it is implemented on a larger scale at all KCCC outpatient sites.

No significant financial relationships to disclose.

Serum antibodies in epilepsy and seizure-associated disorders

OBJECTIVE

To investigate whether autoantibodies to ion channels and other neural antigens are present in the sera of patients with epilepsy and seizure-related diseases.

METHODS

Sera were obtained from 139 patients, including 26 with preexisting autoimmune disease, 46 in whom an autoimmune basis was suspected, and 67 with drug-resistant epilepsy. The sera were assayed for antibodies to voltage-gated potassium (VGKC) and calcium (VGCC) channels, glutamic acid decarboxylase (GAD), gangliosides, glutamate receptor type 3, cardiolipins, DNA, and nuclear antigens; the results were compared with results from a large cohort of healthy and disease controls.

RESULTS

Increased titers of VGKC antibodies (>100 pM) were detected in 16 of 139 (11%) patients with seizures but only 1 control (0.5%). Eight VGKC-positive patients presented with an acute/subacute illness, and 5 of these had the highest VGKC antibodies; 3 patients improved spontaneously, another 5 patients responded well to immunomodulatory therapy. The other VGKC-positive patients had longer disease duration (>6 years) and intermediate levels of antibodies; immunotherapies have not been tested in this group. Very high levels of GAD antibodies (>1,000 U) were found in an additional 3 patients (2.1%) with long-standing drug-resistant epilepsy.

CONCLUSIONS

The presence of autoantibodies to voltage-gated potassium channels and glutamic acid decarboxylase suggests that the immune system may contribute to certain forms of epilepsy or seizure-associated disorders. Further studies are needed to determine whether the antibodies are pathogenic.

Alpha7-acetylcholine receptor antibodies in two patients with Rasmussen encephalitis

Rasmussen encephalitis (RE) sera were screened for antibodies to human alpha7 nicotinic acetylcholine receptors (nAChRs) using electrophysiology, calcium imaging, and ligand binding assays. Sera from two of nine patients with RE blocked ACh-induced currents through alpha7 nAChRs and the ACh-induced rise in intracellular free calcium ([Ca2+]i) and inhibited (125)I-alpha-bungarotoxin binding in cells expressing alpha7 nAChRs. Thus, the alpha7 nAChR is a potential target for pathogenic antibodies in patients with RE.

Anti-glial nuclear antibody: marker of lung cancer-related paraneoplastic neurological syndromes

We describe a new antibody, called anti-glial nuclear antibody (AGNA), in patients with paraneoplastic neurological syndromes (PNS) and small-cell lung carcinoma (SCLC). AGNA was initially identified in 24 sera of our archives by immunohistochemistry on rat cerebellum. AGNA positive sera showed a characteristic nuclear staining of the Bergmann glia in the Purkinje cell layer. Immunoblots and probing a cerebellar expression library with AGNA sera did not identify the antigen. Twenty of the 24 patients with AGNA had PNS and all but two had lung cancer. AGNA was identified in 13/113 (11.5%) patients with SCLC compared with 0/122 with other types of cancer (p<0.0001). The frequency of AGNA was not higher than expected for the presence of SCLC in the different PNS subtypes except in LEMS (p=0.0002). AGNA was present in 13/30 (43%) of LEMS patients with SCLC, compared with 0/19 of LEMS patients without cancer (p=0.0006). We conclude that the recognition of AGNA is helpful since this antibody is found in PNS associated with SCLC, particularly LEMS, in which other onconeural antibodies are absent.

[Evidence-based medicine for the public]

The methods of evidence-based medicine demand high quality and up-to-date medical information. Ideally, this information is based on data from controlled clinical trials. When such external evidence is available, it provides a base for an effective patient-physician consultation, and is also essential for the consumer friendly presentation of medical information. This article sketches the international and German developments and approaches to preparing and maintaining evidence-based patient information and its influences on the models of physician-patient communication.

Leitlinien

Now more than ever physicians need effective management of the constantly increasing flood of medical information. The authors discuss possibilities for developing clinical guidelines as a core element of this information management and the requirements of these possibilities. The development of clinical guidelines is a process also suitable for involving patient and consumer expertise in health care. Models of involving patients are described and how these processes can build an important base for shared decision making of physicians and patients.

Absence of antibodies to glutamate receptor type 3 (GluR3) in Rasmussen encephalitis

OBJECTIVE

To determine the prevalence of serum antibodies to the ionotropic glutamate receptor 3 (GluR3) in patients with Rasmussen encephalitis (RE), a severe epileptic disorder, and to compare with serum from control subjects and patients with intractable epilepsy (IE).

METHODS

The authors looked for serum immunoglobulin (Ig) G antibodies to GluR3 in 30 patients with RE, including two patients who had plasma exchange and 12 who had been treated with IV Igs with varying results, and 49 patients with IE and 23 healthy individuals, using ELISA with GluR3B peptide, Western blot analysis of recombinant full-length GluR3, immunoprecipitation of [35S]- and [125I]-labeled GluR3 extracellular domains, immunohistochemistry on rat brain sections, and electrophysiology of GluR3 expressed in Xenopus oocytes.

RESULTS

Low levels of antibodies to the GluR3B peptide were detected using ELISA in only 4 of the 79 patients with epilepsy (2 with RE and 2 with IE); binding to GluR3B in other sera was shown to be nonspecific. One other patient with IE had antibodies to recombinant GluR3 on Western blot analysis. However, none of the sera tested precipitated either the [35S]- or the [125I]-labeled GluR3 domains; none bound to rat brain sections in a manner similar to rabbit antibodies to GluR3; and none of the nine sera tested affected the electrophysiologic function of GluR3.

CONCLUSIONS

GluR3 antibodies were only infrequently found in Rasmussen encephalitis or intractable epilepsy.