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Palermo TM, Li R, Birnie KA, Crombez G, Eccleston C, Kashikar-Zuck S, Stone AL, Walco GA. Updated recommendations on measures for clinical trials in pediatric chronic pain: a multiphase approach from the Core Outcomes in Pediatric Persistent Pain (Core-OPPP) Workgroup. Pain 2024; 165:1086-1100. [PMID: 38112633 PMCID: PMC11017748 DOI: 10.1097/j.pain.0000000000003105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/09/2023] [Accepted: 08/31/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Many gaps remain in finding effective, safe, and equitable treatments for children and adolescents with chronic pain and in accessing treatments in different settings. A major goal of the field is to improve assessment of pain and related experience. Valid and reliable patient-reported outcome measures are critical for advancing knowledge of clinical interventions for pediatric chronic pain. Building on the work of the Ped-IMMPACT group, we previously updated a core outcome set (COS) for pediatric chronic pain clinical trials using stakeholder feedback from providers, youth, and parents. The new COS includes 3 mandatory domains: pain severity, pain-related interference with daily living, and adverse events and 4 optional domains: overall well-being, emotional functioning, physical functioning, and sleep quality. The aim of this study was to use a multiphased approach to recommend specific measures for each of the 7 domains identified in our new COS for pediatric chronic pain. We synthesized evidence through conducting the following: (1) a Delphi study of experts to identify candidate measures for the new COS domains, (2) a review phase to gather evidence for measurement properties for candidate measures, and (3) an expert consensus conference to reach agreement on measurement recommendations. Final recommendations included 9 patient-reported measures. Important contextual considerations are discussed, and guidance is provided regarding strengths and limitations of the recommendations. Implementation of these recommendations may be enhanced by widespread dissemination and ease of access to measurement tools.
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Affiliation(s)
- Tonya M. Palermo
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, United States
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine Seattle, WA, United States
| | - Rui Li
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Kathryn A. Birnie
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Calgary Calgary, AB, Canada
| | - Geert Crombez
- Department of Experimental Clinical Psychology and Health Psychology, Ghent University, Ghent, Belgium
| | | | - Susmita Kashikar-Zuck
- University of Cincinnati, Department of Pediatrics, Cincinnati, OH, United States
- Cincinnati Children's Hospital Medical Center Cincinnati, OH, United States
| | - Amanda L. Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Gary A. Walco
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine Seattle, WA, United States
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Welzel T, Zapf B, Klotsche J, Satirer Ö, Benseler SM, Kuemmerle-Deschner JB. Optimized Treatment of Interleukin (IL-1)-Mediated Autoinflammatory Diseases: Impact of Disease Activity-Based Treatment Adjustments. J Clin Med 2024; 13:2319. [PMID: 38673592 PMCID: PMC11050771 DOI: 10.3390/jcm13082319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Effective control of disease activity in Interleukin-1 autoinflammatory diseases (IL-1 AID) is crucial to prevent damage. The aim was to longitudinally analyze the impact of protocolized disease activity-based treatment adjustments in a real-life cohort. Methods: A single-center study of consecutive children with IL-1 AID followed between January 2016 and December 2019 was performed. Demographics, phenotypes, genotypes, inflammatory markers, physician (PGA), and patient/parent (PPGA) global assessment were captured. Disease activity and treatment changes were assessed. The impact of distinct parameters on disease activity trajectories was analyzed. Results: A total of 56 children were included, median follow-up was 2.1 years reflecting 361 visits. Familial Mediterranean Fever was the most common IL-1 AID. At the first visit, 68% of the patients had moderate/severe disease activity. Disease activity-based treatment adjustments were required in 28/56 children (50%). At last follow-up, 79% had a well-controlled disease. Both PGA and PPGA decreased significantly over time (p < 0.001; p < 0.017, respectively), however, both differed statistically at last visit (p < 0.001). Only PGA showed a significant estimated mean decrease across all IL-1 AID over time. Conclusions: Disease activity-based treatment adjustments can effectively refine treat-to-target strategies, enable personalized precision health approaches, and improve outcomes in children with IL-1 AID.
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Affiliation(s)
- Tatjana Welzel
- Pediatric Rheumatology, University Children’s Hospital Basel, University of Basel, 4031 Basel, Switzerland
- Pediatric Research Centre, University Children’s Hospital Basel, University of Basel, 4031 Basel, Switzerland
- Division of Pediatric Rheumatology, Department of Pediatrics, autoinflammatory reference centre Tuebingen, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Beate Zapf
- Division of Pediatric Rheumatology, Department of Pediatrics, autoinflammatory reference centre Tuebingen, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Jens Klotsche
- German Rheumatism Research Centre Berlin, 10117 Berlin, Germany
| | - Özlem Satirer
- Division of Pediatric Rheumatology, Department of Pediatrics, autoinflammatory reference centre Tuebingen, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Susanne M. Benseler
- Pediatric Rheumatology, Department of Paediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Children’s Health Ireland (CHI), D01 R5P3 Dublin, Ireland
| | - Jasmin B. Kuemmerle-Deschner
- Division of Pediatric Rheumatology, Department of Pediatrics, autoinflammatory reference centre Tuebingen, University Hospital Tuebingen, 72076 Tuebingen, Germany
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Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis of unknown origin, lasting for >6 weeks with onset before 16 years of age. JIA is the most common chronic inflammatory rheumatic condition of childhood. According to the International League Against Rheumatism (ILAR) classification, seven mutually exclusive categories of JIA exist based on disease manifestations during the first 6 months of disease. Although the ILAR classification has been useful to foster research, it has been criticized mainly as it does not distinguish those forms of chronic arthritis observed in adults and in children from those that may be unique to childhood. Hence, efforts to provide a new evidence-based classification are ongoing. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms. The field has witnessed a remarkable improvement in therapeutic possibilities of JIA owing to the availability of new potent drugs and the possibility to perform controlled trials with support from legislative interventions and large networks availability. The goal of drug therapy in JIA is to rapidly reduce disease activity to inactive disease or clinical remission, minimize drug side effects and achieve a quality of life comparable to that of healthy peers. As JIA can influence all aspects of a child's and their family's life, researchers increasingly recognize improvement of health-related quality of life as a key treatment goal.
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Ponin L, Poomthavorn P, Pirojsakul K, Lerkvaleekul B, Soponkanaporn S, Chitrapazt N, Vilaiyuk S. Long-term growth and final adult height outcome in childhood-onset systemic lupus erythematosus. Pediatr Rheumatol Online J 2022; 20:4. [PMID: 35073942 PMCID: PMC8785598 DOI: 10.1186/s12969-022-00663-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 01/09/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Growth impairment is the most common complication in patients with childhood-onset systemic lupus erythematosus (cSLE). There are limited data on risk factors affecting growth development in Asian patients with cSLE. This study aimed to determine the predictors of growth impairment in such patients. METHODS All SLE patients aged < 15 years diagnosed in Ramathibodi Hospital between 2006 and 2016 were enrolled in a retrospective cohort study. Baseline characteristics, including height, weight, clinical manifestations, disease activity score, and medications, were reviewed from medical records from the time at diagnosis to achievement of final adult height (FAH). Age at menarche in girls, adult voice appearance in boys, and parental height were collected by interview. Parent-adjusted FAH (PaFAH) Z-score was calculated as the difference between FAH Z-score for chronological age of the patients and their mid parental height-Z score. The patients were classified into two groups: (1) normal growth (PaFAH Z-score ≥ - 1.5, 2) growth impairment (PaFAH Z-score < - 1.5). Descriptive statistics and logistic regression analysis were used to analyze the data. RESULTS Of 106 cSLE patients, 19 (18%) were male and 87 (82%) were female. The mean age at study enrollment was 20.6 ± 3.0 years, mean age at diagnosis 12.1 ± 2.3 years, and mean age at achievement of FAH 17.5 ± 1.9 years. Growth impairment was found in 23.6% of patients (52.6% in boys and 17.2% in girls). Predictors of growth impairment were male sex, duration of disease before menarche in girls and adult voice appearance in boys, and cumulative corticosteroid dose (prednisolone equivalent) ≥230 mg/kg received before the late phase of puberty, with odds ratios of 7.07 (95%CI 2.11-23.74), 1.26 (95% CI 1.02-1.56), and 6.99 (95%CI 1.63-30.02), respectively. CONCLUSIONS One-fourth of cSLE patients developed growth impairment, which mostly affected male patients. Longer duration of disease before the late phase of puberty and corticosteroid dose ≥230 mg/kg received before the late phase of puberty were factors predictive of growth impairment.
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Affiliation(s)
- Lalita Ponin
- grid.10223.320000 0004 1937 0490Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Preamrudee Poomthavorn
- grid.10223.320000 0004 1937 0490Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Kwanchai Pirojsakul
- grid.10223.320000 0004 1937 0490Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Butsabong Lerkvaleekul
- grid.10223.320000 0004 1937 0490Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Sirisucha Soponkanaporn
- grid.10223.320000 0004 1937 0490Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Niyata Chitrapazt
- grid.10223.320000 0004 1937 0490Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Biologic disease modifying antirheumatic drugs and Janus kinase inhibitors in paediatric rheumatology - what we know and what we do not know from randomized controlled trials. Pediatr Rheumatol Online J 2021; 19:46. [PMID: 33766063 PMCID: PMC7995584 DOI: 10.1186/s12969-021-00514-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Biologic disease modifying antirheumatic drugs (bDMARDs) and Janus Kinase (JAK) inhibitors are prescribed in adult and paediatric rheumatology. Due to age-dependent changes, disease course, and pharmacokinetic processes paediatric patients with inflammatory rheumatic diseases (PiRD) differ from adult rheumatology patients. METHODS A systematic literature search for randomized clinical trials (RCTs) in PiRD treated with bDMARDs/JAK inhibitors was conducted on Medline, clinicaltrials.gov , clinicaltrialsregister.eu and conference abstracts as of July 2020. RCTs were included if (i) patients were aged ≤20 years, (ii) patients had a predefined rheumatic diagnosis and (iii) RCT reported predefined outcomes. Selected studies were excluded in case of (i) observational or single arm study or (ii) sample size ≤5 patients. Study characteristics were extracted. RESULTS Out of 608 screened references, 65 references were selected, reporting 35 unique RCTs. All 35 RCTs reported efficacy while 34/3 provided safety outcomes and 16/35 provided pharmacokinetic data. The most common investigated treatments were TNF inhibitors (60%), IL-1 inhibitors (17%) and IL-6 inhibitors (9%). No RCTs with published results were identified for baricitinib, brodalumab, certolizumab pegol, guselkumab, risankizumab, rituximab, sarilumab, secukinumab, tildrakizumab, or upadacitinib. In patients with juvenile idiopathic arthritis (JIA) 25/35 RCTs were conducted. The remaining 10 RCTs were performed in non-JIA patients including plaque psoriasis, Kawasaki Disease, systemic lupus erythematosus and non-infectious uveitis. In JIA-RCTs, the control arm was mainly placebo and the concomitant treatments were either methotrexate, non-steroidal anti-inflammatory drugs (NSAID) or corticosteroids. Non-JIA patients mostly received NSAID. There are ongoing trials investigating abatacept, adalimumab, baricitinib, brodalumab, certolizumab pegol, etanercept, guselkumab, infliximab, risankizumab, secukinumab, tofacitinib and tildrakizumab. CONCLUSION Despite the FDA Modernization Act and support of major paediatric rheumatology networks, such as the Pediatric Rheumatology Collaborative Study Group (PRCSG) and the Paediatric Rheumatology International Trials Organization (PRINTO), which resulted in drug approval for PiRD indications, there are limited RCTs in PiRD patients. As therapy response is influenced by age-dependent changes, pharmacokinetic processes and disease course it is important to consider developmental changes in bDMARDs/JAK inhibitor use in PiRD patients. As such it is critical to collaborate and conduct international RCTs to appropriately investigate and characterize efficacy, safety and pharmacokinetics of bDMARDs/JAK inhibitors in paediatric rheumatology.
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Physical activity assessment in children and adolescents with juvenile idiopathic arthritis compared with controls. Arch Pediatr 2020; 28:47-52. [PMID: 33250332 DOI: 10.1016/j.arcped.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/13/2020] [Accepted: 10/02/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We aimed to assess physical activity (PA) in children with juvenile idiopathic arthritis (JIA) compared with healthy peers and to determine factors influencing PA level. METHODS This was a cross-sectional study of the measured level of PA in children with JIA, compared with age- and gender-matched healthy schoolchildren. PA was estimated using a physical activity questionnaire for children and for adolescents (cPAQ/aPAQ). Disease activity was evaluated with the Juvenile Arthritis Disease Activity Score (JADAS). Functional ability was assessed with the Childhood Health Assessment Questionnaire (CHAQ). RESULTS A total of 55 children with JIA and 55 healthy control schoolchildren were included. Children with JIA had significantly lower levels of PA compared with their healthy peers as assessed with the cPAQ/aPAQ (P=0.0121). In total, 76% of the JIA group spent the day sleeping and sitting, which was significantly higher compared with the reference group (P=0.001 and P=0.055, respectively). Low PA level was associated with systemic JIA (P=0.002, OR=2.123), polyarticular JIA with positive rheumatoid factor (P=0.001, OR=2.014), JADAS-27≥6 (P=0.001, OR=2.524), patients undergoing treatment (P=0.001, OR=1.271), and higher CHAQ (P=0.002, OR=2.461). CONCLUSION Children with JIA were less physically active than their healthy peers and less active than recommended for general health.
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Brunner HI, Quartier P, Alexeeva E, Constantin T, Koné-Paut I, Marzan K, Schneider R, Wulffraat NM, Chasnyk V, Tirosh I, Kallinich T, Kuemmerle-Deschner J, Wouters C, Lauwerys B, Nikishina I, Trachana M, Vougiouka O, Martini A, Lovell DJ, Levy J, Vritzali E, Ruperto N. Efficacy and Safety of Canakinumab in Patients With Systemic Juvenile Idiopathic Arthritis With and Without Fever at Baseline: Results From an Open-Label, Active-Treatment Extension Study. Arthritis Rheumatol 2020; 72:2147-2158. [PMID: 32648697 DOI: 10.1002/art.41436] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/27/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the long-term efficacy and safety of canakinumab and explore prediction of response in patients with systemic juvenile idiopathic arthritis (JIA) with or without fever at treatment initiation. METHODS At enrollment, patients with active systemic JIA (ages 2 to <20 years) started open-label canakinumab (4 mg/kg every 4 weeks subcutaneously). Efficacy measures included the adapted American College of Rheumatology (ACR) Pediatric 50/70/90 criteria, the Juvenile Arthritis Disease Activity Score (JADAS), and clinically inactive disease and clinical remission on medication, evaluated by either the JADAS or ACR criteria. RESULTS Of the 123 patients (70 with fever and 52 without fever [fever status was not reported for 1 patient]), 84 (68.3%) completed the study (median duration 1.8 years). Comparable efficacy (adapted ACR Pediatric 50/70/90/100) was observed by day 15 in both subgroups (60.0%/48.6%/37.1%/24.3% in those with fever and 67.3%/48.1%/34.6%/19.2% in those without fever), and further increased thereafter. By month 6, clinical remission according to the JADAS or the ACR criteria was achieved in 17 (24.3%) and 26 (37.1%), respectively, of patients with fever and 9 (17.3%) and 12 (23.1%), respectively, of patients without fever. Median time to onset of clinical remission according to the JADAS or ACR criteria was 57 and 30 days, respectively, in those with fever, and 58 and 142 days, respectively, in those without fever. An adapted ACR Pediatric 50 response by day 15 was the strongest predictor of achieving clinical remission according to the JADAS (odds ratio [OR] 13 [95% confidence interval (95% CI) 4, 42]; P < 0.0001) or glucocorticoid discontinuation (OR 19 [95% CI 3, 114]; P = 0.002). Of the 71 of 123 patients (57.7%) who received glucocorticoids at study entry, 27 (38.0%) discontinued glucocorticoids and 21 (29.6%) reached a dose of <0.2 mg/kg/day, with no difference between those with and those without fever; 13 patients (10.6%) tolerated a sustained canakinumab dose reduction to 2 mg/kg every 4 weeks. No new safety findings were observed. CONCLUSION Canakinumab provided rapid and sustained improvement of active systemic JIA irrespective of the presence of fever at treatment initiation.
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Affiliation(s)
- Hermine I Brunner
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Pierre Quartier
- Université de Paris, Institut IMAGINE, Centre de référence national pour les Rhumatismes inflammatoires et les maladies Auto-Immunes Systémiques rares de l'Enfant, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Ekaterina Alexeeva
- Federal State Autonomous Institution National Medical Research Center of Children's Health of the Ministry of Health of the Russian Federation, Federal State Autonomous Educational Institution of Higher Education, I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | | | - Isabelle Koné-Paut
- Centre de Référence des Maladies Auto-Inflammatoires rares et des Amyloses, CHU de Biĉetre, AP-HP, University of Paris Sud, Paris, France
| | | | - Rayfel Schneider
- University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Vyacheslav Chasnyk
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Irit Tirosh
- The Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel
| | - Tilmann Kallinich
- Charité University Medicine Berlin and Leibniz Institut, Berlin, Germany
| | | | - Carine Wouters
- Universitair Ziekenhuis Leuven and Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bernard Lauwerys
- Université catholique de Louvain and Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Irina Nikishina
- VA Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - Maria Trachana
- Hippokration General Hospital and Thessaloniki University School of Medicine, Thessaloniki, Greece
| | - Olga Vougiouka
- P&A Kyriakou Children's Hospital and Athens University School of Medicine, Athens, Greece
| | | | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Jeremy Levy
- Biometrical Practice BIOP, Basel, Switzerland
| | | | - Nicolino Ruperto
- IRCCS, Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
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Greer AE, Iversen MD. Measures of Pediatric Function and Physical Activity in Arthritis. Arthritis Care Res (Hoboken) 2020; 72 Suppl 10:499-521. [PMID: 33091268 DOI: 10.1002/acr.24239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Maura D Iversen
- Sacred Heart University, Fairfield, Connecticut, Karolinska Instituet, Stockholm, Sweden, and Brigham& Women's Hospital, Boston, Massachusetts
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Lee RR, Rashid A, Thomson W, Cordingley L. "Reluctant to Assess Pain": A Qualitative Study of Health Care Professionals' Beliefs About the Role of Pain in Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2020; 72:69-77. [PMID: 30629337 PMCID: PMC6973019 DOI: 10.1002/acr.23827] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 12/18/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Reducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals' (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA. METHODS Semi-structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach. RESULTS Twenty-one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain. CONCLUSION These findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs' accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.
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Affiliation(s)
- Rebecca Rachael Lee
- Manchester University Hospitals NHS Foundation TrustManchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Amir Rashid
- Manchester University Hospitals NHS Foundation TrustManchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Wendy Thomson
- Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Lis Cordingley
- Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
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Uziel Y. Juvenile Idiopathic Arthritis-Education, Knowledge, and Patient Outcomes. J Pediatr 2019; 209:10-11. [PMID: 30737036 DOI: 10.1016/j.jpeds.2019.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/15/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Brunner HI, Rider LG, Kingsbury DJ, Co D, Schneider R, Goldmuntz E, Onel KB, Giannini EH, Lovell DJ. Pediatric Rheumatology Collaborative Study Group - over four decades of pivotal clinical drug research in pediatric rheumatology. Pediatr Rheumatol Online J 2018; 16:45. [PMID: 29996857 PMCID: PMC6042275 DOI: 10.1186/s12969-018-0261-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 06/20/2018] [Indexed: 11/10/2022] Open
Abstract
IMPORTANCE Specialized research networks are essential to achieve drug approvals for rare pediatric diseases. Such networks help realize the potential of global legislation enacted upon the recognition that most children are treated with drugs whose most beneficial dose and regimen have not been established in pediatric patients. The Pediatric Rheumatology Collaborative Study Group (PRCSG) is a North American clinical trials network that is specialized in the performance of clinical trials of new therapies for pediatric populations with rheumatic diseases. This review provides an overview of the strategies employed by this research network to achieve drug and biologic approvals for children with pediatric rheumatic diseases, particularly juvenile idiopathic arthritis. OBSERVATIONS Clinical trial conduct in rare pediatric diseases has required global recruitment. Supported or led by the PRCSG, highly responsive, validated, composite measures have been established to assess drug efficacy. For pediatric orphan diseases with high disease burdens, specialized investigative sites and study designs are needed to complete adequately powered trials at the high standard necessary to enable drug labeling by regulatory agencies. Novel trial designs have been utilized for more efficient testing of innovative drug candidates. All these have been developed or co-developed by the PRCSG research network. CONCLUSIONS AND RELEVANCE Specialized research networks in pediatric rheumatology, such as the PRCSG, have changed the landscape of available therapies and improved overall disease outcomes for children with pediatric rheumatic diseases.
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Affiliation(s)
- Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center & Cincinnati Children's Research Foundation, MLC 4010, Cincinnati, OH, 45229, USA.
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, USA
| | | | - Dominic Co
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rayfel Schneider
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, Rheumatologic Autoimmune Diseases Section, National Institutes of Health, Bethesda, MD, USA
| | - Karen B Onel
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward H Giannini
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center & Cincinnati Children's Research Foundation, MLC 4010, Cincinnati, OH, 45229, USA
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center & Cincinnati Children's Research Foundation, MLC 4010, Cincinnati, OH, 45229, USA
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Cimaz R, Marino A, Martini A. How I treat juvenile idiopathic arthritis: A state of the art review. Autoimmun Rev 2017; 16:1008-1015. [DOI: 10.1016/j.autrev.2017.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 12/22/2022]
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Brunner HI, Ruperto N, Tzaribachev N, Horneff G, Chasnyk VG, Panaviene V, Abud-Mendoza C, Reiff A, Alexeeva E, Rubio-Pérez N, Keltsev V, Kingsbury DJ, Del Rocio Maldonado Velázquez M, Nikishina I, Silverman ED, Joos R, Smolewska E, Bandeira M, Minden K, van Royen-Kerkhof A, Emminger W, Foeldvari I, Lauwerys BR, Sztajnbok F, Gilmer KE, Xu Z, Leu JH, Kim L, Lamberth SL, Loza MJ, Lovell DJ, Martini A. Subcutaneous golimumab for children with active polyarticular-course juvenile idiopathic arthritis: results of a multicentre, double-blind, randomised-withdrawal trial. Ann Rheum Dis 2017; 77:21-29. [PMID: 28507219 PMCID: PMC5754736 DOI: 10.1136/annrheumdis-2016-210456] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 03/03/2017] [Accepted: 03/12/2017] [Indexed: 11/30/2022]
Abstract
Objective This report aims to determine the safety, pharmacokinetics (PK) and efficacy of subcutaneous golimumab in active polyarticular-course juvenile idiopathic arthritis (polyJIA). Methods In this three-part randomised double-blinded placebo-controlled withdrawal trial, all patients received open-label golimumab (30 mg/m2 of body surface area; maximum: 50 mg/dose) every 4 weeks together with weekly methotrexate during Part 1 (weeks 0–16). Patients with at least 30% improvement per American College of Rheumatology Criteria for JIA (JIA ACR30) in Part 1 entered the double-blinded Part 2 (weeks 16–48) after 1:1 randomisation to continue golimumab or start placebo. In Part 3, golimumab was continued or could be restarted as in Part 1. The primary outcome was JIA flares in Part 2; secondary outcomes included JIA ACR50/70/90 responses, clinical remission, PK and safety. Results Among 173 patients with polyJIA enrolled, 89.0% (154/173) had a JIA ACR30 response and 79.2%/65.9%/36.4% demonstrated JIA ACR50/70/90 responses in Part 1. At week 48, the primary endpoint was not met as treatment groups had comparable JIA flare rates (golimumab vs placebo: 32/78=41% vs 36/76=47%; p=0.41), and rates of clinical remission were comparable (golimumab vs placebo: 10/78=12.8% vs 9/76=11.8%). Adverse event and serious adverse event rates were similar in the treatment groups during Part 2. Injection site reactions occurred with <1% of all injections. PK analysis confirmed adequate golimumab dosing for polyJIA. Conclusion Although the primary endpoint was not met, golimumab resulted in rapid, clinically meaningful, improvement in children with active polyJIA. Golimumab was well tolerated, and no unexpected safety events occurred. Clinical Trial Registration NCT01230827; Results.
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Affiliation(s)
- Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicolino Ruperto
- Istituto Giannina Gaslini, Pediatria II - Rheumatologia, PRINTO, Genoa, Italy
| | | | - Gerd Horneff
- Department of Pediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Vyacheslav G Chasnyk
- Hospital Pediatry, State Pediatric Medical Academy, Saint Petersburg, Russian Federation
| | | | - Carlos Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital "Dr. Ignacio Morones Prieto" and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, Mexico, San Luis Potosí, Mexico
| | - Andreas Reiff
- Department of Rheumatology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Ekaterina Alexeeva
- Children's Health of RAMS and IM Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Nadina Rubio-Pérez
- Hospital Universitario, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | | | | | | | - Irina Nikishina
- Pediatric Department, V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Earl D Silverman
- Department of Rheumatology, The Hospital for Sick Children, Toronto, Canada
| | - Rik Joos
- ZNA Jan Palfijn, Antwerpen, Belgium
| | | | | | - Kirsten Minden
- Department of Pediatric Rheumatology, Charité University Medicine, Berlin, Germany
| | - Annet van Royen-Kerkhof
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ivan Foeldvari
- Klinikum Eilbek, Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Bernard R Lauwerys
- Pôle de pathologies rhumatismales systémiques et inflammatoires, Université catholique de Louvain, Institut de Recherche Clinique, Brussels, Belgium
| | - Flavio Sztajnbok
- Nucleo de Estudos da Saúde do Adolescente, Hospital Universitario Pedro Ernesto, Rio de Janeiro, Brazil
| | - Keith E Gilmer
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Zhenhua Xu
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Jocelyn H Leu
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Lilianne Kim
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Sarah L Lamberth
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Matthew J Loza
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alberto Martini
- Istituto Giannina Gaslini, Pediatria II - Rheumatologia, PRINTO, Genoa, Italy
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Uziel Y. Juvenile Idiopathic Arthritis in the Era of International Cooperation. Rambam Maimonides Med J 2017; 8:RMMJ.10278. [PMID: 28178439 PMCID: PMC5298364 DOI: 10.5041/rmmj.10278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic disease of childhood. Improved understanding of its pathogenesis has led to international cooperation in clinical studies. Multicenter, international collaborations and research facilitate rapid enrollment of enough patients to enable a variety of studies, including those of epidemiology, diagnostic and classification criteria, genetic disease predisposition, pathogenesis, outcomes, and treatment protocols. In the last 20 years, the vision of the Pediatric Rheumatology International Trial Organization (PRINTO) has become a reality of worldwide collaboration in pediatric rheumatology research, including North American and European research groups. Major advances have been made in treating systemic JIA and its main complication, macrophage-activating syndrome (MAS). Single Hub and Access Point to Pediatric Rheumatology in Europe (SHARE) is a project of the European Society of Pediatric Rheumatology with the goal of improving clinical care. Based on evidence in the scientific literature, position papers regarding optimal clinical approaches and care have been published. Formal, validated assessment tools to evaluate response to treatment have been developed. Recommendations have been established to encourage international research collaborations, especially in light of major advances achieved in the genetics of pediatric rheumatologic diseases and the need to share biological samples among different countries and continents. Every participating country has disease information available for patients and families. Additionally, educational programs and updated syllabi for pediatric rheumatology have been written to promote similar, high-level academic training in different countries. These efforts have resulted in significant improvements in treatment and in patient prognosis. However, improved cooperation is needed to enhance research with biological and genetic samples. The Israeli Research Group for Pediatric Rheumatology is very active and has made significant contributions to the field.
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Affiliation(s)
- Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- E-mail:
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Verazza S, Davì S, Consolaro A, Bovis F, Insalaco A, Magni-Manzoni S, Nicolai R, Marafon DP, De Benedetti F, Gerloni V, Pontikaki I, Rovelli F, Cimaz R, Marino A, Zulian F, Martini G, Pastore S, Sandrin C, Corona F, Torcoletti M, Conti G, Fede C, Barone P, Cattalini M, Cortis E, Breda L, Olivieri AN, Civino A, Podda R, Rigante D, La Torre F, D’Angelo G, Jorini M, Gallizzi R, Maggio MC, Consolini R, De Fanti A, Muratore V, Alpigiani MG, Ruperto N, Martini A, Ravelli A. Disease status, reasons for discontinuation and adverse events in 1038 Italian children with juvenile idiopathic arthritis treated with etanercept. Pediatr Rheumatol Online J 2016; 14:68. [PMID: 27993144 PMCID: PMC5170898 DOI: 10.1186/s12969-016-0126-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/24/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Data from routine clinical practice are needed to further define the efficacy and safety of biologic medications in children with juvenile idiopathic arthritis (JIA). The aim of this analysis was to investigate the disease status, reasons for discontinuation and adverse events in Italian JIA patients treated with etanercept (ETN). METHODS In 2013, all centers of the Italian Pediatric Rheumatology Study Group were asked to make a census of patients given ETN after January 2000. Patients were classified in three groups: group 1 = patients still taking ETN; group 2 = patients discontinued from ETN for any reasons; group 3 = patients lost to follow-up while receiving ETN. All three groups received a retrospective assessment; patients in group 1 also underwent a cross-sectional assessment. RESULTS 1038 patients were enrolled by 23 centers: 422 (40.7%) were in group 1, 462 (44.5%) in group 2, and 154 (14.8%) in group 3. Median duration of ETN therapy was 2.5 years. At cross-sectional assessment, 41.8% to 48.6% of patients in group 1 met formal criteria for inactive disease, whereas 52.4% of patients in group 2 and 55.8% of patients in group 3 were judged in clinical remission by their caring physician at last visit. A relatively greater proportion of patients with systemic arthritis were discontinued or lost to follow-up. Parent evaluations at cross-sectional visit in group 1 showed that 52.4% of patients had normal physical function, very few had impairment in quality of life, 51.2% had no pain, 76% had no morning stiffness, and 82.7% of parents were satisfied with their child's illness outcome. Clinically significant adverse events were reported for 27.8% of patients and ETN was discontinued for side effects in 9.5%. The most common adverse events were new onset or recurrent uveitis (10.2%), infections (6.6%), injection site reactions (4.4%), and neuropsychiatric (3.1%), gastrointestinal (2.4%), and hematological disorders (2.1%). Ten patients developed an inflammatory bowel disease and 2 had a malignancy. One patient died of a fulminant streptococcal sepsis. CONCLUSIONS Around half of the patients achieved complete disease quiescence under treatment with ETN. The medication was overall well tolerated, as only one quarter of patients experienced clinically significant adverse events and less than 10% had treatment discontinued for toxicity.
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Affiliation(s)
| | | | - Alessandro Consolaro
- Università degli Studi di Genova, Genova, Italy ,Istituto Giannina Gaslini, Genova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fabrizia Corona
- Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Milano, Italy
| | - Marta Torcoletti
- Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Conti
- Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Claudia Fede
- Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Patrizia Barone
- Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele, Catania, Italy
| | | | | | | | | | - Adele Civino
- Azienda Ospedaliera Card. G. Panico, Tricase, Italy
| | - Rosanna Podda
- Ospedale Regionale per le Microcitemie, Cagliari, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Alberto Martini
- Università degli Studi di Genova, Genova, Italy ,Istituto Giannina Gaslini, Genova, Italy
| | - Angelo Ravelli
- Università degli Studi di Genova, Genova, Italy. .,Istituto Giannina Gaslini, Genova, Italy. .,Pediatria II-Reumatologia, Istituto G. Gaslini, Largo G. Gaslini 5, 16147, Genova, Italy.
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Clark J, Gardiner C, Barnes A. International palliative care research in the context of global development: a systematic mapping review. BMJ Support Palliat Care 2016; 8:7-18. [DOI: 10.1136/bmjspcare-2015-001008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 05/17/2016] [Accepted: 07/14/2016] [Indexed: 01/18/2023]
Abstract
ContextAn increasing amount of health policy is formulated at global level. At this global level, palliative care has attracted support primarily from normative institutions (WHO), not funding agencies. To attract greater global attention from policymakers, it has been argued that an international approach to research is required. However, the extent to which an international approach is being undertaken is unknown.ObjectivesTo systematically identify and thematically synthesise all international palliative care research, defined as research involving two or more countries, or focused on the global level.MethodsFive bibliographic databases (CINAHL, Cochrane Library, ASSIA, Web of Knowledge, Psychinfo) were searched for journal articles relevant to international and global palliative care and end-of-life care. Data were extracted using a piloted extraction form and findings were synthesised.Results184 studies were included, published across 75 different academic journals. Research emanates from and focuses on all world regions and there is increasing focus on the global level. Thematically, there is a high focus on Evaluation (n=53) and views of Stakeholders (n=38). The review revealed a predominantly observational research approach and few interventional studies were identified.ConclusionsInternational palliative care research is a relatively new, but growing field. However, many gaps in the evidence base remain and palliative care research continues to take place outside broader discourses of international development. The relative absence of interventional research demonstrating the effectiveness and cost-effectiveness of palliative care risks limiting the tools with which advocates can engage with international policymakers on this topic.
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Abstract
In systemic lupus erythematosus renal involvement is more frequent in children than in adults. Overall, 60-80% of children with systemic lupus erythematosus have urinary or renal function abnormalities early in the disease course. In 90% of patients, renal disease occurs within two years from disease onset. Clinically significant renal involvement ranges from asymptomatic urinary findings to nephrotic syndrome and renal failure. Long-term prognosis is similar to that observed in adults. Treatment aspects that are peculiar to children include drug side-effects, such as growth inhibition induced by steroids, the need to consider morbidity-related issues with respect to the very long life expectancy of patients and the problems related to the impact of disease in adolescents. The recent availability of a childhood SLE definition of improvement and the presence of large international paediatric rheumatology networks should, in the future, facilitate the implementation of controlled clinical trials devoted to paediatric SLE.
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Affiliation(s)
- F Perfumo
- Nephrology Unit, University of Genoa, Istituto G. Gaslini, Genoa, Italy
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Tudur Smith C, Williamson PR, Beresford MW. Methodology of clinical trials for rare diseases. Best Pract Res Clin Rheumatol 2014; 28:247-62. [DOI: 10.1016/j.berh.2014.03.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gueddari S, Amine B, Rostom S, Badri D, Mawani N, Ezzahri M, Moussa F, Shyen S, Abouqal R, Chkirat B, Hajjaj-Hassouni N. Physical activity, functional ability, and disease activity in children and adolescents with juvenile idiopathic arthritis. Clin Rheumatol 2014; 33:1289-94. [DOI: 10.1007/s10067-014-2576-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 12/31/2013] [Accepted: 03/06/2014] [Indexed: 10/25/2022]
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Hasija R, Pistorio A, Ravelli A, Demirkaya E, Khubchandani R, Guseinova D, Malattia C, Canhao H, Harel L, Foell D, Wouters C, De Cunto C, Huemer C, Kimura Y, Mangge H, Minetti C, Nordal EB, Philippet P, Garozzo R, Martini A, Ruperto N. Therapeutic approaches in the treatment of juvenile dermatomyositis in patients with recent-onset disease and in those experiencing disease flare: an international multicenter PRINTO study. ACTA ACUST UNITED AC 2013; 63:3142-52. [PMID: 21647864 DOI: 10.1002/art.30475] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate response to therapy over a 24-month period in a large prospective international cohort of patients with juvenile dermatomyositis (DM). METHODS The study included 145 patients with recent-onset juvenile DM and 130 juvenile DM patients experiencing disease flare, all of whom were <18 years old. Disease activity parameters and therapeutic approaches in 4 geographic areas were analyzed at baseline and at 6, 12, and 24 months. Response was assessed according to the Pediatric Rheumatology International Trials Organization (PRINTO) juvenile DM response criteria, and data were reported "as observed" and in the intent-to-treat (ITT) population. RESULTS Patients with recent-onset juvenile DM at baseline had higher baseline disease activity and greater improvement over 24 months when compared to juvenile DM patients experiencing disease flare at baseline. Methotrexate (MTX) or high-dose corticosteroids were administered more frequently to patients with recent-onset juvenile DM, compared to juvenile DM patients experiencing disease flare, who were more likely to receive cyclosporine. Compared to patients from Western and Eastern Europe, a higher proportion of patients from South and Central America and North America received pulse steroids, and the average steroid dosage was higher in the North American and South and Central American patients. The use of MTX was similar in all 4 regions, while cyclosporin A was more frequently used in Western Europe. In the "as observed" analysis, 57.9% of the patients with recent-onset juvenile DM and 36.4% of the patients experiencing disease flare (P<0.001) reached at least a 70% response by PRINTO criteria at 6 months; these proportions had increased at month 24 to 78.4% and 51.2%, respectively (P<0.001). Corresponding results of the ITT analysis were much lower, with only one-third of the patients able to maintain the initial assigned therapy over 24 months. CONCLUSION Patients with recent-onset juvenile DM are more likely to achieve significant clinical improvement over 24 months, when compared to patients experiencing flares of juvenile DM. Internationally, various therapeutic approaches are used to treat this disease.
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23
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Miettunen PM, Pistorio A, Palmisani E, Ravelli A, Silverman E, Oliveira S, Alessio M, Cuttica R, Mihaylova D, Espada G, Pasic S, Insalaco A, Ozen S, Porras O, Sztajnbok F, Lazarevic D, Martini A, Ruperto N. Therapeutic approaches for the treatment of renal disease in juvenile systemic lupus erythematosus: an international multicentre PRINTO study. Ann Rheum Dis 2012; 72:1503-9. [PMID: 23100607 DOI: 10.1136/annrheumdis-2012-201937] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To evaluate therapeutic approaches and response to therapy in juvenile systemic lupus erythematosus (SLE) with renal involvement in a large prospective international cohort from four geographic areas. METHODS New onset and flared patients with active renal disease (proteinuria ≥0.5 g/24 h) were enrolled in 2001-2004. Therapeutic approaches and disease activity parameters were analysed at baseline, 6, 12 and 24 months. Response was assessed by the PRINTO/ACR criteria. RESULTS 218/557 (79.8% female subjects, 117 new onset and 101 flared) patients with active renal disease were identified; 66 patients were lost to follow-up and 11 died. Mean age at disease onset for new onset group was higher than for flared group (13.1 vs 10.2 years, p<0.0001). At baseline, both groups had similar renal activity with similar median doses of corticosteroids (1.0-0.76 mg/kg/day). Cyclophosphamide (43.1%) and azathioprine (22%) were the most common immunosuppressive drugs. At baseline, South American patients received higher doses of corticosteroids than in other areas in new onset (median 1.16 vs 0.8-1 mg/kg/day) while cyclophosphamide use was similar in all four regions in the new onset group. There were no differences regarding the use of azathioprine or mycophenolate mofetil worldwide. PRINTO 70 response was reached in a greater percentage of new onset versus flared patients (74.8% vs 53.3%; p=0.005) at 6 months while at 24 months ACR 90 was reached by 69.9% and 56.1%, respectively. CONCLUSIONS New onset and flared juvenile SLE improved similarly over 24 months with minimal differences in therapeutic approaches worldwide.
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Affiliation(s)
- Paivi M Miettunen
- Division of Pediatric Rheumatology, University of Calgary, Alberta Children's Hospital, Calgary, Canada
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Rider LG, Werth VP, Huber AM, Alexanderson H, Rao AP, Ruperto N, Herbelin L, Barohn R, Isenberg D, Miller FW. Measures of adult and juvenile dermatomyositis, polymyositis, and inclusion body myositis: Physician and Patient/Parent Global Activity, Manual Muscle Testing (MMT), Health Assessment Questionnaire (HAQ)/Childhood Health Assessment Questionnaire (C-HAQ), Childhood Myositis Assessment Scale (CMAS), Myositis Disease Activity Assessment Tool (MDAAT), Disease Activity Score (DAS), Short Form 36 (SF-36), Child Health Questionnaire (CHQ), physician global damage, Myositis Damage Index (MDI), Quantitative Muscle Testing (QMT), Myositis Functional Index-2 (FI-2), Myositis Activities Profile (MAP), Inclusion Body Myositis Functional Rating Scale (IBMFRS), Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), Cutaneous Assessment Tool (CAT), Dermatomyositis Skin Severity Index (DSSI), Skindex, and Dermatology Life Quality Index (DLQI). Arthritis Care Res (Hoboken) 2012; 63 Suppl 11:S118-57. [PMID: 22588740 DOI: 10.1002/acr.20532] [Citation(s) in RCA: 258] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Lisa G Rider
- Environmental Autoimmunity Group, Program of Clinical Research, National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland 20892-1301, USA.
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25
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Mina R, Klein-Gitelman MS, Ravelli A, Beresford MW, Avcin T, Espada G, Eberhard BA, Schanberg LE, O'Neil KM, Silva CA, Higgins GC, Onel K, Singer NG, von Scheven E, Imundo LF, Nelson S, Giannini EH, Brunner HI. Inactive disease and remission in childhood-onset systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2012; 64:683-93. [PMID: 22238253 DOI: 10.1002/acr.21612] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To define inactive disease (ID) and clinical remission (CR) and to delineate variables that can be used to measure ID/CR in childhood-onset systemic lupus erythematosus (cSLE). METHODS Delphi questionnaires were sent to an international group of pediatric rheumatologists. Respondents provided information about variables to be used in future algorithms to measure ID/CR. The usefulness of these variables was assessed in 35 children with ID and 31 children with minimally active lupus (MAL). RESULTS While ID reflects cSLE status at a specific point in time, CR requires the presence of ID for >6 months and considers treatment. There was consensus that patients in ID/CR can have <2 mild nonlimiting symptoms (i.e., fatigue, arthralgia, headaches, or myalgia) but not Raynaud's phenomenon, chest pain, or objective physical signs of cSLE; antinuclear antibody positivity and erythrocyte sedimentation rate elevation can be present. Complete blood count, renal function testing, and complement C3 all must be within the normal range. Based on consensus, only damage-related laboratory or clinical findings of cSLE are permissible with ID. The above parameters were suitable to differentiate children with ID/CR from those with MAL (area under the receiver operating characteristic curve >0.85). Disease activity scores with or without the physician global assessment of disease activity and patient symptoms were well suited to differentiate children with ID from those with MAL. CONCLUSION Consensus has been reached on common definitions of ID/CR with cSLE and relevant patient characteristics with ID/CR. Further studies must assess the usefulness of the data-driven candidate criteria for ID in cSLE.
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Affiliation(s)
- Rina Mina
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, William S. Rowe Division of Rheumatology, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
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Klepper SE. Measures of pediatric function: Child Health Assessment Questionnaire (C-HAQ), Juvenile Arthritis Functional Assessment Scale (JAFAS), Pediatric Outcomes Data Collection Instrument (PODCI), and Activities Scale for Kids (ASK). Arthritis Care Res (Hoboken) 2011; 63 Suppl 11:S371-82. [DOI: 10.1002/acr.20635] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Ruperto N, Martini A. Current medical treatments for juvenile idiopathic arthritis. Front Pharmacol 2011; 2:60. [PMID: 22013422 PMCID: PMC3189546 DOI: 10.3389/fphar.2011.00060] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 09/21/2011] [Indexed: 11/30/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) differs markedly from adult rheumatoid arthritis. It is not a single disease, but an exclusion diagnosis that gather together all forms of arthritis that begin before the age of 16 years, persist for more than 6 weeks, and are of unknown origin. The advent of the new biological treatments has dramatically changed both the observed responses to treatment and the expectations of therapies. The implementation of an adequate legislation as well as the presence of international research networks of pediatric rheumatology have contributed to foster the conduct of controlled clinical trials and the development of validated outcome measures. This review will currently describe the methodological approach for performing clinical trials in JIA as well as the current available drug treatment.
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Affiliation(s)
- Nicolino Ruperto
- Pediatria II e Reumatologia, Istituto G Gaslini Genoa, University of GenoaGenoa, Italy
| | - Alberto Martini
- Pediatria II e Reumatologia, Istituto G Gaslini Genoa, University of GenoaGenoa, Italy
- Department of Pediatrics, University of GenoaGenoa, Italy
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Abstract
Juvenile idiopathic arthritis is a heterogeneous group of diseases characterised by arthritis of unknown origin with onset before age of 16 years. Pivotal studies in the past 5 years have led to substantial progress in various areas, ranging from disease classification to new treatments. Gene expression profiling studies have identified different immune mechanisms in distinct subtypes of the disease, and can help to redefine disease classification criteria. Moreover, immunological studies have shown that systemic juvenile idiopathic arthritis is an acquired autoinflammatory disease, and have led to successful studies of both interleukin-1 and interleukin-6 blockade. In other forms of the disease, synovial inflammation is the consequence of a disturbed balance between proinflammatory effector cells (such as T-helper-17 cells), and anti-inflammatory regulatory cells (such as FOXP3-positive regulatory T cells). Moreover, specific soluble biomarkers (S100 proteins) can guide individual treatment. Altogether these new developments in genetics, immunology, and imaging are instrumental to better define, classify, and treat patients with juvenile idiopathic arthritis.
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Affiliation(s)
- Berent Prakken
- Centre for Molecular and Cellular Intervention, Department of Paediatrics, University Medical Centre Utrecht, Netherlands
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Beresford MW. Juvenile idiopathic arthritis: new insights into classification, measures of outcome, and pharmacotherapy. Paediatr Drugs 2011; 13:161-73. [PMID: 21500870 DOI: 10.2165/11588140-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Significant advances have taken place in recent years in our understanding of the aetiopathogenesis, management, and clinical outcome of juvenile idiopathic arthritis (JIA). Fundamental to this advancement has been international collaborative efforts of the clinical scientific community and all those involved in the multidisciplinary care of children and young people with JIA. A key factor has been facing the challenge of developing a robust classification system for JIA, a clinically very heterogeneous group of conditions. JIA illustrates the necessity of disease classification to enable scientific progress but also the iterative and evolving process this entails. What is emerging is the imperative to improve our understanding of the biologic and genetic basis of JIA to underpin classification systems. Growing emphasis is centered on improved holistic care and outcome of children and young people with JIA. The expectation of patients, their families, and clinicians is the goal of inactive disease, remission off treatment, and the health and psychosocial well-being of young people emerging into adulthood. Validated tools that reflect these challenges are being developed, including those measuring disease improvement, flare, remission and minimal disease activity, health-related quality of life, and composite scores of activity and damage. Clinical research networks have driven success in developing an evidence-base for the treatment of JIA. Randomized comparative trials have demonstrated the benefit of early use of intra-articular corticosteroid injections, and the importance of methotrexate as the first-line, disease-modifying antirheumatic drug in JIA. The introduction of biologic therapies has opened a major new epoch in the medical management of JIA, with recent trials published on etanercept, infliximab, adalimumab, abatacept, tocilizumab, and anakinra. This review focuses on recent advances in JIA, especially developments in its classification, validation of appropriate measures of holistic outcome, and the specific contribution of established and newer pharmacologic agents available for treating children and young people.
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Affiliation(s)
- Michael W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Ruperto N, Martini A. Emerging drugs to treat juvenile idiopathic arthritis. Expert Opin Emerg Drugs 2011; 16:493-505. [DOI: 10.1517/14728214.2011.581662] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ruperto N, Hanrahan LM, Alarcón GS, Belmont HM, Brey RL, Brunetta P, Buyon JP, Costner MI, Cronin ME, Dooley MA, Filocamo G, Fiorentino D, Fortin PR, Franks AG, Gilkeson G, Ginzler E, Gordon C, Grossman J, Hahn B, Isenberg DA, Kalunian KC, Petri M, Sammaritano L, Sánchez-Guerrero J, Sontheimer RD, Strand V, Urowitz M, von Feldt JM, Werth VP, Merrill JT. International consensus for a definition of disease flare in lupus. Lupus 2010; 20:453-62. [PMID: 21148601 DOI: 10.1177/0961203310388445] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Lupus Foundation of America (LFA) convened an international working group to obtain a consensus definition of disease flare in lupus. With help from the Paediatric Rheumatology International Trials Organization (PRINTO), two web-based Delphi surveys of physicians were conducted. Subsequently, the LFA held a second consensus conference followed by a third Delphi survey to reach a community-wide agreement for flare definition. Sixty-nine of the 120 (57.5%) polled physicians responded to the first survey. Fifty-nine of the responses were available to draft 12 preliminary statements, which were circulated in the second survey. Eighty-seven of 118 (74%) physicians completed the second survey, with an agreement of 70% for 9/12 (75%) statements. During the second conference, three alternative flare definitions were consolidated and sent back to the international community. One hundred and sixteen of 146 (79.5%) responded, with agreement by 71/116 (61%) for the following definition: "A flare is a measurable increase in disease activity in one or more organ systems involving new or worse clinical signs and symptoms and/or laboratory measurements. It must be considered clinically significant by the assessor and usually there would be at least consideration of a change or an increase in treatment." The LFA proposes this definition for lupus flare on the basis of its high face validity.
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Affiliation(s)
- N Ruperto
- Gaslini Pediatria II, Reumatologia, PRINTO, Genova, Italy
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Ruperto N, Giannini EH, Pistorio A, Brunner HI, Martini A, Lovell DJ. Is it time to move to active comparator trials in juvenile idiopathic arthritis?: a review of current study designs. ACTA ACUST UNITED AC 2010; 62:3131-9. [PMID: 20662054 DOI: 10.1002/art.27670] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Nicolino Ruperto
- IRCCS, G. Gaslini Hospital, Paediatric Rheumatology International Trials Organisation, Genoa, Italy.
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Ruperto N, Pistorio A, Ravelli A, Hasija R, Guseinova D, Filocamo G, Demirkaya E, Malattia C, Martini A. Criteria to define response to therapy in paediatric rheumatic diseases. Eur J Clin Pharmacol 2010; 67 Suppl 1:125-31. [DOI: 10.1007/s00228-010-0937-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 08/24/2010] [Indexed: 10/18/2022]
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Ruperto N, Lovell DJ, Li T, Sztajnbok F, Goldenstein-Schainberg C, Scheinberg M, Penades IC, Fischbach M, Alcala JO, Hashkes PJ, Hom C, Jung L, Lepore L, Oliveira S, Wallace C, Alessio M, Quartier P, Cortis E, Eberhard A, Simonini G, Lemelle I, Chalom EC, Sigal LH, Block A, Covucci A, Nys M, Martini A, Giannini EH. Abatacept improves health-related quality of life, pain, sleep quality, and daily participation in subjects with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2010; 62:1542-51. [PMID: 20597110 DOI: 10.1002/acr.20283] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 06/24/2010] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess health-related quality of life (HRQOL) in abatacept-treated children/adolescents with juvenile idiopathic arthritis (JIA). METHODS In this phase III, double-blind, placebo-controlled trial, subjects with active polyarticular course JIA and an inadequate response/intolerance to ≥1 disease-modifying antirheumatic drug (including biologics) received abatacept 10 mg/kg plus methotrexate (MTX) during the 4-month open-label period (period A). Subjects achieving the American College of Rheumatology Pediatric 30 criteria for improvement (defined "responders") were randomized to abatacept or placebo (plus MTX) in the 6-month double-blind withdrawal period (period B). HRQOL assessments included 15 Child Health Questionnaire (CHQ) health concepts plus the physical (PhS) and psychosocial summary scores (PsS), pain (100-mm visual analog scale), the Children's Sleep Habits Questionnaire, and a daily activity participation questionnaire. RESULTS A total of 190 subjects from period A and 122 from period B were eligible for analysis. In period A, there were substantial improvements across all of the CHQ domains (greatest improvement was in pain/discomfort) and the PhS (8.3 units) and PsS (4.3 units) with abatacept. At the end of period B, abatacept-treated subjects had greater improvements versus placebo in all domains (except behavior) and both summary scores. Similar improvement patterns were seen with pain and sleep. For participation in daily activities, an additional 2.6 school days/month and 2.3 parents' usual activity days/month were gained in period A responders with abatacept, and further gains were made in period B (1.9 versus 0.9 [P = 0.033] and 0.2 versus -1.3 [P = 0.109] school days/month and parents' usual activity days/month, respectively, in abatacept- versus placebo-treated subjects). CONCLUSION Improvements in HRQOL were observed with abatacept, providing real-life tangible benefits to children with JIA and their parents/caregivers.
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Ruperto N, Pistorio A, Ravelli A, Rider LG, Pilkington C, Oliveira S, Wulffraat N, Espada G, Garay S, Cuttica R, Hofer M, Quartier P, Melo-Gomes J, Reed AM, Wierzbowska M, Feldman BM, Harjacek M, Huppertz HI, Nielsen S, Flato B, Lahdenne P, Michels H, Murray KJ, Punaro L, Rennebohm R, Russo R, Balogh Z, Rooney M, Pachman LM, Wallace C, Hashkes P, Lovell DJ, Giannini EH, Gare BA, Martini A. The Paediatric Rheumatology International Trials Organisation provisional criteria for the evaluation of response to therapy in juvenile dermatomyositis. Arthritis Care Res (Hoboken) 2010; 62:1533-41. [PMID: 20583105 DOI: 10.1002/acr.20280] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 06/17/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To develop a provisional definition for the evaluation of response to therapy in juvenile dermatomyositis (DM) based on the Paediatric Rheumatology International Trials Organisation juvenile DM core set of variables. METHODS Thirty-seven experienced pediatric rheumatologists from 27 countries achieved consensus on 128 difficult patient profiles as clinically improved or not improved using a stepwise approach (patient's rating, statistical analysis, definition selection). Using the physicians' consensus ratings as the "gold standard measure," chi-square, sensitivity, specificity, false-positive and-negative rates, area under the receiver operating characteristic curve, and kappa agreement for candidate definitions of improvement were calculated. Definitions with kappa values >0.8 were multiplied by the face validity score to select the top definitions. RESULTS The top definition of improvement was at least 20% improvement from baseline in 3 of 6 core set variables with no more than 1 of the remaining worsening by more than 30%, which cannot be muscle strength. The second-highest scoring definition was at least 20% improvement from baseline in 3 of 6 core set variables with no more than 2 of the remaining worsening by more than 25%, which cannot be muscle strength (definition P1 selected by the International Myositis Assessment and Clinical Studies group). The third is similar to the second with the maximum amount of worsening set to 30%. This indicates convergent validity of the process. CONCLUSION We propose a provisional data-driven definition of improvement that reflects well the consensus rating of experienced clinicians, which incorporates clinically meaningful change in core set variables in a composite end point for the evaluation of global response to therapy in juvenile DM.
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Affiliation(s)
- Nicolino Ruperto
- Paediatric Rheumatology International Trials Organisation, Genoa, Italy.
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Brunner HI, Klein-Gitelman MS, Higgins GC, Lapidus SK, Levy DM, Eberhard A, Singer N, Olson JC, Onel K, Punaro M, Schanberg L, von Scheven E, Ying J, Giannini EH. Toward the development of criteria for global flares in juvenile systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2010; 62:811-20. [PMID: 20535792 PMCID: PMC3049164 DOI: 10.1002/acr.20126] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To develop a definition of global flare in juvenile systemic lupus erythematosus (SLE) and derive candidate criteria for measuring juvenile SLE flares. METHODS Pediatric rheumatologists answered 2 Delphi questionnaires to achieve consensus on a common definition of juvenile SLE flare and identify variables for use in candidate flare criteria. The diagnostic accuracy of these candidate flare criteria was tested with data from juvenile SLE patients (n = 98; 623 visits total). Physician-rated change in the juvenile SLE course (worsening, yes/no) between visits served as the criterion standard. RESULTS There was 96% consensus that a "a flare is a measurable worsening of juvenile SLE disease activity in at least one organ system, involving new or worse signs of disease that may be accompanied by new or worse SLE symptoms. Depending on the severity of the flare, more intensive therapy may be required." Variables suggested for use in flare criteria were: physician-rated disease activity (V1), patient well-being, protein:creatinine ratio, a validated disease activity index (V2), the Child Health Questionnaire physical summary score (V3), anti-double-stranded DNA antibodies, erythrocyte sedimentation rate, and complement levels. Using multiple logistic regression, several candidate flare criteria were derived with area under the receiver operating characteristic curve (AUC) as high as 0.92 (sensitivity >or=85%, specificity >or=85%); classification and regression tree analysis suggested that V1, V2, and V3 suffice to identify juvenile SLE flares (AUC 0.81; sensitivity = 64%, specificity = 86%). CONCLUSION Consensus about a definition of global disease flare for juvenile SLE has been obtained and promising candidate flare criteria have been developed. These will need further assessment of their ease of use and accuracy in prospective study.
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Affiliation(s)
- Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
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Groen W, Ünal E, Nørgaard M, Maillard S, Scott J, Berggren K, Sandstedt E, Stavrakidou M, van der Net J. Comparing different revisions of the Childhood Health Assessment Questionnaire to reduce the ceiling effect and improve score distribution: Data from a multi-center European cohort study of children with JIA. Pediatr Rheumatol Online J 2010; 8:16. [PMID: 20478036 PMCID: PMC2885385 DOI: 10.1186/1546-0096-8-16] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 05/17/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The original version of the Childhood Health Assessment Questionnaire (CHAQ30orig) suffers from a ceiling effect and hence has reduced clinical validity. The purpose of this study was to evaluate the effect of adding eight more demanding items (CHAQ38) and a new categorical response option (CATII) on discriminant validity and score distribution in a European patient sample. METHODS Eighty-nine children with Juvenile Idiopathic arthritis (JIA) and 22 healthy controls, aged 7-16 years, were recruited from eight centres across Europe. Eight new CHAQ items and scoring option were translated back and forth for the countries in which they were not already present. Demographic, clinical, and CHAQ data were collected on-site. Subsequently, five different scoring methods were applied, i.e. the original method (CHAQ30orig) and four alternatives. These alternatives consisted of the mean item scores for the 30 and 38-question versions with either the original (CATI), or the new categorical response option (CATII). The five versions were tested for their ability to distinguish between patients and controls. Furthermore score distributions were evaluated and visualized by box and whisker plots. RESULTS Two CHAQ revisions with the new response option showed poor discriminative ability, whereas one revised version (CHAQ38CATI) had comparable discriminative ability comparable to the original CHAQ. A profound ceiling effect was observed in the original scoring method of the CHAQ (27%). The addition of eight more demanding items and application of a plain mean item score reduced this significantly to 14% (chi2 = 4.21; p < 0.05). CONCLUSIONS Revising the CHAQ by adding eight more demanding items and applying a plain mean item scoring (CHAQ38CATI) maintained discriminant ability and reduced the ceiling effect in a European patient sample. The new categorical response option (CATII) seemed promising, but was less able to distinguish children with JIA from healthy controls and had less favourable distribution characteristics. The CHAQ38CATI is advocated for future use in mildly affected JIA patients.
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Affiliation(s)
- W Groen
- Child Development and Exercise Centre, University Hospital for Children and Youth 'Het Wilhelmina Kinderziekenhuis' University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - E Ünal
- Physical Therapy and Rehabilitation Department, Hacettepe University, Ankara, Turkey
| | - M Nørgaard
- Department of Physiotherapy, Århus University Hospital, Skejby, Århus, Denmark
| | - S Maillard
- Institute of Child Health, Great Ormond Street Childrens Hospital, London, UK
| | - J Scott
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - K Berggren
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - E Sandstedt
- Department of Physiotherapy, The Queen Silvia Children's Hospital, Göteborg, Sweden
| | - M Stavrakidou
- Pediatric Immunology and Rheumatology Referral Center First Dept of Pediatrics, Ippokration General Hospital, Thessaloniki, Greece
| | - J van der Net
- Child Development and Exercise Centre, University Hospital for Children and Youth 'Het Wilhelmina Kinderziekenhuis' University Medical Centre Utrecht, Utrecht, the Netherlands
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Andrade-Ortega L. [Outcome measures]. REUMATOLOGIA CLINICA 2009; 5 Suppl 3:9-12. [PMID: 21794661 DOI: 10.1016/j.reuma.2009.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 07/22/2009] [Accepted: 07/22/2009] [Indexed: 05/31/2023]
Abstract
Inflammatory myositis are rare and heterogeneous diseases. Most clinical and therapeutic studies differ in diagnostic and inclusion criteria as well as in improvement measures. Several collaborative study groups have recently developed and validated outcome measures for both activity and damage of these diseases. The broad use of these core set measures will result in standardized clinical studies, with more reliable results that will allow comparing between individual studies.
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Affiliation(s)
- Lilia Andrade-Ortega
- Servicio de Reumatología, Centro Médico Nacional 20 de Noviembre, ISSSTE, México D. F., México; Universidad Nacional Autónoma de México, México D. F., México.
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Ozen S, Wallace C. Editorial and introduction: new developments in paediatric rheumatic diseases. Best Pract Res Clin Rheumatol 2009; 23:583-7. [DOI: 10.1016/j.berh.2009.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ravelli A, Ruperto N, Trail L, Felici E, Sala E, Martini A. Clinical assessment in juvenile dermatomyositis. Autoimmunity 2009; 39:197-203. [PMID: 16769653 DOI: 10.1080/08916930600622553] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Juvenile dermatomyositis (JDM) is a multisystem inflammatory disease of unknown etiology that affects primarily the skin and muscles. Although the prognosis of JDM has improved considerably in the last three decades, a number of patients may develop irreversible damage due to the disease activity or its treatment. This damage may cause permanent disability and affect the quality of life of patients and their families. In the clinical management of patients with JDM, there is, therefore, the need of monitoring the level of disease activity, the accrual of organ damage, and the impact of the illness on patients' daily living. A reliable assessment of these different aspects of disease requires the availability of well-designed and standardized clinical tools. In the recent years, there has been increasing collaborative effort to devise new assessment measures and these measures have been included into disease activity and damage core sets of outcome variables that have been developed through international consensus. In addition, preliminary definitions of clinical improvement for patients with JDM and other idiopathic inflammatory myopathies have been created. In this review, the latest advances in the development of standardized instruments for the clinical assessment of JDM patients are illustrated and the recent international efforts that have led to the development of core sets of outcome measures and to preliminary definitions of improvement for JDM clinical trials are summarized.
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Affiliation(s)
- Angelo Ravelli
- Istituto di Ricovero e Cura a Carattere Scientifico G. Gaslini, Università di Genova, Dipartimento di Pediatria, Italy.
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van Brussel M, van Doren L, Timmons BW, Obeid J, van der Net J, Helders PJM, Takken T. Anaerobic-to-aerobic power ratio in children with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2009; 61:787-93. [DOI: 10.1002/art.24536] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Geerdink LM, Prince FHM, Looman CWN, van Suijlekom-Smit LWA. Development of a digital Childhood Health Assessment Questionnaire for systematic monitoring of disease activity in daily practice. Rheumatology (Oxford) 2009; 48:958-63. [DOI: 10.1093/rheumatology/kep135] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Apaz MT, Saad-Magalhães C, Pistorio A, Ravelli A, de Oliveira Sato J, Marcantoni MB, Meiorin S, Filocamo G, Pilkington C, Maillard S, Al-Mayouf S, Prahalad S, Fasth A, Joos R, Schikler K, Mozolova D, Landgraf JM, Martini A, Ruperto N. Health-related quality of life of patients with juvenile dermatomyositis: results from the Pediatric Rheumatology International Trials Organisation multinational quality of life cohort study. ACTA ACUST UNITED AC 2009; 61:509-17. [PMID: 19333974 DOI: 10.1002/art.24343] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the health-related quality of life (HRQOL) change over time, as measured by the Child Health Questionnaire (CHQ), and its determinants in patients with active juvenile dermatomyositis (DM). METHODS We assessed patients with juvenile DM at both baseline and 6 months of followup, and healthy children age < or =18 years. Potential determinants of poor HRQOL included demographic data, physician's and parent's global assessments, muscle strength, functional ability as measured by the Childhood Health Assessment Questionnaire (C-HAQ), global disease activity assessments, and laboratory markers. RESULTS A total of 272 children with juvenile DM and 2,288 healthy children were enrolled from 37 countries. The mean +/- SD CHQ physical and psychosocial summary scores were significantly lower in children with juvenile DM (33.7 +/- 11.7 versus 54.6 +/- 4.1) than in healthy children (45.1 +/- 9.0 versus 52 +/- 7.2), with physical well-being domains being the most impaired. HRQOL improved over time in responders to treatment and remained unchanged or worsened in nonresponders. Both physical and psychosocial summary scores decreased with increasing levels of disease activity, muscle strength, and parent's evaluation of the child's overall well-being. A C-HAQ score >1.6 (odds ratio [OR] 5.06, 95% confidence interval [95% CI] 2.03-12.59), child's overall well-being score >6.2 (OR 5.24, 95% CI 2.27-12.10), and to a lesser extent muscle strength and alanine aminotransferase level were the strongest determinants of poor physical well-being at baseline. Baseline disability and longer disease duration were the major determinants for poor physical well-being at followup. CONCLUSION We found that patients with juvenile DM have a significant impairment in their HRQOL compared with healthy peers, particularly in the physical domain. Physical well-being was mostly affected by the level of functional impairment.
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Affiliation(s)
- Maria Teresa Apaz
- Paediatric Rheumatology International Trials Organisation, Genoa, Italy
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Lelieveld OTHM, Armbrust W, van Leeuwen MA, Duppen N, Geertzen JHB, Sauer PJJ, van Weert E. Physical activity in adolescents with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2008; 59:1379-84. [DOI: 10.1002/art.24102] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ruperto N, Lovell DJ, Quartier P, Paz E, Rubio-Pérez N, Silva CA, Abud-Mendoza C, Burgos-Vargas R, Gerloni V, Melo-Gomes JA, Saad-Magalhães C, Sztajnbok F, Goldenstein-Schainberg C, Scheinberg M, Penades IC, Fischbach M, Orozco J, Hashkes PJ, Hom C, Jung L, Lepore L, Oliveira S, Wallace CA, Sigal LH, Block AJ, Covucci A, Martini A, Giannini EH. Abatacept in children with juvenile idiopathic arthritis: a randomised, double-blind, placebo-controlled withdrawal trial. Lancet 2008; 372:383-91. [PMID: 18632147 DOI: 10.1016/s0140-6736(08)60998-8] [Citation(s) in RCA: 334] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Some children with juvenile idiopathic arthritis either do not respond, or are intolerant to, treatment with disease-modifying antirheumatic drugs, including anti-tumour necrosis factor (TNF) drugs. We aimed to assess the safety and efficacy of abatacept, a selective T-cell costimulation modulator, in children with juvenile idiopathic arthritis who had failed previous treatments. METHODS We did a double-blind, randomised controlled withdrawal trial between February, 2004, and June, 2006. We enrolled 190 patients aged 6-17 years, from 45 centres, who had a history of active juvenile idiopathic arthritis; at least five active joints; and an inadequate response to, or intolerance to, at least one disease-modifying antirheumatic drug. All 190 patients were given 10 mg/kg of abatacept intravenously in the open-label period of 4 months. Of the 170 patients who completed this lead-in course, 47 did not respond to the treatment according to predefined American College of Rheumatology (ACR) paediatric criteria and were excluded. Of the patients who did respond to abatacept, 60 were randomly assigned to receive 10 mg/kg of abatacept at 28-day intervals for 6 months, or until a flare of the arthritis, and 62 were randomly assigned to receive placebo at the same dose and timing. The primary endpoint was time to flare of arthritis. Flare was defined as worsening of 30% or more in at least three of six core variables, with at least 30% improvement in no more than one variable. We analysed all patients who were treated as per protocol. This trial is registered, number NCT00095173. FINDINGS Flares of arthritis occurred in 33 of 62 (53%) patients who were given placebo and 12 of 60 (20%) abatacept patients during the double-blind treatment (p=0.0003). Median time to flare of arthritis was 6 months for patients given placebo (insufficient events to calculate IQR); insufficient events had occurred in the abatacept group for median time to flare to be assessed (p=0.0002). The risk of flare in patients who continued abatacept was less than a third of that for controls during that double-blind period (hazard ratio 0.31, 95% CI 0.16-0.95). During the double-blind period, the frequency of adverse events did not differ in the two treatment groups. Adverse events were recorded in 37 abatacept recipients (62%) and 34 (55%) placebo recipients (p=0.47); only two serious adverse events were reported, both in controls (p=0.50). INTERPRETATION Selective modulation of T-cell costimulation with abatacept is a rational alternative treatment for children with juvenile idiopathic arthritis. FUNDING Bristol-Myers Squibb.
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Ruperto N, Martini A. Network in pediatric rheumatology: the example of the Pediatric Rheumatology International Trials Organization. World J Pediatr 2008; 4:186-91. [PMID: 18822926 DOI: 10.1007/s12519-008-0034-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pediatric rheumatic diseases (PRDs) are rare conditions associated with significant sequelae affecting the quality of life and long-term outcome. The research aimed at studying new therapeutic approaches is difficult because of logistic, methodological and ethical problems. DATA SOURCES To address these problems, two international networks, the Pediatric Rheumatology Collaborative Study Group (PRCSG) and the Pediatric Rheumatology International Trials Organization (PRINTO) were established. The two networks share the goal to promote, facilitate and conduct high quality research for PRDs. RESULTS The PRINTO and PRCSG networks have standardized the evaluation of response to therapy in juvenile idiopathic arthritis (JIA), juvenile systemic lupus erythematosus, and juvenile dermatomyositis, drafted clinical remission criteria in JIA, and provided cross-cultural adapted and validated quality of life instruments including the Childhood Health Assessment Questionnaire and the Child Health Questionnaire into 32 different languages. In this paper we reviewed how the networks of the PRINTO and PRCSG have created the basic premises for the best future assessment of PRDs. CONCLUSIONS The PRINTO and PRCSG networks can be regarded as a model for international cooperation or collaboration in other pediatric subspecialties.
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Affiliation(s)
- Nicolino Ruperto
- IRCCS Istituto G. Gaslini, Pediatria II, Reumatologia, Genoa, Italy.
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Ruperto N, Meiorin S, Iusan SM, Ravelli A, Pistorio A, Martini A. Consensus procedures and their role in pediatric rheumatology. Curr Rheumatol Rep 2008; 10:142-6. [PMID: 18460270 DOI: 10.1007/s11926-008-0025-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Delphi Technique and Nominal Group Technique are two well-recognized consensus-formation methodologies specifically designed to combine judgments from a group of experts. The Delphi Technique utilizes a series of well-defined questionnaire-based surveys, whereas Nominal Group Technique is a structured face-to-face meeting designed to facilitate consensus. Consensus-formation techniques require that each step build on the results of the previous steps. In this review, we describe these techniques, how they work, and their practical application in pediatric rheumatology, where they have been widely used to develop the outcome measures of several chronic rheumatic diseases, including juvenile idiopathic arthritis, rheumatoid arthritis, systemic lupus erythematosus, and idiopathic inflammatory myopathies, as well as the classification criteria for juvenile systemic sclerosis and juvenile vasculitides.
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Affiliation(s)
- Nicolino Ruperto
- IRCCS G. Gaslini, Pediatria II-PRINTO, University of Genoa, Largo Gaslini, 5, 16147 Genova, Italy.
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Ruperto N, Martini A, Lovell DJ, Giannini EH. Performing trials in children with rheumatic diseases: Comment on the editorial by Lehman. ACTA ACUST UNITED AC 2008; 58:1201-2; author reply 1203. [DOI: 10.1002/art.23413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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