Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Pediatric Antibiotic-refractory Lyme Arthritis: A Multicenter Case-control Study

OBJECTIVE

Few factors have consistently been linked to antibiotic-refractory Lyme arthritis (ARLA). We sought to identify clinical and treatment factors associated with pediatric ARLA.

METHODS

We performed a case-control study in 3 pediatric rheumatology clinics in a Lyme-endemic region (2000-2013). Eligible children were aged ≤ 18 years with arthritis and had positive testing for Lyme disease by Western blot. Cases were 49 children with persistently active arthritis despite ≥ 8 weeks of oral antibiotics or ≥ 2 weeks of parenteral antibiotics; controls were 188 children whose arthritis resolved within 3 months of starting antibiotics. We compared preselected demographic, clinical, and treatment factors between groups using logistic regression.

RESULTS

Characteristics positively associated with ARLA were age ≥ 10 years, prolonged arthritis at diagnosis, knee-only arthritis, and worsening after starting antibiotics. In contrast, children with fever, severe pain, or other signs of systemic inflammation were more likely to respond quickly to treatment. Secondarily, low-dose amoxicillin and treatment nonadherence were also linked to higher risk of ARLA. Greater antibiotic use for children with ARLA was accompanied by higher rates of treatment-associated adverse events (37% vs 15%) and resultant hospitalization (6% vs 1%).

CONCLUSION

Older children and those with prolonged arthritis, arthritis limited to the knees, or poor initial response to antibiotics are more likely to have antibiotic-refractory disease and treatment-associated toxicity. Children with severe symptoms of systemic inflammation have more favorable outcomes. For children with persistently active Lyme arthritis after 2 antibiotic courses, pediatricians should consider starting antiinflammatory treatment and referring to a pediatric rheumatologist.

Mast cells and exosomes in hyperoxia-induced neonatal lung disease

Chronic lung disease of prematurity (CLD) is a frequent sequela of premature birth and oxygen toxicity is a major associated risk factor. Impaired alveolarization, scarring, and inflammation are hallmarks of CLD. Mast cell hyperplasia is a feature of CLD but the role of mast cells in its pathogenesis is unknown. We hypothesized that mast cell hyperplasia is a consequence of neonatal hyperoxia and contributes to CLD. Additionally, mast cell products may have diagnostic and prognostic value in preterm infants predisposed to CLD. To model CLD, neonatal wild-type and mast cell-deficient mice were placed in an O2 chamber delivering hyperoxic gas mixture [inspired O2 fraction (FiO2) of 0.8] (HO) for 2 wk and then returned to room air (RA) for an additional 3 wk. Age-matched controls were kept in RA (FiO2 of 0.21). Lungs from HO mice had increased numbers of mast cells, alveolar simplification and enlargement, and increased lung compliance. Mast cell deficiency proved protective by preserving air space integrity and lung compliance. The mast cell mediators β-hexosaminidase (β-hex), histamine, and elastase increased in the bronchoalveolar lavage fluid of HO wild-type mice. Tracheal aspirate fluids (TAs) from oxygenated and mechanically ventilated preterm infants were analyzed for mast cell products. In TAs from infants with confirmed cases of CLD, β-hex was elevated over time and correlated with FiO2. Mast cell exosomes were also present in the TAs. Collectively, these data show that mast cells play a significant role in hyperoxia-induced lung injury and their products could serve as potential biomarkers in evolving CLD.

An assessment of variables affecting transition readiness in pediatric rheumatology patients

BACKGROUND

We sought to identify which adolescent patient characteristics might lead to subjective reported independence in accessing medical care when patients transition from pediatric to adult medicine.

METHODS

Pediatric and adult rheumatologists were asked which pediatric patient characteristics they believed would improve transition to adult medical care. Based on these responses, a questionnaire was created and administered to 76 teenage/young adult patients in a pediatric rheumatology clinic. The first set of questions included demographic, disease features, and life skills questions. The second set of questions pertained to self-reported independence in managing medical care. Data was analyzed to see if there were any significant associations between an individual's response to demographic, disease feature, or life skills questions and the independence outcome questions.

RESULTS

In our study, older age correlated with self-reported independence in almost all questions asked regarding accessing medical care. Other patient characteristics that were associated with increased self-perceived autonomy included having a younger parent, having a family member with a similar disease, longer disease duration, having a comorbid non-rheumatic diagnosis, and having had a summer job.

CONCLUSIONS

The patient characteristics that we found associated with self-reported independence in obtaining medical care should be considered when determining which patients might be more likely to make a successful transition.

Papular xanthomas and erosive arthritis in a 3 year old girl, is this a new MRH variant?

Xanthomatous skin lesions and arthritis in children are not a common association. We present the case of a 3 year old girl who presented with xanthomatous lesions in the periungual region of both hands, around the nares and on her forehead, associated with significant arthritis that was clinically compatible with multicentric reticulohistiocytosis. However, pathology of the xanthomatous lesions was more suggestive of papular xanthoma, a disease that is not associated with arthritis. Based on her presentation and the negative lipid workup, she was treated for presumed multicentric reticulohistiocytosis. Multiple treatment strategies were utilized, with improvement on a combination of infliximab, methotrexate, and prednisone. We review the different diagnoses that should be considered in children with xanthomas and arthritis as well as the different pharmacologic therapies used in children with multicentric reticulohistiocytosis.

Epstein Barr virus induced lymphoma in a child with IPEX syndrome

IPEX syndrome (immune deficiency, polyendocrinopathy, enteropathy, X-linked) is a disorder or regulatory T cell (Treg) function which can result in early death due to infection or complications related to autoimmunity. Therapeutic options for these patients can include allogeneic stem cell transplantation (SCT) or the use of immunosuppressive regimens to control the manifestations of autoimmunity. We report a patient with IPEX syndrome who was managed with rapamycin and subsequently developed EBV induced lymphoma.

Evaluation of the presentation of systemic onset juvenile rheumatoid arthritis: data from the Pennsylvania Systemic Onset Juvenile Arthritis Registry (PASOJAR)

OBJECTIVE

To characterize the initial clinical and laboratory features of patients with systemic onset juvenile rheumatoid arthritis (soJRA) through a Web-based registry.

METHODS

Patients diagnosed with soJRA in the last 15 years at 3 medical centers in Pennsylvania were identified. Data were collected retrospectively using a Web-based interface in compliance with patient privacy standards. Inferential statistics were used to compare features of patients with and without macrophage activation syndrome.

RESULTS

We identified 136 patients; 88% of patients presented with arthritis (8% mono-, 45% oligo-, 47% polyarticular). The most common joints involved were the knee (68% of patients with arthritis), wrist (68%), and ankle (57%). The International League of Associations for Rheumatology criteria for systemic juvenile idiopathic arthritis (SJIA) identified only 30% of patients at presentation.

CONCLUSION

We successfully characterized the presenting features of a relatively rare disease, soJRA, through the use of a Web-based registry. Current classification criteria for SJIA may not be particularly sensitive for diagnosis at presentation.

Lyme disease presenting as popliteal cyst in children

Lyme disease is the most common tick-borne disease in North America. Our review of the literature found few reports of Lyme disease presented in the orthopaedic literature. However, Lyme disease presenting as a popliteal cyst, with or without rupture, is rarely reported. We present 4 cases of Lyme disease that initially presented to our pediatric orthopaedic clinic for treatment of a popliteal cyst. The early diagnosis and treatment of Lyme disease may help prevent the often-devastating long-term sequelae of Lyme disease. The goal of this article is to increase the awareness of Lyme disease presenting in children as a popliteal cyst.

Crystal structures and freezing of dipolar fluids

We investigate the crystal structure of classical systems of spherical particles with an embedded point dipole at T=0. The ferroelectric ground state energy is calculated using generalizations of the Ewald summation technique. Due to the reduced symmetry compared to the nonpolar case the crystals are never strictly cubic. For the Stockmayer (i.e., Lennard-Jones plus dipolar) interaction three phases are found upon increasing the dipole moment: hexagonal, body-centered orthorhombic, and body-centered tetragonal. An even richer phase diagram arises for dipolar soft spheres with a purely repulsive inverse power law potential approximately r(-n). A crossover between qualitatively different sequences of phases occurs near the exponent n=12. The results are applicable to electro- and magnetorheological fluids. In addition to the exact ground state analysis we study freezing of the Stockmayer fluid by density-functional theory.

Density-functional theory for vacancies in hard-sphere crystals

The equilibrium vacancy concentration in solids can be computed from density-functional theory (DFT) if allowance is made for density profiles with less than one particle per lattice site. For the fundamental-measure theory (FMT), this approach predicts reasonably small vacancy concentrations in hard sphere crystals, in contrast to earlier DFTs. Using an asymptotic analysis of the FMT functional, it is shown that the number of vacancies depends exponentially on the distance to the close packing density, as expected from heuristic arguments. The prefactor of the exponential is calculated for three recently suggested variants of the theory, using density profiles obtained from a quasifree minimization. Extrapolation of the asymptotic behavior to the melting density yields good agreement with other estimates and computer simulation results.

Hard-sphere solids near close packing: testing theories for crystallization

The freezing transition of hard spheres has been well described by various versions of density-functional theory (DFT). These theories should possess the close-packed crystal as a special limit, which represents an extreme testing ground for the quality of such liquid-state based theories. We therefore study the predictions of DFT for the structure and thermodynamics of the hard-sphere crystal in this limit. We examine the Ramakrishnan-Yussouff (RY) approximation and two variants of the fundamental-measure theory (FMT) developed by Rosenfeld and co-workers. We allow for general shapes of the density peaks, going beyond the common Gaussian approximation. In all cases we find that upon approaching close packing, the peak width vanishes proportionally to the free distance a between the particles and the free energy depends logarithmically on a. However, different peak shapes and next-to-leading contributions to the free energy result from the different approximate functionals. For the RY theory, within the Gaussian approximation, we establish that the crystalline solutions form a closed loop with a stable and an unstable branch both connected to the close-packing point at a=0, consistent with the absence of a liquid-solid spinodal. That version of FMT that has previously been applied to freezing, predicts asymptotically steplike density profiles confined to the cells of self-consistent cell theory. But a recently suggested improved version which employs tensor weighted densities yields wider and almost Gaussian peaks that are shown to be in very good agreement with computer simulations.

Why all crystals need not be bcc: symmetry breaking at the liquid-solid transition revisited

Alexander and McTague [Phys.Rev. Lett. 41, 702 (1978)] argued that if there is a spinodal point associated with the liquid-solid transition in a fluid of spherically symmetric particles, the bcc phase will be uniquely favored as the only accessible symmetry breaking structure that forms a regular three-dimensional lattice. By reconsidering their analysis in the framework of density-functional theory, we show that at a liquid-solid spinodal in fact many other solid stuctures also are simultaneously accessible, among them the fcc structure. Nevertheless, the bcc structure is still shown to be special, as, independent of the details of the interaction, the free energy of the unstable bcc phase close to the spinodal is always lower than that of the other solidlike structures. We illustrate our general results by explicit calculations on a toy model, the "Onsager solid." This simple model also indicates that the ultimately stable crystal phase, which, as usual for sufficiently steep repulsive forces, turns out to be fcc, is dictated by properties of the free energy that cannot be obtained perturbatively starting from the spinodal point.

Vesicles in solutions of hard rods

The surface free energy of ideal hard rods near curved hard surfaces is determined to second order in curvature for surfaces of general shapes. In accordance with previous results for spherical and cylindrical surfaces it is found that this quantity is nonanalytical when one of the principal curvatures changes signs. This prohibits writing it in the common Helfrich form. It is shown that the nonanalytical terms are the same for any aspect ratio of the rods. These results are used to find the equilibrium shape of vesicles immersed in solutions of rodlike (colloidal) particles. The presence of the particles induces a change in the equilibrium shape and a shift of the prolate-oblate transition in the vesicle phase diagram, which are calculated within the framework of the spontaneous curvature model. As a consequence of the special form of the energy contribution due to the rods, these changes cannot be accounted for by a simple rescaling of the elastic constants of the vesicle as for solutions of spherical colloids or polymers.