Proposed Response Parameters for Twelve-Month Drug Trial in Juvenile Systemic Sclerosis: Results of the Hamburg International Consensus Meetings

OBJECTIVE

Juvenile systemic sclerosis (SSc) is an orphan disease, associated with high morbidity and mortality. New treatment strategies are much needed, but clearly defining appropriate outcomes is necessary if successful therapies are to be developed. Our objective here was to propose such outcomes.

METHODS

This proposal is the result of 4 face-to-face consensus meetings with a 27-member multidisciplinary team of pediatric rheumatologists, adult rheumatologists, dermatologists, pediatric cardiologists, pulmonologists, gastroenterologists, a statistician, and patients. Throughout the process, we reviewed the existing adult data in this field, the more limited pediatric literature for juvenile SSc outcomes, and data from 2 juvenile SSc patient cohorts to assist in making informed, data-driven decisions. The use of items for each domain as an outcome measure in an open label 12-month clinical trial of juvenile SSc was voted and agreed upon using a nominal group technique.

RESULTS

After voting, the domains agreed on were global disease activity, skin, Raynaud's phenomenon, digital ulcers, musculoskeletal, cardiac, pulmonary, renal, and gastrointestinal involvement, and quality of life. Fourteen outcome measures had 100% agreement, 1 item had 91% agreement, and 1 item had 86% agreement. The domains of biomarkers and growth/development were moved to the research agenda.

CONCLUSION

We reached consensus on multiple domains and items that should be assessed in an open label, 12-month clinical juvenile SSc trial as well as a research agenda for future development.

Mesenchymal Stem Cells in the Pathogenesis and Therapy of Autoimmune and Autoinflammatory Diseases

Mesenchymal stem cells (MSCs) modulate immune responses and maintain self-tolerance. Their trophic activities and regenerative properties make them potential immunosuppressants for treating autoimmune and autoinflammatory diseases. MSCs are drawn to sites of injury and inflammation where they can both reduce inflammation and contribute to tissue regeneration. An increased understanding of the role of MSCs in the development and progression of autoimmune disorders has revealed that MSCs are passive targets in the inflammatory process, becoming impaired by it and exhibiting loss of immunomodulatory activity. MSCs have been considered as potential novel cell therapies for severe autoimmune and autoinflammatory diseases, which at present have only disease modifying rather than curative treatment options. MSCs are emerging as potential therapies for severe autoimmune and autoinflammatory diseases. Clinical application of MSCs in rare cases of severe disease in which other existing treatment modalities have failed, have demonstrated potential use in treating multiple diseases, including rheumatoid arthritis, systemic lupus erythematosus, myocardial infarction, liver cirrhosis, spinal cord injury, multiple sclerosis, and COVID-19 pneumonia. This review explores the biological mechanisms behind the role of MSCs in autoimmune and autoinflammatory diseases. It also covers their immunomodulatory capabilities, potential therapeutic applications, and the challenges and risks associated with MSC therapy.

Reimagining global mental health in Africa

In 2001, the WHO launched The World Health Report most specifically addressing low-income and middle-income countries (LAMICs). It highlighted the importance of mental health (MH), identifying the severe public health impacts of mental ill health and made 10 recommendations. In 2022, the WHO launched another world MH report and reaffirmed the 10 recommendations, while concluding that 'business as usual for MH will simply not do' without higher infusions of money. This paper suggests the reason for so little change over the last 20 years is due to the importation and imposition of Western MH models and frameworks of training, service development and research on the assumption they are relevant and acceptable to Africans in LAMICs. This ignores the fact that most mental and physical primary care occurs within local non-Western traditions of healthcare that are dismissed and assumed irrelevant by Western frameworks. These trusted local institutions of healthcare that operate in homes and spiritual spaces are in tune with the lives and culture of local people. We propose that Western foundations of MH knowledge are not universal nor are their assumptions of society globally applicable. Real change in the MH of LAMICs requires reimagining. Local idioms of distress and healing, and explanatory models of suffering within particular populations, are needed to guide the development of training curricula, research and services. An integration of Western frameworks into these more successful approaches are more likely to contribute to the betterment of MH for peoples in LAMICs.

Management of systemic sclerosis: British Society for Rheumatology guideline scope

This guideline will provide a practical roadmap for management of SSc that builds upon the previous treatment guideline to incorporate advances in evidence-based treatment and increased knowledge about assessment, classification and management. General approaches to management as well as treatment of specific complications will be covered, including lung, cardiac, renal and gastrointestinal tract disease, as well as RP, digital vasculopathy, skin manifestations, calcinosis and impact on quality of life. It will include guidance related to emerging approved therapies for interstitial lung disease and account for National Health Service England prescribing policies and national guidance relevant to SSc. The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol. This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence accreditation.

Training community-based psychotherapists to maintain a therapeutic alliance: A psychotherapy practice research network study

The goal of this study was to test the efficacy of training community-based psychotherapists who were part of a practice research network to be more attuned to their patients' experiences of the therapeutic relationship. We were particularly interested in the effect of therapist training on the congruence of alliance ratings with their patients. Forty psychotherapists who treated 117 patients were randomly assigned to receive either no training or training, whose learning objectives were to help therapists to develop and maintain a therapeutic alliance. The training included workshops and ongoing consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. We used the truth and bias model and response surface analysis within a multilevel modeling context to test hypotheses. There was a significantly faster rate of alliance growth in the training versus the no training condition when the alliance was rated by therapists, but not when rated by patients. Trained therapists experienced greater temporal congruence in alliance ratings with their patients compared to untrained therapists. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association not significant among untrained therapists. Training therapists in key interpersonally focused skills may lead them to be better attuned to their patients' experiences of the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

POS1304 CORRELATION OF SKIN SCORES (LoSCAT) WITH PATIENT REPORTED OUTCOMES IN JUVENILE LOCALISED SCLERODERMA

Background

Juvenile localised scleroderma (JLS) or morphea is a rare condition, causing inflammation and fibrosis in skin and underlying tissues. A validated skin score (Localized Scleroderma Cutaneous Assessment Tool, LoSCAT) has been developed [1]. This tool has both activity (mLoSSi) and damage indices (LoSDI). Several patient-reported outcomes (PRO) have been studied in JLS including visual analogue scales (VAS), functional and health-related quality of life measures.

Objectives

To assess the associations between different PROs and the activity and damage indices of the LoSCAT.

Methods

Participants aged 4 to 17 were recruited from 3 tertiary paediatric rheumatology centres in the UK and attended 4 visits at 3 monthly intervals as part of a program of research on JLS. Patient-reported VAS (6 different scales), the Children’s Dermatology Life Quality Index (CDLQI) and Childhood Health Assessment Questionnaires (CHAQ) were completed at each visit. LoSCAT was completed by the two same clinicians throughout the study (both trained in skin score techniques). Pearson correlation coefficients were calculated between each PRO and each component of the LoSCAT.

Results

24 participants completed all 4 visits and 1 attended 3 visits. 20 participants were female (80%) and 5 were male (20%). Mean age at diagnosis was 7.6 years with mean disease duration of 4.9 years. Subtype of disease was linear head in 5/25 (20%), linear limb 12/25 (48%), generalised morphoea 1/25 (4%), mixed 5/25 (20%) and superficial plaque in 2/25 (8%). Table 1 shows the correlations with figures in bold highlighting positive correlations which were statistically significant (p<0.05) and medium-sized (r>0.3).

Table 1.

Correlation between patient reported outcomes and LoSCAT

PROTotal skin activity (mLoSSi)Total skin damage (LoSDI)r (95% CI)p-valuer (95% CI)p-valueCDLQI0.61 (0.02, 1.20)0.0440.42 (0.01, 0.83)0.044CHAQ0.30 (0.03, 0.57)0.0270.20 (-0.14, 0.54)0.244VAS 1: How much IMPACT has your disease had on your life in the PAST MONTH?0.49 (0.00, 0.98)0.0500.38 (0.06, 0.71)0.021VAS 2: How much has your condition (localized scleroderma) affected you OVERALL in the PAST MONTH?0.59 (0.09, 1.09)0.0220.42 (0.13, 0.72)0.005VAS 3: Have your lesions felt itchy and/or scratchy in PAST MONTH?0.40 (-0.01, 0.81)0.0560.31 (0.03, 0.59)0.028VAS 4: Have you felt numbness, tingling, and/or other “funny” feeling in or around your lesion in PAST MONTH?0.55 (0.04, 1.05)0.0330.33 (-0.04, 0.71)0.084VAS 5: How much WORRY do you have about LONG- -TERM problems from your disease?0.40 (-0.01, 0.81)0.0530.32 (0.00, 0.63)0.047VAS 6: How much WORRY do you have about problems from MEDICATIONS used to treat your condition?0.41 (0.00, 0.82)0.0500.29 (-0.09, 0.66)0.131

The VAS of symptoms of numbness/tingling showed a strong positive correlation with mLoSSi but a weak and/or non-significant correlation with LoSDI. VAS itchy/scratchy did not show a strong correlation with mLoSSi but showed a moderate correlation with LoSDI. Patient global VAS correlated with both mLoSSi and LoSDI, as did CDLQI. CHAQ correlated with activity only.

Conclusion

Symptoms within lesions are often interpreted as indicating disease activity. A previous study in adults and children showed itch positively correlated with mLoSSi suggesting it may be a marker of active disease [2]. However, in our study numbness/tingling correlated with disease activity whereas itch did not. Further work is required to understand whether itch correlates to both activity and damage and whether numbness/tingling is a better indicator of activity than itch. Limitations of our study include a heterogenous group of participants with longstanding high-burden disease.

References

[1]Arkachaisri et al. Rheumatology 2010. 49(2): 373-81.

[2]Klimas et al. Br J Derm 2015; 175:1329-1337

Acknowledgements

This study was funded by Scleroderma & Raynaud’s UK.

Disclosure of Interests

None declared

POS0168 NON-INVASIVE IMAGING IN JUVENILE LOCALISED SCLERODERMA: HIGH-FREQUENCY ULTRASOUND, THERMOGRAPHY, LASER DOPPLER & MULTISPECTRAL IMAGING

Background

Outcome measures which can differentiate activity (inflammation) from damage (fibrosis/atrophy) would facilitate development of new treatment strategies in juvenile localized scleroderma (JLS) to target the inflammatory phase of the disease.

Objectives

To evaluate whether in JLS, non-invasive imaging modalities (high frequency ultrasounds (HFUS), multispectral imaging (MSI), laser doppler imaging (LDI) & infra-red thermography (IRT)) can detect differences between affected & non-affected skin, as a next step in developing these as outcome measures. Our hypothesis was that blood flow (and therefore temperature & oxygenation) would be increased in lesional skin.

Methods

Participants aged 4-17 were recruited from 3 paediatric rheumatology centres in the UK. For each participant, a single lesion was selected. HFUS (30MHz), MSI (bespoke camera and tuneable liquid crystal filter, coupled to custom analysis software, 500nm/710nm wavelengths), LDI and IRT imaging were performed at four sites relating to each lesion: two of affected skin (centre & inner edge of lesion) and two of non-affected skin (one cm from edge of lesion (‘outer’) & contralateral unaffected side). Imaging was performed at 4 visits at 3 monthly intervals. Mean values were compared between the four sites using data from all visits by mixed-effects linear regression to account for individual-level clustering.

Results

24 participants completed all 4 visits and 1 attended 3. 20 participants were female (80%) & 5 male (20%). Mean age at diagnosis was 7.6 years & disease duration 4.9 years. Subtype of disease was linear head in 5/25 (20%), linear limb 12/25 (48%), generalised morphea 1/25 (4%), mixed 5/25 (20%) and superficial plaque in 2/25 (8%).

Table 1 shows a subset of data. All 4 imaging techniques could detect differences between healthy (outer/contralateral) & affected skin (centre/inner edge). For HFUS, there was strong evidence of a difference between affected & unaffected skin (p<0.001) indicating affected skin is thinner than unaffected. Higher mean values of oxygenation, perfusion & temperature were observed in affected compared to non-affected skin in MSI, LDI and IRT respectively. There was no statistical difference seen between inner edge and centre of the lesion in any of the methods.

Table 1.

Mean differences between different locations for each imaging technique

Imaging techniqueLocationOverall mean difference (95% CI)p-valueHFUS (mm)Centre - Contralateral-0.34 (-0.46, -0.22)<0.001Inner edge - Contralateral-0.30 (-0.40, -0.20)<0.001Centre - Outer-0.35 (-0.46, -0.24)<0.001Inner edge - Outer-0.31 (-0.40, -0.21)<0.001Centre - Inner edge-0.04 (-0.10, 0.02)0.168MSI (rel units)Centre - Contralateral0.06 (0.03, 0.10)<0.001Inner edge - Contralateral0.06 (0.03, 0.09)<0.001Centre - Outer0.04 (0.01, 0.07)0.012Inner edge - Outer0.03 (0.00, 0.06)0.028Centre - Inner edge0.01 (0.00, 0.02)0.251LDI Relative perfusion unitsCentre - Contralateral44.8 (24.4, 65.2)<0.001Inner edge - Contralateral47.9 (21.0, 74.8)<0.001Centre - Outer19.1 (1.0, 37.1)0.039Inner edge - Outer24.8 (6.7, 42.9)0.007Centre - Inner edge-3.5 (-20.3, 13.2)0.679IRT oCCentre - Contralateral0.58 (0.24, 0.91)0.001Inner edge - Contralateral0.44 (0.13, 0.75)0.005Centre - Outer0.44 (0.22, 0.66)<0.001Inner edge - Outer0.30 (0.09, 0.52)0.006Centre - Inner edge0.14 (-0.05, 0.32)0.153

The overall mean difference is the measurement of the first location minus the measurement from the second location (e.g. centre minus contralateral), averaged across the four visits.

Conclusion

Our results suggest non-invasive imaging can detect differences between healthy & unaffected skin in JLS. Whether each technique is only measuring activity & not damage requires further evaluation. The leading edge of lesions has historically been considered as most active compared to the centre. However, no difference was seen between centre & inner edge measurements suggesting that in future studies, imaging protocols can be simplified.

Acknowledgements

This study was funded by Scleroderma & Raynaud’s UK.

Disclosure of Interests

None declared

POS0172 DIFFUSE JUVENILE SYSTEMIC SCLEROSIS PATIENTS SHOW DISTINCT ORGAN INVOLVEMENT AND HAVE MORE SEVERE DISEASE IN THE LARGEST jSSc COHORT OF THE WORLD. RESULTS FROM THE THE JUVENILE SCLERODERMA INCEPTION COHORT. www.juvenile-scleroderma.com

Background

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1 000 000 children (1). In adult patients there are significant differences between the clinical presentation of diffuse and limited subtypes (2). We reviewed clinical differences in presentation of subtypes in patients in the juvenile systemic scleroderma inception cohort up to 2021.

Objectives

To study the clinical presentation of jSSc patients with diffuse (djSSc) and limited (ljSSc) subtypes.

Methods

We reviewed the clinical baseline characteristics of the patients, who were recruited to the juvenile scleroderma inception cohort (jSScC) (3, 4) till 1st of December 2021. jSScC is a prospective cohort of jSSc patients, who developed the first non-Raynaud´s symptom before the age of 16 years and are under the age of 18 years at the time of inclusion.

Results

210 patients with jSSc were included in the cohort, 71% (n=162) had diffuse subtype. The median age at onset of Raynaud phenomenon was 10.4 years (7.3 – 12.9) and the median age at the first non-Raynaud symptom was 10.9 years (7.4 – 13.2). Median disease duration was 2.5 years (1 – 4.4) at the time of inclusion. The female/male ratio was significantly lower in the djSSc subtype (3.7:1 versus 5:1, p<0.001). Antibody profile was quite similar, with the exception of a significantly higher number of anticentromere positive patients in the ljSSc (12% versus 2%, p=0.013). Decreased FVC < 80% was found in approximately 30% and decreased DLCO < 80% was found in around 40% in both subtypes. Pulmonary hypertension assessed by ultrasound was identified in 5% in both groups. Patients with diffuse subtype had significantly higher modified Rodnan Skin Score (mRSS) (16 versus 4.5, p<0.001), sclerodactyly (84% versus 60%, p<0.001), history of digital ulceration (62% versus 31%, p<0.001), decreased Body Mass Index (BMI) < -2 z score (20% versus 4%, p=0.003) and decreased joint range of motion (64% versus 46%, p=0.019). Patients with ljSSc had significantly higher rate of cardiac involvement (13% versus 2%, p=0.001).

Regarding patient related outcomes djSSc patients had more severe disease, looking at patient reported global disease activity (VAS 0 – 100) (40 versus 25, p=0.039), patient reported global disease damage (VAS 0 – 100) (40 versus 25, p=0.021) and patient reported assessment of ulceration activity (10 versus 0, p=0.044). Regarding physician related outcomes the physician reported global disease activity (VAS 0 – 100) (32 versus 20, p<0.001) and physician reported global disease damage (VAS 0 – 100) (30 versus 15, p=0.014) was significantly higher in djSSc.

Conclusion

In this jSSc cohort, the largest in the world, djSSc patients have a significantly more severe disease than ljSSc patients. Interestingly, we found no differences regarding interstitial lung disease and pulmonary hypertension.

References

[1]Beukelman T, Xie F, Foeldvari I. Assessing the prevalence of juvenile systemic sclerosis in childhood using administrative claims data from the United States. Journal of Scleroderma and Related Disorders. 2018;3(2):189-90.

[2]Dougherty DH, Kwakkenbos L, Carrier ME, Salazar G, Assassi S, Baron M, et al. The Scleroderma Patient-Centered Intervention Network Cohort: baseline clinical features and comparison with other large scleroderma cohorts. Rheumatology (Oxford). 2018;57(9):1623-31.

[3]Foeldvari I, Klotsche J, Kasapcopur O, Adrovic A, Terreri MT, Sakamoto AP, et al. Differences sustained between diffuse and limited forms of juvenile systemic sclerosis in expanded international cohort. www.juvenile-scleroderma.com. Arthritis Care Res (Hoboken). 2021.

[4]Foeldvari I, Klotsche J, Torok KS, Kasapcopur O, Adrovic A, Stanevica V, et al. CHARACTERISTICS OF THE FIRST 80 PATIENTS AT TIMEPOINT OF FIRST ASSESSMENT INCLUDED IN THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM. Journal of Scleroderma and Related Disorders. 2018;4(1-13).

Disclosure of Interests

None declared

Interpersonal Psychotherapy and Mentalizing-Synergies in Clinical Practice

Interpersonal psychotherapy (IPT) is an evidence-supported, relationally focused treatment for people living with depression and other psychiatric disorders in the context of stressful life events. Mentalizing, also relationally focused, promotes the ability to perceive, understand, and interpret human behavior in terms of intentional mental states of others or oneself, in order to support social leaning. IPT and mentalization-based treatments (MBT) both seek to improve interpersonal effectiveness, albeit with different emphases in the therapeutic process, with IPT promoting interpersonal problem solving and MBT promoting understanding of the obstacles to this outcome. In this article, the authors propose that the central intentions of IPT and mentalizing are essentially linked and complementary; understanding others and oneself in relationships facilitates interpersonal problem resolution and symptomatic recovery and enhances resilience. The clinical synergies of IPT and mentalizing are elaborated and illustrated through a case example of treatment for a socially isolated woman with depression and interpersonal sensitivities.

Explanatory Models for Mental Distress Among University Students in Ethiopia: A Qualitative Study

Background

Socio-culturally determined processes account for how individuals give meanings to health, illness, causal attributions, expectations from treatment, and related outcomes. There is limited evidence of explanatory models for mental distress among higher education institutions in Ethiopia. The objective of this study was to explore the explanatory models for mental distress among Wolaita Sodo University.

Methods

The current study used a phenomenological research approach, and we collected data from 21 students. The participants were purposively recruited based on eligibility criteria. Semi-structured interviews were conducted from December 2017 to January 2018 using the Short Explanatory Models Interview. The interviews were audio-recorded, transcribed into the Amharic language and translated into English. Data were analyzed using framework analysis with the assistance of open code software 4.02.

Results

Most students experienced symptoms of being anxious, fatigue, headaches and feelings of hopelessness. They labeled these symptoms like anxiety or stress. The most commonly reported causal explanations were psychosocial factors. Students perceived that their anxiety or stress was severe that mainly affected their mind, which in turn impacted their interactions with others, academic result, emotions and motivation to study. Almost all the students received care from informal sources, although they wanted to receive care from mental health professionals. They managed their mental distress using positive as well as negative coping strategies.

Conclusion

The policy implication of our findings is that mental health interventions in higher education institutions in Ethiopia should take into account the explanatory models of students’ psychological distress.

Feasibility and acceptability of brief individual interpersonal psychotherapy among university students with mental distress in Ethiopia

Background

The prevalence of mental distress among university students in low- and middle-income countries (LMICs) is increasing; however, the majority do not receive evidence-based psychological intervention. This calls for the provision of culturally adapted psychological therapy in higher education institutions in LMICs. The aim of this pilot study is to evaluate the feasibility and acceptability of Interpersonal Psychotherapy adapted for Ethiopia (IPT-E) among Wolaita Sodo University students and to assess the preliminary outcomes of IPT-E in reducing symptoms of mental distress and in improving functioning.

Methods

We used a quasi-experimental single-group pre-post-test study design. As indicators of feasibility of IPT-E, we used consent, treatment completion and attrition. We used Client Satisfaction Questionnaire and semi-structured interview to measure the acceptability of the intervention, self-reporting IPT-E checklist to assess treatment adherence and World Health Organization Disability Assessment and Self-Reporting Questionnaire-20 tools to assess functional impairment and mental distress, respectively. We used percentage, frequency, mean and standard deviation to summarize the demographic variables, feasibility and acceptability of IPT-E. We analyzed changes from pre- to post-tests of mental distress and functioning results using paired t-test and Wilcoxon signed-rank tests. Independent sample t-test and one way-ANOVA used to assess the difference in mean score of in demographic variables at baseline and eight weeks. The qualitative data was analyzed with the support of open code 4.02.

Results

IPT-E was feasible (consent rate = 100%; completion rate = 92.31%; attrition rate = 7.69%; mean score of the sessions = 8 and mode of the session = 8). The total mean score of treatment satisfaction was 27.83 (SD = 4.47). After the delivery of IPT-E, symptoms of mental distress were decreased, functioning was improved and therapist adherence to the treatment model was 100% (i.e. treatment delivered according to the IPT-E guideline).

Conclusion

IPT-E was feasible and acceptable to treat university students with mental distress in low-income country setting. The preliminary results also suggest promising viability of IPT-E in higher education institutions of low-income country setting for students with symptoms of anxiety and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00570-1.

Presentation, Treatment Response and Short-Term Outcomes in Paediatric Multisystem Inflammatory Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS)

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the pathogen responsible for Coronavirus Disease 2019 (COVID-19). Whilst most children and young people develop mild symptoms, recent reports suggest a novel paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). Case definition and classification are preliminary, treatment is empiric and disease-associated outcomes are unclear. Here, we report 29 patients with PIMS-TS who were diagnosed, admitted and treated in the English North West between March and June 2020. Consistent with patterns observed internationally, cases peaked approximately 4 weeks after the initial surge of COVID-19-like symptoms in the UK population. Clinical symptoms included fever (100%), skin rashes (72%), cardiovascular involvement (86%), conjunctivitis (62%) and respiratory involvement (21%). Some patients had clinical features partially resembling Kawasaki disease (KD), toxic shock syndrome and cytokine storm syndrome. Male gender (69%), black, Asian and other minority ethnicities (BAME, 59%) were over-represented. Immune modulating treatment was used in all, including intravenous immunoglobulin (IVIG), corticosteroids and cytokine blockers. Notably, 32% of patients treated with IVIG alone went into remission. The rest required additional treatment, usually corticosteroids, with the exception of two patients who were treated with TNF inhibition and IL-1 blockade, respectively. Another patient received IL-1 inhibition as primary therapy, with associated rapid and sustained remission. Randomized and prospective studies are needed to investigate efficacy and safety of treatment, especially as resources of IVIG may be depleted secondary to high demand during future waves of COVID-19.

Living on the edge: the role of Atgolgin-84A at the plant ER-Golgi interface

The plant Golgi apparatus is responsible for the processing of proteins received from the endoplasmic reticulum (ER) and their distribution to multiple destinations within the cell. Golgi matrix components, such as golgins, have been identified and suggested to function as putative tethering factors to mediate the physical connections between Golgi bodies and the ER network. Golgins are proteins anchored to the Golgi membrane by the C-terminus either through transmembrane domains or interaction with small regulatory GTPases. The golgin N-terminus contains long coiled-coil domains, which consist of a number of α-helices wrapped around each other to form a structure similar to a rope being made from several strands, reaching into the cytoplasm. In animal cells, golgins are also implicated in specific recognition of cargo at the Golgi.Here, we investigate the plant golgin Atgolgin-84A for its subcellular localization and potential role as a tethering factor at the ER-Golgi interface. For this, fluorescent fusions of Atgolgin-84A and an Atgolgin-84A truncation lacking the coiled-coil domains (Atgolgin-84AΔ1-557) were transiently expressed in tobacco leaf epidermal cells and imaged using high-resolution confocal microscopy. We show that Atgolgin-84A localizes to a pre-cis-Golgi compartment that is also labelled by one of the COPII proteins as well as by the tether protein AtCASP. Upon overexpression of Atgolgin-84A or its deletion mutant, transport between the ER and Golgi bodies is impaired and cargo proteins are redirected to the vacuole. LAY DESCRIPTION: The Golgi apparatus is a specialised compartment found in mammalian and plant cells. It is the post office of the cell and packages proteins into small membrane boxes for transport to their destination in the cell. The plant Golgi apparatus consist of many separate Golgi bodies and is responsible for the processing of proteins received from the endoplasmic reticulum (ER) and their distribution to multiple destinations within the cell. Specialised proteins called golgins have been suggested to tether Golgi bodies and the ER. Here we investigate the plant golgin Atgolgin-84A for its exact within the Golgi body and its potential role as a tethering factor at the ER-Golgi interface. For this, we have fused Atgolgin-84A with a fluorescent protein from jellyfish and we are producing this combination in tobacco leaf cells. This allows us to see the protein using laser microscopy. We show that Atgolgin-84A localises to a compartment between the ER and Golgi that is also labelled by the tether protein AtCASP. When Atgolgin-84A is produced in high amounts in the cell, transport between the ER and Golgi bodies is inhibited and proteins are redirected to the vacuole.

Short-term outcome of surgical arthrodiastasis of the ankle with Ilizarov frame in a cohort of children and young people with juvenile idiopathic arthritis

Objectives

Despite medical advances, life-changing articular damage may still occur in patients with JIA. We report a cohort with destructive arthropathy of the ankle treated by surgical arthrodiastasis.

Methods

Eight patients (nine ankles) received arthrodiastasis by means of an Ilizarov frame between 2009 and 2013. Patient- and clinician-reported outcome measures were collated prospectively, with retrospective analysis of demographics, disease and pre-surgical treatment.

Results

Pre-surgery, all patients received IA CS (mean 0.8 injections/year) and MTX (mean diagnosis to treatment 3.8 years; two of eight started within 3 months). Seven of eight patients received biologic drugs. Pain scores improved by 56 and 29% (P < 0.005) at 6 and 12 months post-frame removal. American Academy Orthopaedic Foot and Ankle Society ankle–hindfoot scale, Oxford Ankle Foot Questionnaire-Child and Oxford Ankle Foot Questionnaire-Parent scores improved by 171, 62 and 80%, respectively (P < 0.005) at 12 months post-frame removal. Patients remained satisfied with surgical treatment for a mean of 13.3 months. There was transient pin site infection in three patients, and all patients had radiological improvement in joint space.

Conclusion

Arthrodiastasis with an Ilizarov frame is a safe, well-tolerated technique that should be considered as a short-term joint-preserving procedure to improve pain and function when damage has occurred. Delays to systemic medical treatment in this cohort would be considered out-with standard modern practice but, although less prevalent, destructive ankle arthropathy continues to occur in JIA, and we believe this study to be relevant. The ankle is particularly susceptible to damage and, even if localized, should be treated early and aggressively with DMARDs and rapid progression to biologic therapies.

Levelof evidence

Level IV.

Toronto Addis Ababa Academic Collaboration: A Relational, Partnership Model for Building Educational Capacity Between a High- and Low-Income University

Educational partnerships between academic health sciences centers in high- and low-resource settings are often formed as attempts to address health care disparities. In this Perspective, the authors describe the Toronto Addis Ababa Academic Collaboration (TAAAC), an educational partnership between the University of Toronto and Addis Ababa University. The TAAAC model was designed to help address an urgent need for increased university faculty to teach in the massive expansion of universities in Ethiopia. As TAAAC has developed and expanded, faculty at both institutions have recognized that the need to understand contextual factors and to have clarity about funding, ownership, expertise, and control are essential elements of these types of collaborative initiatives. In describing the TAAAC model, the authors aim to contribute to wider conversations and deeper theoretical understandings about these issues.

Recommendations for Canadian Mental Health Practitioners Working With War-Exposed Immigrants and Refugees

With the inception of the mental health strategy for Canada, Changing Directions, Changing Lives, the ever increasing ethnic diversity in this country demands re-examination of our approaches to mental wellbeing and illness in the immigrant and refugee population arriving from war-torn countries. Contemporary clinical practice among mental health practitioners is not reflective of the emerging literature in this field, which points towards meaningful and culturally competent care. This article seeks to bridge the gap between existing knowledge and current practice, and provides recommendations for mental health practitioners who work with this population.

Hypercalcaemic Pancreatitis, Adrenal Insufficiency, Autoimmune Thyroiditis and Diabetes Mellitus in a girl with Probable Sarcoidosis

INTRODUCTION

Sarcoidosis is a multisystemic granulomatous disease with diverse and often non-specific symptoms during childhood. The clinical manifestations sometimes include endocrinopathies related to sarcoid infiltration of various endocrine organs, but more commonly due to the associated autoimmune endocrine disorders. There are only a few reports of multiple autoimmune and non-autoimmune endocrine problems occurring simultaneously in patients with sarcoidosis. We report a girl with probable sarcoidosis who also had Hashimoto's thyroiditis, Type 1 diabetes (T1D) and secondary adrenal insufficiency.

CASE PRESENTATION

A 9-year-old girl previously diagnosed with autoimmune hypothyroidism and vitamin D deficiency, presented with hypercalcemic pancreatitis after initiating vitamin D supplementation that lead to a diagnosis of probable sarcoidosis. Secondary adrenal insufficiency and T1D were subsequently diagnosed. Her angiotensin converting enzyme levels on 2 occasions were 106 and 135 nmol/mL/min (normal range 10 - 43). All investigations conducted to exclude several infectious and malignant conditions that may mimic sarcoidosis were negative. The patient showed a good response to treatment with hydrocortisone, levothyroxine, insulin and methotrexate.

CONCLUSIONS

To our knowledge, ours is the youngest ever patient reported in the literature with sarcoidosis to develop multiple autoimmune and non-autoimmune endocrinopathies.

Can Seeding in the Clinic Reach a Wide Audience? A Proof of Concept Study on Spreading a Health Message About Juvenile Idiopathic Arthritis Using a Shareable Online Video

Background

Shareable online video offers the potential for spreading a health message across online and real world social networks. Seeding a message in a clinical setting may be advantageous.

Objective

To investigate the potential of an online video to spread a health message about juvenile idiopathic arthritis (JIA) when delivered or seeded in a clinical setting and investigate factors that influence sharing behavior.

Methods

Multimethod proof of concept study. Concepts for two different styles of video were developed using focus groups and interviews and reviewed by an online market research panel. We compared dissemination of the two videos from two specialist pediatric rheumatology clinics in NHS Hospitals. Participants were 15 patients, family members, and clinical staff with knowledge of JIA at concept stage; 300 market research panel members in development stage; and 38 patients and their parents or guardians in the seeding stage. Newly diagnosed patients with JIA and/or parents or guardians were invited to view and share an online video with a health message about JIA across real-life and electronic social networks. Main outcome measures were viewing statistics, sharing behavior and patterns, and participant feedback.

Results

Of 38 patients and/or their parents or guardians given links, 26 visited the video webpage and shared the link, 2 visited and did not share, and 10 did not visit. Most links were viewed and shared within a few days. A total of 3314 pageviews were recorded with a mean of 89.6 pageviews per link (range 0-1245). Links were accessed from 26 countries, with most viewers in the United Kingdom (82.5%). Mothers were the most active group of sharers.

Conclusions

Distribution of a video link in a clinical setting may be an effective way to spread a health message. Parents or guardians of children with JIA are more likely to share a link than young people. Dissemination depends on a small number of active sharers, the content of the video, and the willingness of participants to share health information about themselves.

Trial Registration

UK Clinical Research Network Study Portfolio ID (UKCRN): 13747; http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=13747 (Archived by WebCite at http://www.webcitation.org/6eeXlMmM6).

Inflammasome activation and vitiligo/nonsegmental vitiligo progression

BACKGROUND

Polymorphisms of NLR (nucleotide-binding domain and leucine rich repeat containing) family, pyrin domain containing protein 1 (NLRP1) have been found in patients with vitiligo/nonsegmental vitiligo (NSV), and increased NLRP1 expression has been detected in the leading edge of lesional skin biopsies.

OBJECTIVES

To evaluate the presence and intensity of NLRP1 immunostaining in lesional and perilesional skin of patients with vitiligo/NSV and to search for possible correlations between NLRP1 and interleukin (IL)-1β expression, lymphocytic infiltrates and disease activity.

METHODS

Of 14 consecutive vitiligo/NSV patients, eight had active disease [Vitiligo European Task Force (VETF) spreading score +1 to +5], one patient had stable disease and five patients had regressive disease (VETF spreading score -1 to -3). We performed immunostaining for NLRP1, B and T lymphocytes, IL-1β and kallikrein 7 on lesional and perilesional vitiligo skin.

RESULTS

NLRP1 and IL-1β immunostaining in perilesional vitiligo/NSV skin was significantly associated with progressive disease (P = 0·009 and 0·04, respectively) and performed better than the simple detection of lymphocytic infiltrates.

CONCLUSIONS

Our findings suggest that markers of the NLRP1 inflammasome could be a useful test for assessing disease activity in addition to the detection of inflammatory infiltrates in the progressing margins of vitiligo/NSV lesions.

Psychotherapy Knowledge Translation and Interpersonal Psychotherapy: Using Best-Education Practices to Transform Mental Health Care in Canada and Ethiopia

Psychotherapies, such as Interpersonal Psychotherapy (IPT), that have proven effective for treating mental disorders mostly lie dormant in consensus-treatment guidelines. Broadly disseminating these psychotherapies by training trainers and front-line health workers could close the gap between mental health needs and access to care. Research in continuing medical education and knowledge translation can inform the design of educational interventions to build capacity for providing psychotherapy to those who need it. This paper summarizes psychotherapy training recommendations that: adapt treatments to cultural and health organizational contexts; consider implementation barriers, including opportunity costs and mental health stigma; and engage local opinion leaders to use longitudinal, interactive, case-based teaching with reflection, skills-coaching, simulations, auditing and feedback. Community-based training projects in Northern Ontario, Canada and Ethiopia illustrate how best-education practices can be implemented to disseminate evidence-supported psychotherapies, such as IPT, to expand the therapeutic repertoire of health care workers and improve their patients' clinical outcomes.

Establishing a surgical partnership between Addis Ababa, Ethiopia, and Toronto, Canada

BACKGROUND

Academic partnerships between high- and low/middle-income countries can improve the quality of surgical education and health care delivery in each setting. We report the perceived needs related to collaborative surgical education in a resource-limited setting.

METHODS

We used qualitative methods to elicit the opinions of surgical faculty members and surgical residents and quantitative methods to outline surgical procedure type and volume.

RESULTS

Ethiopian faculty members identified the management of trauma and emergency surgical care as a priority. They identified supervision in the operating room (OR), topic-specific lectures and supervising resident assessments in the clinic as appropriate roles for partners. Residents were in agreement with faculty members, highlighting a desire for supervision in the OR and topic-specific lectures.

CONCLUSION

We present specific experiences and needs of a surgical teaching unit in a low-income country, paving the way to form a meaningful and responsive relationship between 2 surgical departments in 2 universities.

Improving physician-patient communication through coaching of simulated encounters

OBJECTIVE

Effective communication between physicians and their patients is important in optimizing patient care. This project tested a brief, intensive, interactive medical education intervention using coaching and standardized psychiatric patients to teach physician-patient communication to family medicine trainees.

METHODS

Twenty-six family medicine trainees (9 PGY1, 11 PGY2, 6 fellows) from five university-affiliated hospitals conducted four once-weekly, 30-minute videotaped interviews with "difficult" standardized patients. After each interview, trainees received 1 hour of individual coaching that incorporated self-assessment and skills-teaching from experienced psychiatrists. Two follow-up interviews with standardized patients occurred 1 week and an average of 6 months post-intervention. Trainee self-reported physician-patient communication efficacy was measured as a control 1 month before the intervention; during the month of the intervention; and an average of 6 months after the intervention. Coach-rated physician-patient communication competence was measured each week of the intervention.

RESULTS

Improvements in physician-patient communication were demonstrated. Self-efficacy for physician-patient communication improved significantly during the intervention, in contrast to no improvement during the control period (i.e., training-as-usual). This improvement was sustained during the follow-up period.

CONCLUSIONS

This innovative educational intervention was shown to be highly effective in improving trainee communication competence and self-efficacy. Future applications of this brief model of physician training have potential to improve communication competence and, in turn, can improve patient care.