Clinical Characteristics of Adolescents With Juvenile Idiopathic Arthritis Transitioning to Adult Rheumatology Care in Canada: Results From the CAPRI Registry

OBJECTIVE

Using Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) juvenile idiopathic arthritis (JIA) registry data, we describe (1) clinical characteristics of patients with JIA transitioning to adult care, (2) prevalence of disease-related damage and complications, and (3) changes in disease activity during the final year prior to transfer.

METHODS

Registry participants who turned 17 years between February 2017 and November 2021 were included. Clinical characteristics and patient-reported outcomes (PROs) at the last recorded pediatric rheumatology visit, and changes observed in the year prior to that visit were analyzed. Physicians completed an additional questionnaire characterizing cumulative disease-related damage and adverse events by age 17 years.

RESULTS

At their last visit, 88 of 131 participants (67%) had inactive and 42 (32%) had active disease. Overall, 96 (73%) were on medications and 41 (31%) were on biologic disease-modifying antirheumatic drugs. Among 80 participants for whom the additional questionnaire was completed, 26% had clinically detected joint damage, 31% had joint damage on imaging, 14% had uveitis, and 7.5% had experienced at least 1 serious adverse event. During the final year, 44.2% of patients were in remission, 28.4% attained inactive disease, and 27.4% became or remained active. Mean scores of PROs were stable overall during that last year, but a minority reported marked worsening.

CONCLUSION

A substantial proportion of youth with JIA transitioning to adult care in Canada had a high disease burden, which was reflected by their degree of disease activity, joint damage, or ongoing medication use. These results will inform pediatric and adult providers of anticipated needs during transition of care.

Reductions in Bone Mineral Density Are Apparent Early in Children With Prevalent Osteonecrosis Lesions Following Leukemia Therapy

Osteonecrosis (ON) is a serious complication of childhood acute lymphoblastic leukemia. We determined the prevalence of osteonecrotic lesions in our patient population by a one-time multisite magnetic resonance imaging (MRI) more than 1 year following leukemia therapy. MRI findings were evaluated in relationship to clinical factors (including longitudinal changes in bone mineral density [BMD]). Eighty-six children enrolled in the Steroid Associated Osteoporosis in the Pediatric Population (STOPP) study were evaluated for ON at 3.1 ± 1.3 years following therapy. Thirty children had a total of 150 confirmed ON lesions (35%). Lumbar spine (LS) BMD Z-scores (mean ± SD) were low at diagnosis and similar between patients with and without ON (-1.09 ± 1.53 versus -1.27 ± 1.25, p = 0.549). LS BMD Z-scores declined from baseline to 12 months in children with ON (-0.31 ± 1.02) but not in those without (0.13 ± 0.82, p = 0.035); the hip BMD Z-scores from baseline to 24 months declined in both groups, but to a greater extent in those with ON (-1.77 ± 1.22) compared to those without (-1.03 ± 1.07, p = 0.045). At the time of the MRI, mean total hip and total body (TB) BMD Z-scores were lower in children with ON (hip -0.98 ± 0.95 versus -0.28 ± 1.06, p = 0.010; TB -1.36 ± 1.10 versus -0.48 ± 1.50, p = 0.018). Pain occurred in 11/30 (37%) with ON versus 20/56 (36%) without, p = 0.841. In multivariable models, older age at diagnosis (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.15-2.13; p = 0.004), and hip BMD Z-score at MRI (OR 2.23; 95% CI, 1.02-4.87; p = 0.046) were independently associated with ON. Overall, one-third of children demonstrated ON after leukemia therapy. Those with ON had greater reductions in spine and hip BMD Z-scores in the first 1 and 2 years of therapy, respectively. Older age and lower hip BMD Z-scores at MRI were significantly associated with prevalent, off-therapy ON. These data assist in identifying children at risk of ON. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Higher concentrations of vitamin D in Canadian children with juvenile idiopathic arthritis compared to healthy controls are associated with more frequent use of vitamin D supplements and season of birth

A number of studies have demonstrated that patients with autoimmune disease have lower levels of vitamin D prompting speculation that vitamin D might suppress inflammation and immune responses in children with juvenile idiopathic arthritis (JIA).  The objective of this study was to compare vitamin D levels in children with JIA at disease onset with healthy children. We hypothesized that children and adolescents with JIA have lower vitamin D levels than healthy children and adolescents. Data from a Canadian cohort of children with new-onset JIA (n= 164, data collection 2007-2012) were compared to Canadian Health Measures Survey (CHMS) data (n=4027, data collection 2007-2011). We compared 25-hydroxy vitamin D (25(OH)D) concentrations with measures of inflammation, vitamin D supplement use, milk intake, and season of birth. Mean 25(OH)D level was significantly higher in patients with JIA (79 ± 3.1 nmol/L) than in healthy controls (68 ± 1.8 nmol/L P <.05). Patients with JIA more often used vitamin D containing supplements (50% vs. 7%; P <.05). The prevalence of 25(OH)D deficiency (<30 nmol/L) was 6% for both groups. Children with JIA with 25(OH)D deficiency or insufficiency (<50 nmol/L) had higher C-reactive protein levels. Children with JIA were more often born in the fall and winter compared to healthy children. In contrast to earlier studies, we found vitamin D levels in Canadian children with JIA were higher compared to healthy children and associated with more frequent use of vitamin D supplements. Among children with JIA, low vitamin D levels were associated with indicators of greater inflammation.

[An abscessed granulomatous prostatitis]

INTRODUCTION

Prostatic abscesses are usually diagnosed in the setting of bacterial prostatitis. Rarely, they reveal or complicate granulomatous prostatitis.

CASE REPORT

A 55-year-old man was admitted for acute urinary retention. Urine culture was sterile, with leukocyturia > 10⁶/ml. After failure of antibiotic therapy with cefotaxime, CT scan revealed a necrotic prostatic collection and a nodular non-necrotic tissular lesion in the left upper lung lobe. Trans-rectal drainage of the prostatic lesion and lung biopsies revealed granuloma with multinucleated giant cells (without mycobacteria). The diagnosis of granulomatosis with polyangiitis was confirmed by high level of anti-proteinase 3 antibodies. Treatment with steroids and rituximab resulted in apyrexia, regression of the inflammatory syndrome and clinical manifestations.

CONCLUSION

The diagnosis of granulomatosis with polyangiitis should be considered in the presence of a non-infectious granulomatous prostatitis with systemic involvement.

A new Canadian inception cohort for juvenile idiopathic arthritis: The Canadian Alliance of Pediatric Rheumatology Investigators Registry

Objectives

The aim was to describe the design, methods and initial findings of a new Canadian inception cohort of children with JIA, The Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) JIA Registry.

Methods

The CAPRI JIA Registry was started in 2017 to collect information prospectively on children enrolled within 3 months of JIA diagnosis across Canada. The registry has a non-traditional modular design, with no artificially set times for registry visits to occur, streamlined multi-method data collection that requires 2–4 min per visit, and reports cumulative incidence of treatments, outcomes and adverse events calculated by Kaplan–Meier survival methods.

Results

A total of 166 patients, enrolled a median of 6 weeks after JIA diagnosis at 10 centres, were included. The median age at diagnosis was 9 years [interquartile range (IQR) 3, 13], 61% were female and 51% had oligoarticular JIA. The median three-variable clinical Juvenile Arthritis Disease Activity Score was 6.5 (IQR 4, 10) at enrolment, and the median time to first attainment of clinically inactive disease (CID) was 24 weeks (by 1 year, 81%). Within 1 year of diagnosis, 70% of patients had started a DMARD and 35% a biologic agent. The rates of adverse events and serious adverse events were 60 and 5.8 per 100 patient-years, respectively.

Conclusion

This streamlined and flexible registry minimizes the burden of data collection and interference with clinic operations. Initial findings suggest that treatments for newly diagnosed patients with JIA in Canada have intensified, and now 81% of patients attain CID within 1 year of diagnosis.

Development of Canadian Recommendations for the Management of ANCA-Associated Vasculitides: Results of the National Needs Assessment Questionnaire

Objectives :

To study variations in Canadian clinical practice patterns for the management of ANCA-associated vasculitis (AAV) and identify points to consider for the development of national recommendations.

Material and Methodology :

A 30-item needs assessment questionnaire was sent to all members of the Canadian Vasculitis network (CanVasc), Canadian Rheumatology Association (CRA), Canadian Thoracic Society (CTS) and Canadian Society of Nephrology (CSN). Respondent characteristics, practice patterns, concerns and expectations were analyzed.

Results :

Among 132 physicians who followed at least 1 vasculitis patient and responded to the survey, 39% stated that they felt confident in their management of AAV. Several variations in practice were observed regarding diagnostic procedure, induction and maintenance treatments and use of biologics; some were due to logistic constraints (difficulties in access to some specific tests, drugs or care; lack of health care coverage for the costs). The top 5 topics for which recommendations are expected involve treatment for remission induction, maintenance, refractory disease, and relapse as well as biologics.

Conclusion :

Practice variations identified in this needs assessment survey will serve to formulate key questions for the development of CanVasc recommendations.

[Vitamin B12 deficiency due to nitrous oxide use: unrecognized cause of combined spinal cord degeneration]

INTRODUCTION

Nitrous oxide is widely used in anesthesia. It is usually safe but may be associated with severe side effects when it is used repeatedly or on a prolonged time. Here, we report a case of drug-induced subacute combined spinal cord degeneration related to cobalamin deficiency.

CASE REPORT

A 20-year-old man with sickle-cell disease (SS) who was followed for severe recurrent vaso-occlusive crisis with repeated hospital admissions presented with ascending motor and sensitive neurological deficits that were later associated with bladder dysfunction. He was first considered to develop Guillain-Barre syndrome. However, persisting neurological signs despite adequate treatment lately led to diagnose subacute combined medullar degeneration due to abnormal cobalamin (vitamin B12) metabolism induced by repeated use of nitrous oxide during painful episodes of sickle-cell disease.

CONCLUSION

Inhaled nitric oxide is widely used in the treatment of vaso-occlusive crisis. Clinicians should be aware of possible severe neurologic side effects.

Heavy metals in water, sediment and tissues of Liza saliens from Esmoriz-Paramos lagoon, Portugal

Esmoriz-Paramos lagoon is an ecosystem of great ecological importance that is located on the northwest coast of Portugal and has been degraded as a result of industrial and anthropogenic activities. Concentrations of heavy metals (Cr, Cu, Pb and Zn) were measured in water, sediment and in tissues (liver and muscle) of Liza saliens, which is the dominant fish from the lagoon. Comparisons between metal concentrations in water and sediments were made with those in tissues of fish caught at the lagoon. Metals in water were quantified predominantly bound to particulate and equalled or exceeded the limit of chronic reference values. Metal concentrations in sediments varied among sampled sites. The relative order of concentrations was "Zn > Cu approximately Pb > Cr" the same pattern observed for metals in water. Metals in fish tissues showed higher concentrations in liver (262 mg CuxKg(-1) and 89 mg ZnxKg(-1)) than in muscle (<3 mg CuxKg(-1) and 26 mg ZnxKg(-1)), while Pb and Cr were not detected. These results suggest that Cu and Zn are the metals of major concern in the lagoon. Mullet detritivorous feeding habits, bioaccumulation pattern and the high sediment metals concentrations relative to the water suggest that sediments can be the most important source of contamination in this ecosystem. The positive relationship found between Cu in liver and fish length demonstrates that time of exposure is a crucial factor in bioaccumulation. Condition indices (K and HSI) in mullets from the lagoon were higher compared to mullets from sea, suggesting abnormal condition in the lagoon population. We conclude that metals chronic exposure in the lagoon can impose considerable fish stress. The results also show that the lagoon is an area of environmental concern.

Rose Dieback Caused by Trichothecium roseum in Argentina

Rose (Rosa sp.) is one of the most important ornamentals in Argentina. Since 2002, a severe disease has been observed on crops cultivated for cut flowers and garden plants in Escobar, San Pedro, Río Negro, and the surrounding area of Buenos Aires and La Plata. Symptoms consisted of a stem dieback progressing to plant death. In some cases, stem cankers were observed on the dieback limits. Mean incidence of stem dieback was 8% regardless of location. The disease was associated with pruning or harvest wounds. The objective of this study was to identify the causal agent of the described symptoms. Small pieces of diseased tissues from cvs. Rafaela, Merlise, Confeti, Mini rosal, Exótica, Macarena, and Peckowo were surfaced sterilized with a 2-min immersion in 0.2% NaOCl, washed with sterile distilled water, the tissue blotted dry, placed on 2% potato dextrose agar (PDA), and incubated at 22°C. Pure salmon-colored fungal colonies developed within 72 h. Hyaline, two-celled (the upper cell slightly larger), ovoid to ellipsoid conidia formed in chains at the apex of simple, long, slender, septate conidiophores. These characteristics are consistent with the description of Trichothecium roseum (Pers.) Link ex Gray (1) The pathogenicity tests were carried out on 10 plants of cv. Rafaela and 10 plants of cv. Mini Rosal using a conidial suspension (2.4 × 10⁵ spores/ml). All plants were pruned just before inoculation. Another 10 pruned plants (five from each cultivar) were sprayed with sterile water and served as controls. Inoculated and noninoculated plants were placed in a climatic chamber at 20°C and covered with polyethylene bags for 3 days to achieve a humid environment. Stem dieback was evident 7 days after inoculation on both cultivars and cankers appeared in 14 days. A dense, white mold that turned salmon-pink covered all the stems within 25 days. Inoculated plants died after 40 days. Symptoms did not develop on the control plants. The pathogen was recovered from inoculated stems, thus fulfilling Koch's postulates. To our knowledge, this is the first report of T. roseum causing a disease on rose in Argentina. Reference: (1) K. H. Domsch et al. Compendium of Soil Fungi. Academic Press. London, 1980.

A randomized controlled trial of mailed osteoporosis education to older adults

INTRODUCTION

Osteoporosis represents a growing public health concern; however, current rates of management are sub-optimal. The aim of our study was to assess, in a randomized controlled trial, the effect of a mailed educational intervention on older adults' knowledge, attitudes, and preventive behaviors regarding osteoporosis. The setting was a large publicly funded state pharmacy benefits program. The patients were 31,715 Medicare beneficiaries from Pennsylvania who participated in a drug benefits program for low-to-moderate income elderly people.

METHODS

All women aged over 65 years, and all men and women with a history of fracture or long-term oral use of glucocorticoid, were included. Approximately half of the participants (intervention group) were randomly selected to receive three mailings aimed at improving knowledge of osteoporosis and enhancing preventive activities, such as using calcium and vitamin D, reducing fall risks in the home, obtaining a bone mineral density (BMD) test, and taking medications when necessary. The other participants did not receive the intervention mailings and served as controls. We surveyed a sample of intervention and control subjects to determine the effects of the intervention on knowledge, attitudes, self-efficacy (confidence in one's ability to perform specific activities), and behavior regarding osteoporosis prevention and treatment. Six hundred randomly selected participants in the intervention group and an equal number in the control group were invited to participate.

RESULTS

Twenty-six had died and 636 of the remaining 1,185 (54%) completed the survey. Respondents and non-respondents did not differ significantly with respect to measured sociodemographic factors. All scales had good reliability (all Cronbach's alphas>0.65). Knowledge of osteoporosis was generally very good and did not differ between intervention (mean=65% correct responses) and control subjects (mean=67% correct; P=0.4). Perceived susceptibility to osteoporosis was relatively high and similar across groups (P=0.4). Self-efficacy for participating in osteoporosis prevention and treatment was very strong in both the intervention (mean=4.3 on a 0-5 scale) and control (mean=4.2, P=0.03) groups . On average, subjects in the intervention group reported participating in 3.5 of 6 preventive osteoporosis activities compared with 3.4 in the control group (P=0.5).

CONCLUSIONS

Compared with the controls, a mailed educational intervention for osteoporosis was not associated with better knowledge, higher perceived susceptibility, or performance of preventive measures among the at-risk older adults that we studied. The intervention group demonstrated a small increase in self-efficacy. More intensive patient interventions or intervention aimed at other aspects of the care process may be required to bring about changes that lead to a reduction in fractures.

Primary Sjögren's syndrome in children and adolescents: are proposed diagnostic criteria applicable?

OBJECTIVE

To compare the proposed criteria for the diagnosis of primary Sjögren's syndrome (pSS) in childhood to the validated American-European Consensus Group (AECG) classification criteria for pSS in adults.

METHODS

Charts of 7 children with pSS seen at British Columbia's Children's Hospital (BCCH) and data on 128 children identified through Medline in the English language literature between 1963 and 2003 were reviewed for pediatric and AECG criteria for pSS. The presence of > or = 4 criteria was required to satisfy the respective classification criteria. The expert clinical opinion of pediatric rheumatologists was considered the gold standard for diagnosis.

RESULTS

A total of 24/62 (39%) cases satisfied the AECG criteria; 47/62 (76%) satisfied the proposed pediatric criteria. Inclusion of recurrent parotitis increased the sensitivity of the pediatric clinical criteria. From the cases, 78/133 (59%) satisfied the pediatric oral symptom criteria; only 6/78 (8%) had xerostomia in the absence of recurrent parotitis. There was no reported case of recurrent conjunctivitis in the absence of keratoconjunctivitis sicca. We found 101/130 (78%) cases had at least one positive autoantibody test result [antinuclear antibodies (ANA), rheumatoid factor (RF), SSA, SSB]; 78/123 (63%) had autoantibodies to SSA or SSB.

CONCLUSION

The AECG adult criteria for pSS should not be applied to children as the sensitivity is unacceptably low. The inclusion of recurrent parotitis increases the sensitivity of the pediatric criteria, and recurrent parotitis should alert the clinician to the possibility of pSS. The inclusion of recurrent conjunctivitis did not improve the sensitivity over the AECG ocular criteria. The addition of ANA and RF to the AECG criteria did not change the number of patients satisfying the criteria for pediatric pSS.

[Fungal endophytes in Juncus imbricatus var chamissonis: identification of colonization patterns.]

Colonization patterns corresponding to individual endophytic species were observed in asymptomatic leaves and culms of Juncus imbricatus var chamissonis, a perennial plant. The presence of the fungi within the host was demonstrated by light microscopy after the cleaning and staining of tissues. The main endophytic species, Pleospora aff togwotiensis, was found colonizing the substomatal chamber and growing intercellularly between mesophyll cells. In a second colonization pattern, an unknown fungus was restricted to a single host epidermal cell, showing similar characteristics to other fungal taxa observed on Juncus effusus var pacificus, Pseudotsuga menziessii and Fagus sylvatica. A third colonization pattern, where the mycelium is confined to the substomatal chamber, was also described.

Rheumatoid factor positive, oligoarticular onset juvenile rheumatoid arthritis

We describe 2 children with oligoarticular onset juvenile rheumatoid arthritis (JRA) with early erosive disease. Both patients were rheumatoid factor (RF) positive, but neither had HLA-DR4. These findings suggest RF is associated with early erosive disease, independent of HLA-DR4. RF positive oligoarticular onset JRA should probably be recognized as a separate subgroup of JRA.

Intestinal pseudo-obstruction as an initial presentation of systemic sclerosis in two children

Two children are reported in whom intestinal pseudo-obstruction was the initial manifestation of systemic sclerosis. Gastrointestinal symptoms and skin changes resolved or improved in both children following treatment with prednisone and penicillamine (case 1) or methotrexate (case 2), although radiological changes of the gastrointestinal tract persisted at 3 and 2 yr of follow-up, respectively.

The incentive plan: an approach for modification of physician behavior

Blue Shield of Massachusetts undertook a one-year study in 1981 to determine if a group of obstetrician/gynecologists could be motivated to reduce average length of stay (ALOS) for normal deliveries, cesarean sections, and hysterectomies. The group decreased ALOS for all three procedures. Additional studies are required to determine what portion of the decrease in ALOS can be attributed to change in physician behavior.

RNA and DNA puffs in polytene chromosomes of rhynchosciara: inhibition by extirpation of prothorax

In the giant polytene chromosomes, gene amplification is made visible by formation of DNA puffs, and gene transcription is made visible by formation of RNA puffs. Ligation of the anterior portion of the larva at the end of the fourth larval instar inhibited the formation of the DNA puffs that normally develop at this stage and caused regression of RNA puffs.