What drives the decision to optimise biological treatment in children and youngsters with juvenile idiopathic arthritis? A discrete-choice experiment

OBJECTIVE

To analyse factors involved in the decision to optimise biologics in juvenile idiopathic arthritis.

METHODS

A "discrete-choice" methodology was used. In a nominal group meeting, factors which may influence physicians' decisions to optimise biological dose were identified, together with decision nodes. 1000Minds® was used to create multiple fictitious clinical scenarios based on the factors identified, and to deploy surveys that were sent to a panel of experts. These experts decided for each item which of two clinical scenarios prompted them to optimise the dose of biologic. A conjoint analysis was carried out, and the partial-value functions and the weights of relative importance calculated.

RESULTS

In the nominal group, three decision nodes were identified: (1) time to decide; (2) to maintain/reduce or prolong interval; (3) what drug to reduce. The factors elicited were different for each node and included patient and drug attributes. The presence of macrophage activation syndrome (MAS), systemic involvement, or subclinical inflammation made the decision easier (highest weights). The presence of joints of difficult control and year of debut influenced the decision in some but not all, and in different directions. Immunogenicity, adherence, and concomitant treatments were also aspects taken into account.

CONCLUSIONS

The decision to optimise the dose of biological therapy in children and youngster can be divided into several nodes, and the factors, both patient and therapy-related, leading to the decision can be detailed. These decisions taken by experts may be transported to practice, study designs, and guidelines.

Risk scores for Kawasaki disease, a management tool developed by the KAWA-RACE cohort

INTRODUCTION/OBJECTIVES

Asian scores developed to predict unresponsiveness to intravenous immunoglobulin (IVIG) or development of coronary artery aneurysms (CAA) in patients with Kawasaki disease (KD) are not appropriate in Western populations. The purpose of this study is to develop 2 scores, to predict unresponsiveness to IVIG and development of CAA, appropriate for Spanish population.

METHOD

Data of 625 Spanish children with KD collected retrospectively (2011-2016) were used to identify variables to develop the 2 scores of interest: unresponsiveness to IVIG and development of CAA. A statistical model selected best variables to create the scores, and scores were validated with data from 98 patients collected prospectively.

RESULTS

From 625 patients of the retrospective cohort, final analysis was performed in 439 subjects: 37 developed CAA, and 212 were unresponsive to IVIG. For the score to predict CAA, a cutoff ≥ 8 was considered for high risk, considering a score system with a different weight for each of the eight variables. External validation showed a sensitivity of 22% and a specificity of 75%. The score to predict unresponsiveness to IVIG established a cutoff ≥ 8 for high risk, considering a score system with a different weight for each of the nine variables. External validation showed a sensitivity of 78% and a specificity of 50%.

CONCLUSIONS

Two risk scores for KD were developed from Spanish population, to predict development of CAA and unresponsiveness to IVIG; validation in other cohorts could help to implement these tools in the management of KD in other Western populations.

Outpatients with acute osteoarticular infections had favourable outcomes when they received just oral antibiotics without intravenous antibiotics

AIM

The traditional approach for acute paediatric osteoarticular infections (OAI) has comprised initial intravenous antibiotics followed by prompt oral antibiotics. We assessed how providing just oral antibiotics compared to the traditional two-step approach.

METHODS

This prospective study was performed at the Hospital La Paz, Madrid, Spain, from September 2015 to September 2016. We compared 25 outpatients, with good general health and a mean age of 25 months who received just oral antibiotics, with 228 hospitalised children of a similar age who received intravenous and oral antibiotics from other hospitals in the Spanish Network of Osteoarticular Infections.

RESULTS

The groups were comparable in terms of age, sex, fever, erythrocyte sedimentation rate value, C-reactive protein and diagnosis. The oral group comprised 15 with osteomyelitis, seven with septic arthritis, two with osteoarthritis and one with spondylodiscitis. This group had a lower percentage of Staphylococcus aureus (8% vs 26%, p = 0.06) and higher proportion of Kingella kingae (24% vs 9%, p = 0.017) than the intravenous group. There were complications (24%) and follow-up sequelae (6%) in the intravenous group, but none in the oral group.

CONCLUSION

Outpatients with OAI who were in good general health had favourable outcomes when they received oral antibiotics without intravenous antibiotics.

Emergence of KPC-producing Klebsiella pneumoniae in Uruguay: infection control and molecular characterization

We describe the first outbreak of Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP), the infection control measures adopted and the shift in resistance patterns of isolates during antibiotic treatment. The ST258 KPC-KP strain exhibited a multiresistant antibiotic phenotype including co-resistance to gentamycin, colistin and tigecycline intermediate susceptibility. Isolates before and after treatment had different behaviour concerning their antibiotic susceptibility and the population analysis profile study. A progressive increase in the aminoglycosides (acquiring amicacin resistance) and β-lactam MICs, and a decreased susceptibility to fosfomycin was observed throughout the administration of combined antimicrobial regimens including meropenem. A high meropenem resistance KPC-KP homogeneous population (MIC 256 Jg/mL), could arise from the meropenem heterogeneous low-level resistance KPC-KP population (MIC 8 Jg/mL), by the selective pressure of the prolonged meropenem therapy. The kpc gene was inserted in a Tn4401 isoform a, and no transconjugants were detected. The core measures adopted were successful to prevent evolution towards resistance dissemination.

Secondary patellar resurfacing in the treatment of patellofemoral pain after total knee arthroplasty

PURPOSE

This paper reports a prospective review of patients who, between 2004 and 2007, underwent secondary patellar resurfacing (SPR) due to anterior knee pain after a primary total knee arthroplasty (TKA). The aim was to evaluate the clinical outcomes obtained with the SPR and to compare them with radiological findings.

METHODS

A total of twenty-seven consecutive patients met the inclusion criteria. There were twenty-three (85%) women and four (15%) men with a median age of 70 years. The patients were evaluated before and after the surgery with the same functional scores and radiological parameters. Bone scintigraphy was also used in the assessment, and a CT-scan was performed in order to evaluate the femoral component rotation. The median time between TKA and SPR was 18 months.

RESULTS

With a median follow-up of 23 months, seventeen patients (63%) reported a clear subjective improvement after SPR, and patellofemoral scores (primary outcome measure), KSS and WOMAC (secondary outcome measures) showed a statistically significant improvement following the procedure. There were no significant changes after SPR in the Insall-Salvati ratio, the lateral patellar displacement or the lateral patellar tilt. The mean time between TKA and SPR had no statistically significant effect on outcome. The bone scintigraphy revealed increased patellar uptake in seven cases, but this was not related to subsequent improvement after SPR. Rotational computed tomography showed a median internal rotation of the femoral component of 1º. The complications observed were a patellar component loosening and an acute post-infection.

CONCLUSION

No clinical or radiological parameter was found to be related to the final outcome after SPR. There was a discrepancy between functional scale scores and the patient's subjective satisfaction.

The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study

OBJECTIVE

To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR).

METHODS

Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months.

MAIN RESULTS

Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline.

CONCLUSIONS

The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation.

A protein G fragment from the salmonid viral hemorrhagic septicemia rhabdovirus induces cell-to-cell fusion and membrane phosphatidylserine translocation at low pH

The fusion-related properties of segments p9, p3, p4, and p9 + p2 surrounding the p2 phospholipid-binding domain of the protein G (pG) of the salmonid rhabdovirus of viral hemorrhagic septicemia (VHS) (Nuñez, E., Fernandez, A. M., Estepa, A., Gonzalez-Ros, J. M., Gavilanes, F., and Coll, J. M. (1998) Virology 243, 322-330; Estepa, A., and Coll, J. M. (1996) Virology 216, 60-70), have been studied at neutral and fusion (low) pH values by using its derived peptides. Cell-to-cell fusion, translocation of phosphatidylserine, and inhibition of fusion of pG-transfected cells defined the p9 + p2 (fragment 11, sequence 56-110) as a fragment with higher specific activity for anionic phospholipid aggregation than the previously reported p2. While fragment 11, p2, and p3 showed interactions with anionic phospholipids, p9 and p4 showed no interactions with any phospholipids. When added to a cell monolayer model at low pH, fragment 11 induced pH-dependent cell-to-cell fusion and translocated phosphatidylserine from the inner to the outer leaflet of the membrane. At low pH and in the presence of anionic phospholipids, fragment 11 showed more than 80% beta-sheet conformation (IR and CD spectroscopies). Finally, anti-fragment 11 antibodies inhibited low pH-dependent pG-transfected cell-to-cell fusion. All of the data support the conclusion that fragment 11 is a primary determinant of some of the viral cell fusion events in VHSV.

Low flow veno-venous ECMO via subclavian dialysis catheter for severe respiratory failure

BACKGROUND

We present the case of a 12-year-old female with severe postoperative bacterial pneumonia unresponsive to conventional treatment following a failed renal transplant.

CASE REPORT

The patient was placed on low flow veno-venous extracorporeal membrane oxygenation (ECMO) as an adjuvant treatment to antibiotic therapy and maximal ventilatory support. Venous ECMO resulted in rapid improvement and the patient was successfully weaned after 48 hours of circulatory assistance. Two days later, the patient was extubated and safely discharged from the intensive care unit. Eighteen months later, she remains stable on peritoneal dialysis and is awaiting a new donor kidney.

CONCLUSIONS

Low flow veno-venous ECMO represents a new therapeutic alternative for critically ill patients whose condition does not meet the conventional ECMO criteria. Further clinical experience is still needed.

Predictors of stent thrombosis after primary stenting for acute myocardial infarction

The aim of the study was to determine if a hypercoagulable state that may persist for several months after an acute myocardial infarction may contribute to an increased incidence of stent thrombosis. Primary stenting was performed in 104 consecutive patients with acute myocardial infarction using 147 coronary stents. Twenty-eight patients (27%) were diabetic and 55 patients (53%) were smokers. A single stent was placed in 63%, two stents in 33%, and more than two stents in 4% of the patients. Procedural success was obtained in 97% of the patients. All stents were deployed using high-pressure balloon inflation. The reference vessel diameter and minimal lumen diameter after stent deployment were 3.30 +/- 0.42 and 3.23 +/- 0.42 mm, respectively. Six patients (5.7%) developed stent thrombosis within 1 month after the procedure complicated by reinfarction in five of the six patients. At 1-month follow-up, all patients remained alive. On multivariate analysis, independent predictors of stent thrombosis were diabetes mellitus (relative risk [RR] 5.2; 95% confidence interval [CI] 1.8, 25.1), tobacco use (RR 4.5; 95% CI 1.3, 24.5), number of stents: 1 vs. > 1 (RR 3.7; 95% CI 1.1, 15.9), minimal lumen diameter poststent placement (RR 0.03; 95% CI 0.0002, 0.74), and duration of chest pain before intervention (RR 1.1; 95% CI 1.01, 1.25). Stent thrombosis had not been associated with diabetes mellitus and tobacco use previously but is in agreement with the enhanced platelet aggregability, coagulation factor abnormalities, and impaired fibrinolysis characteristic of these patients.

Phospholipid interactions of a peptide from the fusion-related domain of the glycoprotein of VHSV, a fish rhabdovirus

Previous studies mapped a p2 domain (aa 82-109) which binds phosphatidylserine (PS) (Estepa and Coll, 1996a) and contains three contiguous hydrophobic amino acid heptad repeats followed by a positively charged stretch (Coll, 1995b) in the glycoprotein G of the viral hemorrhagic septicemia virus (VHSV), a fish rhabdovirus. Anti-p2 antibodies inhibited low-pH VHSV-induced fusion (Estepa and Coll, 1997) and low-pH PS binding to VHSV (Estepa and Coll, 1996a). We report here further studies on the interaction of the synthetic peptide p2 with phospholipid vesicles. The synthetic p2 peptide was able to mediate aggregation, lipid mixing, and leakage of contents only with negatively charged phospholipid vesicles and in a concentration-dependent manner. As shown by its effect on lipid phase transitions deduced from data with fluorescence polarization and differential scanning calorimetry, the p2 peptide becomes inserted into the hydrophobic negatively charged phospholipid vesicle bilayers. In addition, data based on circular dichroism showed that the p2 peptide folds as a structure with a high content of beta-sheets stabilized by interaction with anionic phospholipids. These studies are potentially relevant to viral fusion in VHSV.

Angiotensin II increases left ventricular mass without affecting myosin isoform mRNAs

We studied the effect of chronic (7 days) angiotensin II (Ang II) infusion in nonpressor and pressor doses on cardiovascular mass and expression of alpha- and beta-myosin heavy chain genes in the left ventricle in normotensive Wistar rats. An increased left ventricular mass was observed in rats receiving non-pressor and pressor doses of Ang II, but only high doses increased arterial pressure. Normalization of arterial pressure during Ang II infusion by losartan, a specific Ang II receptor antagonist, or hydralazine had different effects on left ventricular mass. Losartan prevented the increased left ventricular mass, and hydralazine did not affect left ventricular mass. Northern blot analysis showed that the switch in left ventricular myosin isoform mRNA from the adult to the fetal pattern occurred only in rats given the pressor Ang II dose. Both losartan and hydralazine, in parallel with the normalization of arterial pressure, prevented this myosin isoform switch. Thus, these data suggest that the Ang II-induced increase in left ventricular mass was not dependent on pressure overload, but the switch in myosin isoform mRNA from the adult to the fetal pattern was dependent on pressure overload.

Reversal of hypertrophy: an active biologic process

Evidence from in vivo, in vitro, and genetic studies suggests that the reversal as well as the development of left ventricular hypertrophy do not depend solely on hemodynamic load; other factors are involved. Several humoral agents that may affect mitogenesis of cardiac myocytes and nonmyocitic elements have been identified, including the local renin-angiotensin system, norepinephrine, endothelins, transforming growth factor beta, insulin-like growth factor, bradykinin, prostaglandins, and nitric oxide. Animal studies using various models of left ventricular hypertrophy are beginning to suggest that reversal of hypertrophy may decrease mortality, improve coronary flow reserve, and maintain cardiac performance. Studies in humans are less supportive, and more are needed before it may be concluded that reduction of left ventricular mass decreases the cardiovascular morbidity and mortality associated with cardiac hypertrophy.

Incidence of postoperative posterior capsular opacification with types of senile cataracts

The most frequent postoperative complication in extracapsular cataract surgery is opacification of the posterior capsule. The purpose of this study was to correlate the frequency of capsular opacification with each kind of senile cataract. A total of 566 eyes with cataracts were studied. They had been operated on between 1980 and 1990 using the extracapsular, intercapsular, and phacoemulsification techniques. Our results confirm that senile complete cataracts (mature cataracts) had a significantly lower tendency to produce postoperative capsular opacification than other cataract types (nuclear, cortical, posterior subcapsular).

Micronucleus assay in biomonitoring of patients undergoing excretory urography with diatrizoate and ioxaglate

In order to perform biological monitoring of exposure to radiation and contrast media, we evaluated the micronucleus count (MN) and the mitotic index (MI) in peripheral blood lymphocytes from patients undergoing excretory urography with diatrizoate (20 patients) and ioxaglate (20 patients). Three samples were taken for each patient: A (before exploration), B (immediately after exploration) and C (7 days later). There were no significant differences in the radiation doses received, nor in the dose of contrast agent, between both groups. The micronucleus count increased significantly in sample B in both groups, the increase being more statistically significant in the diatrizoate group (p less than 0.01) than in the ioxaglate group (p less than 0.05). One week later, the MN were still slightly high (p less than 0.05) in the diatrizoate group only. These results suggest a clastogenic effect which depends, to a great extent, on the nature of the contrast medium.

Changes of calcium homeostasis in nerve endings during aging

Calcium uptake reduction in synaptosomes observed in old rats is partly due to a decreased calcium influx through brain voltage-dependent calcium channels. This defect is not due to differences in the polarization of the plasma membrane, but rather to the influx of calcium itself, and may be accentuated at lower concentrations of calcium. We found that the cytosolic calcium concentration in 24-month-old rats is higher than in adults, both at rest and under K-depolarization, and it is suggested that these high calcium levels may partially inactivate synaptosomal calcium channels. The mitochondrial defect may be partially responsible for the increase in cytosolic calcium with age in K-depolarized synaptosomes, but other factors are probably responsible for the increase in resting (Ca2+).