Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

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.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

P2717Type-II MI and chronic myocardial injury rates, invasive management and 4 year mortality among consecutive patients undergoing high sensitivity troponin T testing in the emergency department

Background

In emergency departments (EDs), assessment of patients with suspected acute coronary syndromes (ACS) represents a major workload and high sensitivity troponin (HsTn) T and I levels are frequently measured. A minority of patients have final diagnosis of myocardial infarction (MI).

Methods and results

Among 2738 consecutive patients with suspected ACS presenting to ED at Liverpool Hospital, Australia, between March and June 2014, we determined the relative frequencies of 3 patient groups: type-I MI, type-II MI including chronic myocardial injury (CMI), and assessed the use of invasive and pharmacological therapies and 4-year outcomes. Adjudication of MI was according to the 4th universal definition of MI as follows: 1) type-I MI; 2) type-II MI (including acute myocardial injury), and 3) CMI. Of 995 patients (36%) median age 76 years [IQR 65–83]), with at least 2 HsTnT measurements and one >14ng/l, 727 (73%) had chronic myocardial injury, 171 (17%) had type-II MI; and 97 (9.7%) had type-I MI. Patients with type-I MI (mean age 63 years) were younger than those with type-II MI or chronic myocardial injury by 12 and 14 years respectively. The main triggering factors for type-II MI/acute injury included: sepsis (21.1%), acute heart failure (18.3%), tachyarrhythmia (16.9%), anaemia (8.6%) and a combination of factors (16%). In-hospital angiography (62% had PCI) rates were 95% for patients with type-I MI, 24% (7% PCI) for those with type-II MI and 3.4% for CMI. Mortality at 4 years was 55% for type-II MI, 44% for CMI and 18% for type-1 MI (P<0.001; Figure), though after Cox modelling adjusting for age, gender, renal function and COPD, compared to type 1 MI, type-II MI (hazard ratio 1.61 [95% CIs 0.90–2.86]; p=0.106) and CMI (hazard ratio 1.01 [95% CIs 0.59–1.74]; p=0.963) were not independently associated with increased late mortality, largely because patients with type 1 MI were a decade younger.

Conclusion

Among unselected patients undergoing HsTnT testing in EDs, type-II MI including acute myocardial injury was more common than type-I MI. Chronic myocardial injury, which occurred in 3 of 4 patients. While patients with type-II MI acute myocardial injury had higher late mortality rates than type-I MI, though after multivariable analyses mortality rates were not different.

GaN-Based MSM uv Photodetectors

Results obtained from interdigital metal-semiconductor-metal (MSM) type of GaN based UV photodetectors are presented. MSM devices were fabricated using two types of GaN; high-resistive GaN and Mg doped GaN. For the high-resistive GaN detector, the lowest dark current is ∼0.1 nA and the UV responsivity of the device was about 460 AAV at a DC bias of 30 V. The Mg doped GaN exhibited large gains, 1150 A/W at 2.0 V, but at much higher dark currents, 400 nA. The high gain in this device is not well understood but was attributed to an ‘avalanche’ effect and is under investigation. It was found that the surface plasma treatment plays an important role in the device performance. After an appropriate plasma treatment the detectors showed higher responsivity with lower dark current.

Neurotrophin expression in the adult olfactory epithelium

Published reports of neurotrophin expression in the olfactory system are incomplete because of missing data and conflicting results. Previous studies used a variety of fixation procedures and antibodies on different species and different ages. The aim of the present study was to examine expression of neurotrophins and their receptors using optimized methodologies: five methods of fixation, multiple antibodies, a variety of immunochemical protocols, and RT-PCR. We show here that (i) transcripts for all neurotrophins and their receptors are found in the adult olfactory epithelium; (ii) all neurotrophins are expressed in the supporting cells and the neuronal layers of the undisturbed adult olfactory epithelium while NT4 is found additionally in the horizontal basal cells; (iii) neurotrophin immunoreactivity required a fixative that included parabenzoquinone (not used in previous studies of olfactory tissue); (iv) TrkB and TrkC are restricted to the globose basal cell and neuron layers while TrkA is found in the horizontal basal cells and in the supporting cells where it co-localizes with the low affinity receptor for NGF (p75NTR). These findings confirm that neurotrophins are produced within the olfactory epithelium, suggesting autocrine and paracrine regulation of olfactory neurogenesis.

Polymyositis as a cause of total gut failure

BACKGROUND

Gastrointestinal manifestations are seen in systemic sclerosis and mixed connective tissue disorders but are rare in pure polymyositis.

CASE REPORT

A 44 year old woman with polymyositis who developed total gut failure requiring treatment with total parenteral nutrition is described.

RESULTS

The patient's polymyositis is now fully controlled biochemically, but her gastrointestinal symptoms persist.

Application of neural networks and sensitivity analysis to improved prediction of trauma survival

The performance of trauma departments is widely audited by applying predictive models that assess probability of survival, and examining the rate of unexpected survivals and deaths. Although the TRISS methodology, a logistic regression modelling technique, is still the de facto standard, it is known that neural network models perform better. A key issue when applying neural network models is the selection of input variables. This paper proposes a novel form of sensitivity analysis, which is simpler to apply than existing techniques, and can be used for both numeric and nominal input variables. The technique is applied to the audit survival problem, and used to analyse the TRISS variables. The conclusions discuss the implications for the design of further improved scoring schemes and predictive models.

Psychotropic drug utilization in long-term-care facilities for the elderly in Ontario, Canada

OBJECTIVE

Despite considerable data from a number of countries regarding psychotropic utilization in long-term-care facilities for the elderly, there has been a lack of similar data from Canada. The purpose of this study was to gather prescription data from a series of institutions in Ontario and to compare the results to those of other international studies.

METHOD

Single-day surveys were carried out in six homes for the aged, four nursing, homes, two retirement homes, and a veterans' center. The results were compared to those of recent studies from other countries.

RESULTS

The data revealed considerable differences in rates of prescription between different classes of institutions and between similarly classified institutions. The prescription rate of neuroleptics ranged from 11.8% (of patients) in retirement homes to 29.8% in nursing homes. Antidepressant use ranged from 12.2% in nursing homes to 24.6% in homes for the aged, and benzodiazepine use ranged from 22.5% in nursing homes to 36.4% in retirement homes.

CONCLUSIONS

The overall rate of prescription for psychotropic medications was somewhat lower than in most international studies. The rate of prescription of neuroleptics in nursing homes fell in the midrange of studies, somewhat higher than in recent studies from the United States and an earlier Italian study, but lower than in recent reports from Sweden, Austria, and Australia. The rate of neuroleptic use in homes for the aged was comparable to the rate in the U.S. studies. The overall rate of prescription of antidepressants and benzodiazepines appears to be comparable to that in recent studies from other countries.

Observation of electro-optic and electroabsorption modulation in a Langmuir-Blodgett film Fabry-Perotétalon

Electro-optic and electroabsorption modulation by use of a Langmuir-Blodgett (LB) film-based Fabry-Perot étalon is reported. The modulation was found to be dominated by linear effects in the film. The percentage change in transmission was 15% for electro-optic and 30% for electroabsorption modulation at an rms drive voltage of 53 V. The effective linear electro-optic coefficient of the LB film was 13 pm V(-1) at 633 nm for s-polarized light. We believe that this is the highest value reported to date for thick LB films.

Motor neuron disease with neurofibrillary tangles in a non-Guamanian patient

Neurofibrillary tangles are described in Guamanian and post-encephalitic forms of motor neuron disease (MND) but not in sporadic MND. We report the neuropathological findings in a 79-year-old man who died after a 1-year history of MND without extrapyramidal features or dementia. There was no family history of neurological disease and he had not visited Guam. The spinal cord showed loss of anterior horn cells, and skeletal muscle typical changes of denervation. The brain appeared macroscopically normal but histology revealed many neurofibrillary tangles, particularly in medial temporal lobe structures, insula, nucleus basalis, hippocampus, oculomotor nucleus, raphe nuclei and locus ceruleus. Neurofibrillary tangles were not seen in the primary motor cortex, which appeared histologically unremarkable. Occasional tangles were present in the substantia nigra and pontine nuclei. None were seen in the cerebellum, medulla or spinal cord. The tangles were argyrophilic, and, in sections stained with thioflavin-S, both the intracellular and the extracellular tangles fluoresced strongly under ultraviolet light. The intracellular neurofibrillary tangles reacted strongly with an antibody to tau protein, and only occasional tangles showed weak ubiquitin immunoreactivity. Scattered neuropil threads were present in the cortex in the areas of neurofibrillary tangle formation. No plaques were present in any part of the brain and no A4/beta protein immunoreactivity was detected. Ultrastructural examination revealed Alzheimer-type neurofibrillary tangles composed of paired helical filaments. The present findings further extend the spectrum of diverse neurological disorders associated with neurofibrillary tangles.

Immunological evidence for the co-existence of the Lambert-Eaton myasthenic syndrome and myasthenia gravis in two patients

Two patients are described in whom a clinical and electromyographic diagnosis of the Lambert-Eaton myasthenic syndrome (LEMS) was made. Serum antibodies to voltage-gated calcium channels (VGCCs), the antigenic target in LEMS and to acetylcholine receptors (AChRs), the antigen in myasthenia gravis, were detected at raised titres in both cases, using radioimmunoassays based on 125I-omega-Conotoxin labelled VGCCs and 125I-alpha-Bungarotoxin labelled AChRs. These data provide immunological evidence for the coexistence of the two disorders in these patients.

Darkening of white hair in Parkinson's disease

We describe a patient with long-standing Parkinson's disease who noted that his white hair turned grey and darkened 8 months after the addition of carbidopa to his established levodopa (L-dopa) therapy and 4 months after the introduction of bromocriptine.

Genetic factors in myasthenia gravis: a family study

We studied forty-four patients with myasthenia gravis (MG) and their families. Thirty percent of patients had a confirmed family history of autoimmune disease; in one case this was MG. In all the families with autoimmune disease, the affected relatives were related to the patients through the maternal line. HLA-B8 and DR3 were increased in patients due to the high incidence of these antigens in female, nonthymoma patients with onset before 40 years. HLA-B5 was increased in patients with older onset. The haplotype A1-B8-DR3 was not found to be increased given the presence of B8 or DR3.

An evaluation of the British Pharmacopoeial assay of heparin: a comparison with other methods

The potencies of six commercially manufactured heparins have been measured by the British Pharmacopoeial (BP) assay and activated partial thromboplastin time (APTT), protamine sulphate, and anti-Xa assays. The APTT/BP potency ratios were found to vary with the preparation but this was not dependent on the tissue source of heparin. For mucosal heparins, the anti-Xa/BP potency ratios were close to unity, but for heparin of lung origin the anti-Xa potency was approximately one-quarter of the BP potency. Four heparin fractions prepared by column gel chromatography of a commercial heparin were similarly examined by all four assays, and there was a wide divergence between the BP potency estimates and those obtained with the other methods. The degree of divergence was found to depend on the molecular size of the fraction.

Aspirin, phenacetin, and the kidney: a rheumatism clinic study

In a rheumatism clinic study in Brisbane, the consumption of aspirin and phenacetin compounds (APC) containing more than one kilogram of aspirin and phenacetin was significantly associated with overt renal papillary necrosis (RPN) and with a renal score, but when more than one kilogram of aspirin was taken without phenacetin there was no such association. Analysis and comparison with the parallel New Zealand study showed an overall risk of RPN of at least 10-6% when more than one kilogram of aspirin was taken in APC form, and 0-3% when aspirin was taken without phenacetin. An additive interaction of phenacetin and aspirin is postulated. It is concluded that phenacetin use should be severely restricted.