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.

A population-based study on the quality of life for cancer patients as reported in a tumor registry follow-up

8594

Background: Between 1/96 and 3/00, 94,516 SF-36 or SF-12 Quality of Life (QOL) forms were sent to every patient on the Mayo Clinic tumor registry not seen at the clinic in the last year. This study is a descriptive summary of each patient’s first reported QOL score. Method: QOL scores were combined with tumor registry information about age, gender, tumor site, tumor stage, residence, and date of diagnosis. Responder versus non-responder characteristics were compared via Fisher’s exact tests and two-sample t-tests. Means and standard deviations were used to summarize the data. Patient reported scores and SF norms from a healthy population were compared using one sample t-tests. Results: Data were available on 28,166 patients (48,463 forms). Men were more likely to respond. More patients were male (56%) with a mean age of 66 and filled out their first SF form an average of 9 years after their initial diagnosis. Overall, mean physical and mental subscale scores were not clinically different from the age- and sex-adjusted SF normative data (Table). Within tumor sites, mental subscale scores were similar to the general population. Physical subscale scores were also approximately normal within each of the tumor sites. The exceptions were that patients with lung or musculoskeletal cancers tended to report lower physical scores than a healthy population. Conclusions: Patients responding to a tumor registry follow-up program reported QOL scores that were not clinically different from that of a healthy population. QOL deficits observed in patients with lung cancer and musculoskeletal cancers may indicate a need for targeted interventions specific for these cancer patient populations.

[Table: see text]

No significant financial relationships to disclose.

The relationship between cancer patient treatment decision-making roles and quality of life (QOL)

6075

Background: Failing to meet patient expectations for participating in treatment decisions impacts satisfaction with care, but it is unknown whether this translates into QOL deficits. As part of a larger survey of cancer survivors conducted by the American Cancer Society (ACS), data were gathered on the role patients in Minnesota preferred and the role actually experienced during the treatment decision-making process. Methods: Patients who were diagnosed with one of the ten most common cancers in 2000 completed a survey containing the Profile of Mood States (POMS), the SF-36, and the Control Preferences Scale (CPS). Fisher’s exact tests compared role preference distributions across demographic categories. Two-sample t-tests compared the POMS and SF-36 scores between patients whose preferred role preference was concordant with the role experienced and those with discordant preferred and actual roles. Results: 33% of the 599 consenting patients preferred an active role in treatment decision-making, 52% preferred a collaborative role, and 13% preferred a passive role. The actual roles experienced were 33% active, 50% collaborative, 17% passive. Over 88% of patients had concordant preferred and actual roles. Patients with concordant roles had higher SF-36 physical scores (45 vs 40, p=0.004), higher vitality (50 vs 42, p=0.005), less fatigue (70.2 vs 60.1, p=0.001), better concentration (84 vs 79, p=0.008) and better overall mood (77 vs 73, p=0.006). Role preference differed across gender (p=0.0002) in that more women preferred a collaborative role than men (57.8% vs 45.5%) and fewer women preferred a passive role (9% vs 17.3%). Patients under age 50 experienced more active roles in treatment decisions than those aged 50+ (p=0.04). Patients reporting an active actual role had higher SF-36 physical scores (p=0.005) and higher POMS vigor subscale scores (p=0.04). There were no differences in QOL scores for preferred roles. Conclusions: Patients who experienced discordance between their preferred role and their experience reported substantial QOL deficits in both physical and emotional domains. Oncologists can improve patient satisfaction with care and QOL by meeting patient expectations with respect to the amount of input they have in making treatment decisions.

No significant financial relationships to disclose.

From parallel policies to integrated practice: PMS and PCG/Ts

This paper describes findings from an exploratory study of attempts by primary care clinicians and managers to utilize two distinct Government policy initiatives (the establishment of Primary Care Groups [PCGs] and Trusts [PCTs] and the establishment of Primary Medical Services [PMS] pilots) to promote innovation in primary care. The study purposively selected three whole PCG-PMS sites and one PCT-PMS site. A range of different qualitative methods were used to collect data. Although the data suggest that attempts to integrate the two policies produced impressive corporate innovation by practices working together to benefit patients in whole localities, the four sites shared features that would not necessarily be present in all PCG/Ts. These include a strong history of inter-practice working, mutually supportive relationships between clinicians and managers, and a carefully designed, managed and inclusive change process led by credible clinicians. The study has implications for the continuing implementation of both policies, especially in view of the increasing size of PCTs.

Inequalities in access to healthcare faced by women who are deaf

The Cheshire Deaf Women's Health Project undertook a research study to assess the access to healthcare of women who are deaf in Cheshire, UK. Group discussions took place with 13 women who were hard of hearing and 14 women who were Deaf Sign Language users. Questionnaires were distributed to a stratified random sample of 103 women taken from the social services register, 38 of which were returned. In order to reach more women whose first language was British Sign Language, 129 questionnaires were distributed to the leaders of various clubs and organizations for people who are deaf, and 100 of these were returned. The data revealed inequities in access to healthcare. For example, women who are deaf face a lack of awareness by health staff of how to communicate with them. The survey confirmed that these problems are of major importance to the majority of women who are deaf. For example, fewer than one in 10 deaf women said that they usually fully understand what the doctor says to them when they visit the doctor on their own. There are many other difficulties faced by women who are deaf, leading to inequalities when they are compared with hearing people. Almost half the respondents said that they would be more likely to use health services if help and/or services for deaf women were available. The introduction of various relatively simple measures would greatly help to reduce the inequalities of access to healthcare faced by deaf women. Under the terms of the Disability Discrimination Act 1995, such action is essential if providers are to avoid facing possible legal action.

Personal medical services. Friends and relations

Personal medical services pilot schemes remain internally focused. In many areas hospital doctors' willingness to work with general practice has been hampered by chief executives' fear of loss of income. Health authorities have generally failed to take responsibility for the pilot schemes. There are some fears of the schemes creating inequity at local level.

Primary care. This is your pilot speaking

An evaluation of 14 personal medical services pilot schemes has found the GPs involved welcome the reduction in paperwork. The flexibility in funding of the schemes has allowed GPs greater leeway in managing their workload. Some of the financial risks of running a practice have been removed. It is questionable whether the schemes are fully using the freedoms envisaged. Some schemes reported a lack of support from their health authority.

Effects of anesthetic technique on side effects associated with fentanyl Oralet premedication

STUDY OBJECTIVES

To evaluate the efficacy of 5 to 10 micrograms/kg of oral transmucosal fentanyl citrate (OTFC) as an anesthetic premedication, and to determine whether propofol induction reduces postoperative nausea and vomiting (PONV) in pediatric patients premedicated with OTFC undergoing outpatient surgery.

DESIGN

Prospective, randomized, double-blinded study.

SETTINGS

University of Michigan Health Care Systems and University of Arizona.

PARTICIPANTS

62 ASA physical status I and II children aged 4 to 14 years (8.9 +/- 0.5 years).

INTERVENTIONS

Subjects were randomly assigned to one of four groups: (1) OTFC premedication and halothane induction; (2) OTFC premedication and propofol induction; (3) placebo premedication and halothane induction; and (4) placebo premedication and propofol induction. OTFC or placebo was administered 30 minutes prior to induction, and activity (sedation), apprehension, and cooperation scores were recorded before, at 15 and 30 minutes after study drug, and on induction. All perioperative adverse events were recorded.

MEASUREMENTS AND MAIN RESULTS

Children who received OTFC became drowsier and had a significant change from baseline in combined activity, apprehension, and cooperation scores, whereas those who received placebo became less cooperative at induction. Patients who received OTFC experienced more adverse events overall (p < 0.001) than patients who received placebo. Additionally, OTFC patients experienced more vomiting (p < 0.001) and pruritus (p = 0.049) than controls. The incidence of PONV in patients who received OTFC and halothane induction was 50%, compared to 30% in patients receiving OTFC and a propofol induction (p = NS).

CONCLUSIONS

OTFC in doses of 5 to 10 micrograms/kg was effective in producing sedation and facilitating cooperation with induction; however, it was associated with significant PONV in our study. Although propofol induction did not significantly reduce PONV in our study, further study with a larger sample, and with propofol as the sole anesthetic, may be warranted.

Should pregnancy testing be routine in adolescent patients prior to surgery?

The reliability of the preoperative history obtained from adolescent patients in ruling out pregnancy was prospectively evaluated. Four hundred forty-four patients who underwent 525 procedures were questioned preoperatively regarding the possibility of pregnancy. Regardless of the history, a urine pregnancy test was ordered in accordance with institutional practice. In 508 cases, patients denied the possibility of pregnancy. Eight patients stated that they might be pregnant, and in six cases the parents responded for the patients and denied the possibility of pregnancy. Seventeen patients were not tested due to patient/parent refusal (n = 9) or inability to void (n = 8). All pregnancy tests were negative except one that was questionably negative. This patient had denied the possibility of pregnancy and had been anesthetized prior to test results. Follow-up revealed that the patient was not pregnant. Our data demonstrate that the preoperative history obtained from adolescent patients at our institution regarding their pregnancy status was in agreement with pregnancy test results. We suggest that a detailed history regarding last menstrual period, contraception, sexual activity, and the possibility of pregnancy be obtained in all postmenarchal patients presenting for surgery. Although in other populations history and pregnancy testing did not agree 100% of the time, for our adolescent population, human chorionic gonadotrophin (HCG) testing appears to be necessary only if indicated by patient history.

From FPC to FHSA to ... health commission?

Images

New alkyl N,N-dialkyl-substituted amino acetates as transdermal penetration enhancers

New alcohol derivatives of N,N-disubstituted amino acids with a low toxicity have been synthesized and evaluated for their transdermal penetration enhancing effects on the transport of indomethacin from petrolatum ointments across shed skin of black rat snake (Elaphe obsoleta). The derivatives show excellent penetration enhancement of indomethacin, as high as 3.8 times that of Azone, with decyl N,N-dimethylamino acetate as the lead compound in the series. The release of indomethacin from an ointment containing 1% indomethacin, 5% dodecyl N,N-dimethylamino acetate, and 94% petrolatum was 3.15 micrograms/min1/2/cm2. Saturation studies performed by incorporating varying concentrations of indomethacin, from 0.1 to 10%, into the ointments and determination of the fluxes of indomethacin demonstrated that the saturated concentration of indomethacin in petrolatum base was approximately 1%. Penetration fluxes of indomethacin (1%) through snake skin increased linearly as the concentration of dodecyl N,N-dimethylamino acetate increased from 2.5 to 15%. Experiments involving the pretreatment of the snake skins with dodecyl N,N-dimethylamino acetate indicated that pretreatment of the skin increased the skin permeability significantly. Electron micrograph studies on the snake skin treated with dodecyl N,N-dimethylamino acetate show clearly that the enhancer interacted with both the lipid-rich layer (mesos phase) and the keratin-rich layers (both alpha and beta phases).

Unsaturated cyclic ureas as new nontoxic biodegradable transdermal penetration enhancers I: Synthesis

A new concept was implemented to reduce the toxicity of some new biodegradable transdermal penetration enhancers. These enhancers consist of 1-alkyl-4-imidazolin-2-one and a long-chain alkyl ester group at the N-3 position. The synthesis involves N-alkylation of the parent compound with soft alkylating agents which were prepared in high yields by an improved method. A phase transfer catalysis technique using KOH as the base, tetrabutylammonium bromide as the catalyst, and toluene as the solvent was found to be most effective in the N-alkylation step.

Effects of incubation temperature and bicarbonate on maturation of pig oocytes in vitro

Pig oocytes cultured at 39 degrees C had a higher percentage of polar body formation than did those cultured at 37 degrees C. A culture medium based on Medium 199 with Earle's salts and supplemented with 15% serum from a young castrated boar was just as good as the same formulation containing additional pyruvate, lactate and insulin, and superior to a modified Krebs-Ringer bicarbonate medium. When the bicarbonate buffer system (Earle's salts) of Medium 199 was replaced with a phosphate buffer system (Hank's salts), the rate of polar body formation was decreased. When the Hank's based medium was supplemented with a bicarbonate buffer system, polar body formation was restored to the level in Earle's based medium. This suggests that CO2/bicarbonate may be important for the normal maturation of pig oocytes.

The proper contributions of social workers in health practice

Current and potential future contributions of social workers to health practice are considered at the three levels of direct service to patients, influence on the processes and procedures of the health setting and influence on its future planning and service development. The capacity of U.S.A. and U.K. social work to contribute at these levels is compared in the light of their contrasting relationships to the health system. U.S.A. social work in health care is practised as employees of the health setting or as private practitioners and contains the majority of U.S.A. social workers. It remains a specialism that sustains a major body of published work, commitment to knowledge-building, standard setting and performance review, and a psycho-social orientation shared by a growing number of medical and nursing professionals. Its approach to the health system is that of the pursuit of professional credibility in the secondary setting by adopting the professional-technical practice model of the clinician. U.K. social work since the early 1970s has been committed to generic education and practice and to the development of its own primary setting in social services departments which now employ almost all U.K. social workers. Area team social work in these departments, typified by statutory work with the most deprived sections of the population, has become the dominant culture of British social work, with implications for the occupational identity and career prospects of those social workers who are outposted or attached to health settings but no longer employed by them. British social work and its management now approach the health system from a position of organizational independence which should strengthen their capacity to influence the health system. The cultural differences between social work and medicine, however, are experienced more keenly than ever as many social workers adopt a socio-political practice model that is at odds with the professional-technical model of the clinician. Provision of social work services to the health system has become a questionable priority and raises the issue of whether much of what is now termed "health care' could more appropriately be termed "social care' and provided in a primary social work setting to which medicine and nursing would make their "proper contributions'.

Multiple biological activities of homogeneous human alpha interferon

To identify the active molecule in human alpha interferon preparations, we performed several studies, using both partially purified interferon and homogeneous interferon. Our results indicated that there is little difference between the partially purified and the homogeneous interferon preparations in terms of antiviral activity, inhibition of deoxyribonucleic acid synthesis in human neoplastic cells, and enhancement of human natural killer cell activity.

"Who cares?" A comment on the Australian general practitioner

The recent Australian publication "Who cares?" offers the family medicine student and the family physician: Affirmation of the preminence of the GP as the professional of first resort for a wide range of Australian families. A typology of families in terms of the way they relate to health care and its providers. A picture of the experience of health care offered to some Australian families, and its relevance to their condition. A typology of GPs in terms of their willingness to extend their role to include the family's total 'welfare'. Criticism of the GP in failing to refer patients to existing community services. Implications for medical education in terms of development of the GP's communication skills in relation to both patients and other health and welfare professionals.

Social work and general practice: a review article

Closer collaboration with social workers may be a means of enabling the general practitioner to deal with the psychosocial problems expressed in his practice. Emerging interest on the part of general practitioners in exploring the potential contribution of the social worker to patient care is accompanied by some anxiety and ambivalence. Reports of collaborative projects have come mainly from the United Kingdom, and although these offer some guidelines, it is imperative that any policy proposals for the development of closer general practitioner-social worker collaboration in Australia be grounded in an Australian data base.