Juvenile Dermatomyositis: what comes next? Long-term outcomes in childhood myositis from a patient perspective

BACKGROUND

To describe long-term outcomes in JDM using patient questionnaires and link to longitudinal, prospectively collected data for each patient within the Juvenile Dermatomyositis Cohort and Biomarker Study, UK and Ireland (JDCBS) to determine outcome predictors.  METHODS: JDCBS participants aged ≥ 16y completed the SF36, HAQ and a questionnaire regarding current disease features, medications, education and employment. Data collected from the JDCBS included disease subtype, demographics, clinical and laboratory features. Intensity indices were calculated for physician VAS, modified skin DAS, CMAS and MMT8 by dividing area under the curve (AUC) from longitudinal score trajectories by duration of study follow-up (y). Relationships between questionnaire and JDCBS clinical / laboratory data were investigated fitting statistical models appropriate for cross sectional and longitudinal data.

RESULTS

Of 190 questionnaires sent, 84 (44%) were returned. Average age of respondents was 20.6 years (SD 3.9), time since diagnosis was 12.4 years (SD 5.0), age at onset was 9.2 years (SD 4.3), female to male ratio 4.25:1. Forty-nine (59%) self-reported persistently active disease, 54 (65%) were still taking immunosuppressive medication. 14/32 at school/higher education reported myositis adversely affecting academic results. 18-24 year-olds were twice as likely to be unemployed compared the UK population (OR = 0.456, 95% CI 0.24, 0.84, p = 0.001). Participants ≥ 18 years were three times as likely to be living with a parent/guardian (OR = 3.39, p < 0.001). SF36 MCS and MMT8 intensity index scores were significantly correlated (ρ = 0.328, p = 0.007).

CONCLUSIONS

After 12.4 years, questionnaire responders reported self-perceived high rates of persistently active disease and medication use, reduced rates of employment and were more likely to live with a parent/guardian. Perceived persistently active muscle disease appeared to affect quality of life in these patients and was the most significant contributor to long-term outcomes. Our findings highlight the importance of including the patient perspective in the assessment of long term outcomes, so that that we can start to target initial management strategies more effectively based on a combination of clinical and patient-reported data.

Defining consensus opinion to develop randomised controlled trials in rare diseases using Bayesian design: An example of a proposed trial of adalimumab versus pamidronate for children with CNO/CRMO

Introduction

Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disorder primarily affecting children and adolescents. It can lead to chronic pain, bony deformities and fractures. The pathophysiology of CNO is incompletely understood. Scientific evidence suggests dysregulated expression of pro- and anti-inflammatory cytokines to be centrally involved. Currently, treatment is largely based on retrospective observational studies and expert opinion. Treatment usually includes nonsteroidal anti-inflammatory drugs and/or glucocorticoids, followed by a range of drugs in unresponsive cases. While randomised clinical trials are lacking, retrospective and prospective non-controlled studies suggest effectiveness of TNF inhibitors and bisphosphonates. The objective of the Bayesian consensus meeting was to quantify prior expert opinion.

Methods

Twelve international CNO experts were randomly chosen to be invited to a Bayesian prior elicitation meeting.

Results

Results showed that a typical new patient treated with pamidronate would have an 84% chance of improvement in their pain score relative to baseline at 26 weeks and an 83% chance on adalimumab. Experts thought there was a 50% chance that a new typical patient would record a pain score of 28mm (pamidronate) to 30mm (adalimumab) or better at 26 weeks. There was a modest trend in prior opinion to indicate an advantage of pamidronate vs adalimumab, with a 68% prior chance that pamidronate is superior to adalimumab by some margin. However, it is clear that there is considerable uncertainty about the precise relative merits of the two treatments.

Conclusions

The rarity of CNO leads to challenges in conducting randomised controlled trials with sufficient power to provide a definitive outcome. We address this using a Bayesian design, and here describe the process and outcome of the elicitation exercise to establish expert prior opinion. This opinion will be tested in the planned prospective CNO study. The process for establishing expert consensus opinion in CNO will be helpful for developing studies in other rare paediatric diseases.

Analysis of bovine viral diarrhoea virus: Biobank and sequence database to support eradication in Scotland

Samples from bovine viral diarrhoea virus (BVDV)-positive cattle were gathered by Scottish diagnostic laboratories and used to produce a Biobank of samples with associated location and identification data in support of the Scottish BVDV eradication scheme. The samples were subject to direct amplification and sequencing of the 5'-untranslated region (5'-UTR) to define the viral types and subtypes present. From 2693 samples collected prior to 2016, approximately 2300 sequences were obtained, representing 8 BVDV type 1 subtypes. No BVDV type 2 samples were detected. The samples came from all regions of the UK but 66 per cent were from Scotland. Analysis of the sequences showed great diversity in the 5'-UTR, with 1206 different sequences. Many samples carried virus with identical 5'-UTR sequences; often from single locations, but there were also examples of the same sequence being obtained from samples at several different locations. This work provides a resource that can be used to analyse the movement of BVDV strains both within Scotland and between Scotland and other nations, particularly in the latter stages of the Scottish eradication programme, and so inform the advice available to both livestock keepers and policymakers.

Differences in disease phenotype and severity in SLE across age groups

Objectives

Significant differences have been reported in disease phenotype and severity of systemic lupus erythematosus (SLE) presenting in different age groups. Most indicate a more severe phenotype in juvenile-onset SLE (JSLE). There have been limited studies in older patients and no large studies looking at SLE across all age groups.

Methods

We assessed the effect of age of onset of SLE on the clinical phenotype by analysing data from two large UK cohorts (the UK JSLE Cohort and the UCLH SLE cohort).

Results

A total of 924 individuals were compared (413 JSLE, 511 adult-onset SLE). A female preponderance was present, but less pronounced at either end of the age spectrum. Arthritis was more common with advancing age (93% vs 72%, p < 0.001), whereas renal disease (44% vs 33%, p = 0.001), alopecia (47% vs 23%, p < 0.001) and aphthous ulcerations (39% vs 26%, p = 0.001) were more common in the young. Neuropsychiatric lupus was less common in mature-onset SLE (p < 0.01). JSLE was associated more commonly with thrombocytopenia (21% vs 15%, p = 0.01), haemolytic anaemia (20% vs 3%, p < 0.001), high anti-dsDNA (71% vs 63%, p = 0.009), Sm (22% vs 16%, p = 0.02) and RNP (36% vs 29%, p < 0.04) auto-antibodies. Leucopenia increased with advancing age (p < 0.001). Mortality has been declining over recent decades. However, death rates were substantially higher than the general population. The standardized mortality ratio was 18.3 in JSLE and 3.1 in adult-onset SLE.

Conclusion

These data from the largest-ever direct comparison of JSLE with adult-onset SLE suggest an aggressive phenotype of disease with a worse outcome in patients with JSLE and emphasizes the importance of careful follow-up in this population.

The exaggerated inflammatory response in Behçet's syndrome: identification of dysfunctional post-transcriptional regulation of the IFN-γ/CXCL10 IP-10 pathway

The mechanisms underlying the exaggerated inflammatory response in Behçet's syndrome (BS) remain poorly understood. We investigated the response of CD14(+) blood monocytes to interferon (IFN)-γ, focusing on the chemokine CXCL10. Chemokine synthesis and release were analysed at a protein and mRNA level following stimulation with IFN-γ. Findings in BS patients were compared with 25 healthy controls (HC), 15 rheumatoid arthritis (RA) and 15 systemic lupus erythematosus (SLE) disease control patients. BS monocytes produced significantly more CXCL10 protein than HC monocytes from 2 h following IFN-γ stimulation, despite equivalent quantities of mRNA, suggesting more efficient translation. This was significantly more pronounced in BS with high disease activity and in those with ocular and neurological clinical manifestations. The imbalance between CXCL10 protein and mRNA expression was not observed in either RA or SLE patients, and was not seen with other chemokines studied (CXCL9, CXCL11 and CCL2). Furthermore, BS monocytes treated with an alternative stimulant (LPS) did not show abnormal tumour necrosis factor (TNF)-α release. Sucrose density gradients to segregate monocyte CXCL10 mRNA into free RNA or polysome-associated RNA showed equal proportions in BS and HC samples, suggesting that the difference between BS and HC may be due to reduced negative control of CXCL10 translation in BS at a post-initiation level. We conclude that BS monocytes have dysfunctional post-transcriptional regulation of CXCL10 mRNA, resulting in over-expression of CXCL10 protein upon IFN-γ stimulation. As CXCL10 is a chemokine that recruits mononuclear cells, this abnormality may contribute to the exaggerated inflammatory responses that characterizes BS.

Relapsing polychondritis: reversible airway obstruction or asthma

We describe a patient who presented with poorly controlled asthma. Bronchoscopy showed collapsing airways, characteristic of RP (relapsing polychondritis).

What is stuttering?

When it comes to stuttering, one must be very careful of a priori assumptions they may have formed about the nature of the disorder and its associated behaviors. A broad understanding and thorough familiarity with the evidence are essential to averting misinterpretations, such as those made by Wingate, concerning the bases of terminology (SLD) and category (part-word repetitions) selections. We understand Wingate’s impression regarding the primary role of syllable repetitions, given that typically they are the most common component in the disfluent speech behavior of those who stutter and that in many children they are the dominant disfluency type. Indeed, some children display few monosyllabic whole-word repetitions. Nevertheless, this does not mean that the monosyllabic whole-word repetitions, especially in very young children, are not a valid reflection of stuttering.

As we have shown, Wingate’s argument can be contested in several ways. Because some fundamental measures of accuracy, validity, and internal consistency, as well as reliance on published data, are essential for credibility, we believe that his letter represents a harsh violation of these principles. Wingate has offered an opinion, but that is the limit to the nature of his remarks. His points are merely opinions because he has not considered all the evidence and has not acknowledged all the facts regarding the nature of speech and its identification. Wingate frequently makes sweeping statements (e.g., there are "…clear-cut differences that exist between monosyllabic word repetitions and stutters" [Wingate, 2001, p. 383]) without any substantiation from the research literature and appears to be oblivious to progress in the field. His last paragraph, which completely distorts our record of research, is scientifically dangerous. Although we appreciate his previous contributions to the field, regrettably, as we have stated earlier, his letter fails to meet acceptable scientific standards. We respectfully suggest that Wingate’s call for honestly employed scientific methods in stuttering research be directed at his own writing.

Finally, our large longitudinal study on persistency and recovery in stuttering, as reported in the series of publications (e.g., Yairi & Ambrose, 1999), arbitrarily selected by Wingate for attack as a means to expose his opinion about the "real thing," has been repeatedly and rigorously reviewed by various panels of the National Institutes of Health, the agency supporting this work, and by the editorial boards of several scientific journals, including JSLHR . Having been found to be of sound quality, our ongoing project has been repeatedly approved, and its findings reported in many peer-reviewed publications. We take this record as an indication that many scholars in the field evaluate our research as meritorious.

Immune responses to Dermatophilus congolensis infections

Complex mechanisms underly the establishment of dermatophilosis, an exudative and proliferative skin disease of ruminants. This multicomponent system involves the bacterium Dermatophilus congolensis, transmission by various routes including flies, host genetic factors and immunosuppression by Amblyomma variegatum ticks. Here, Nick Ambrose and colleagues summarize recent evidence for an association between A. variegatum and severe chronic dermatophilosis in cattle. Breed-based differences in resistance to dermatophilosis are probably related to immunity to ticks or resistance to the immunosuppressive effects of ticks. Immunity to dermatophilosis might involve non-classic responses mediated by CD1 antigen presentation and gammadelta T cells. Progress towards vaccination is further complicated by strain-specific acquired immunity to D. congolensis.

Characterization and discrimination of three Theileria parva stabilates involved in East Coast fever vaccination

Three vaccine stabilates of Theileria parva, of which sporozoites are being used against East Coast fever, were characterized by immunological and molecular biology techniques before being used for a national vaccination campaign in Kenya. T. parva Marikebuni stabilates 316 and 3014, and T. parva Lanet were used in this study and were discriminated from other Kenyan field Theileria isolates. IFAT results showed that all the animals were producing antibodies regardless of the stock used. Primers designed on the TPR1 gene sequence were used for PCR and Decamers were used for RAPD. Specific DNA band patterns (1,877 bp; 1,059 bp, and 443 bp) for the three vaccine stocks were observed. These molecular markers could be used to trace vaccinated animals in Kenya and to identify which isolates are responsible for reactions in animals.

Children recovered from stuttering without formal treatment: perceptual assessment of speech normalcy

Current evidence suggests that young children who recover from stuttering are essentially stutter-free. However, there is no evidence to indicate if their speech is perceptually indistinguishable from normally fluent peers or whether they retain perceptually unusual speech. One important example of recovery from stuttering is children who have recovered without receiving formal treatment. An investigation was conducted to determine if the speech of these children is perceptually different from the speech of children who have never stuttered. Speakers consisted of 10 preschool and early school-age children documented as recovered from stuttering without benefit of formal treatment. In a series of studies they were compared with 10 children who had never stuttered. Three groups of judges-sophisticated, unsophisticated, and experienced-were separately asked, using videotaped speech samples of the children, to decide which samples were from children who used to stutter. Results revealed that the children who recovered from stuttering were perceptually indistinguishable from the normal controls. The same result was obtained regardless of whether the samples were presented in paired-stimulus or single-stimulus mode. Two of the groups of judges were also instructed to rate the speech naturalness of the speech samples. The speakers were not distinguished on this measure either. Methodological issues and the implications of the findings are discussed.

Genetics of stuttering: a critical review

The fact that stuttering runs in families has been documented over a long period and has led to speculations and research about the role of a genetic component to this disorder. Although the genetic factor cannot be proved by familial aggregation and twin studies alone, such research has continued to provide support for a relationship between stuttering and genetics. The purposes of this article are to review and critique the research in this area. The article first assesses research methodologies that have been employed in familial studies of stuttering. It proceeds to review and critique incidence, twin, and aggregation studies. In addition, it includes sections on subgroups, genetic models of stuttering, and implications for future research as well as for clinical work. With a focus on improved methodology and recent findings, a current perspective on our knowledge of the genetic component to stuttering is provided. Among other conclusions, the article emphasizes that failure to consider epidemiologic factors has probably biased previous results regarding the genetics of stuttering. New preliminary data also appear to provide evidence that spontaneous recovery and chronicity are influenced by genetic factors. Generally, however, the review of incidence and twin studies, as well as of evidence for the various inheritance models, confirms previous conclusions about the interaction between genetic and environmental factors in stuttering.