A decade of progress in juvenile idiopathic athritis treatments and outcomes in Canada: results from ReACCh-Out and the CAPRI registry

OBJECTIVE

To assess changes in juvenile idiopathic arthritis (JIA) treatments and outcomes in Canada, comparing a 2005-2010 and a 2017-2021 inception cohorts.

METHODS

Patients enrolled within three months of diagnosis in the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) and the Canadian Alliance of Pediatric Rheumatology Investigators Registry (CAPRI) cohorts were included. Cumulative incidences of drug starts and outcome attainment within 70 weeks of diagnosis were compared with Kaplan Meier survival analysis and multivariable Cox regression.

RESULTS

The 2005-2010 and 2017-2021 cohorts included 1128 and 721 patients, respectively. JIA category distribution and baseline clinical juvenile idiopathic arthritis disease activity (cJADAS10) scores at enrolment were comparable. By 70 weeks, 6% of patients (95% CI 5, 7) in the 2005-2010 and 26% (23, 30) in the 2017-2021 cohort had started a biologic DMARD (bDMARD), and 43% (40, 47) and 60% (56, 64) had started a conventional DMARD (cDMARD), respectively. Outcome attainment was 64% (61, 67) and 83% (80, 86) for Inactive disease (Wallace criteria), 69% (66, 72) and 84% (81, 87) for minimally active disease (cJADAS10 criteria), 57% (54, 61) and 63% (59, 68) for pain control (<1/10), and 52% (47, 56) and 54% (48, 60) for a good health-related quality of life.

CONCLUSION

Although baseline disease characteristics were comparable in the 2005-2010 and 2017-2021 cohorts, cDMARD and bDMARD use increased with a concurrent increase in minimally active and inactive disease. Improvements in parent and patient reported outcomes were smaller than improvements in disease activity.

Predictors of persisting pain in children with Juvenile Idiopathic Arthritis: a case control study nested in the ReACCh-Out cohort

BACKGROUND

To identify baseline predictors of persisting pain in children with Juvenile Idiopathic Arthritis (JIA), relative to patients with JIA who had similar baseline levels of pain but in whom the pain did not persist.

METHODS

We used data from the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) inception cohort to compare cases of 'moderate persisting pain' with controls of 'moderate decreasing pain'. Moderate pain was defined as a Visual Analogue Scale (VAS) for pain measurement score of > 3.5 cm. Follow-up was minimum 3 years. Univariate and Multivariate logistic regression models ascertained baseline predictors of persisting pain.

RESULTS

A total of 31 cases and 118 controls were included. Mean pain scores at baseline were 6.4 (SD 1.6) for cases and 5.9 (1.5) for controls. A greater proportion of cases than controls were females (77.4% vs 65.0%) with rheumatoid factor positive polyarthritis (12.9% vs 4.2%) or undifferentiated JIA (22.6% vs 8.5%). Oligoarthritis was less frequent in cases than controls (9.7% vs 33%). At baseline, cases had more active joints (mean of 11.4 vs 7.7) and more sites of enthesitis (4.6 vs 0.7) than controls. In the final multivariate regression model, enthesitis count at baseline (OR 1.40, CI 95% 1.19-1.76), female sex (4.14, 1.33-16.83), and the overall Quality of My Life (QoML) baseline score (0.82, 0.69-0.98) predicted development of persisting pain.

CONCLUSIONS

Among newly diagnosed children with JIA with moderate pain, female sex, lower overall quality of life, and higher enthesitis counts at baseline predicted development of persisting pain. If our findings are confirmed, patients with these characteristics may be candidates for interventions to prevent development of chronic pain.

Risk factors associated with Pneumocystis jirovecii pneumonia in juvenile myositis in North America

OBJECTIVES

Pneumocystis jirovecii pneumonia (PJP) is associated with significant morbidity and mortality in adult myositis patients; however, there are few studies examining PJP in juvenile myositis [juvenile idiopathic inflammatory myopathy (JIIM)]. The purpose of this study was to determine the risk factors and clinical phenotypes associated with PJP in JIIM.

METHODS

An research electronic data capture (REDCap) questionnaire regarding myositis features, disease course, medications and PJP infection characteristics was completed by treating physicians for 13 JIIM patients who developed PJP (PJP+) from the USA and Canada. Myositis features and medications were compared with 147 JIIM patients without PJP (PJP-) from similar geographic regions who enrolled in National Institutes of Health natural history studies.

RESULTS

PJP+ patients were more often of Asian ancestry than PJP- patients [odds ratio (OR) 8.7; 95% CI 1.3, 57.9]. Anti- melanoma differentiation associated protein 5 (MDA5) autoantibodies (OR 12.5; 95% CI 3.0, 52.4), digital infarcts (OR 43.8; 95% CI 4.2, 460.2), skin ulcerations (OR 12.0; 95% CI 3.5, 41.2) and interstitial lung disease (OR 10.6; 95% CI 2.1, 53.9) were more frequent in PJP+ patients. Before PJP diagnosis, patients more frequently received pulse steroids, rituximab and more immunosuppressive therapy compared with PJP- patients. Seven PJP+ patients were admitted to the intensive care unit and four patients died due to PJP or its complications.

CONCLUSIONS

PJP is a severe infection in JIIM that can be associated with mortality. Having PJP was associated with more immunosuppressive therapy, anti-MDA5 autoantibodies, Asian race and certain clinical features, including digital infarcts, cutaneous ulcerations and interstitial lung disease. Prophylaxis for PJP should be considered in juvenile myositis patients with these features.

NF-κB-mediated effects on behavior and cartilage pathology in a non-invasive loading model of post-traumatic osteoarthritis

OBJECTIVE

This study aimed to examine the temporal activation of NF-κB and its relationship to the development of pain-related sensitivity and behavioral changes in a non-invasive murine knee loading model of PTOA.

METHOD

Following knee injury NF-κB activity was assessed longitudinally via in vivo imaging in FVB. Cg-Tg (HIV-EGFP,luc)8Tsb/J mice. Measures of pain-related sensitivity and behavior were also assessed longitudinally for 16 weeks. Additionally, we antagonized NF-κB signaling via intra-articular delivery of an IκB kinase two antagonist to understand how local NF-κB inhibition might alter disease progression.

RESULTS

Following joint injury NF-κB signaling within the knee joint was transiently increased and peaked on day 3 with an estimated 1.35 p/s/cm2/sr (95% CI 0.913.1.792 p/s/cm2/sr) fold increase in signaling when compared to control joints. Furthermore, injury resulted in the long-term development of hindpaw allodynia. Hyperalgesia withdrawal thresholds were reduced at injured knee joints, with the largest reduction occurring 2 days following injury (estimate of between group difference 129.1 g with 95% CI 60.9,197.4 g), static weight bearing on injured limbs was also reduced. Local delivery of an NF-κB inhibitor following joint injury reduced chondrocyte death and influenced the development of pain-related sensitivity but did not reduce long-term cartilage degeneration.

CONCLUSION

These findings underscore the development of behavioral changes in this non-invasive loading model of PTOA and their relationships to NF-κB activation and pathology. They also highlight the potential chondroprotective effects of NF-κB inhibition shortly following joint injury despite limitations in preventing the long-term development of joint degeneration in this model of PTOA.

Somatosensory Testing in Pediatric Patients with Chronic Pain: An Exploration of Clinical Utility

We aimed to evaluate the utility of clinical somatosensory testing (SST), an office adaptation of laboratory quantitative sensory testing, in a biopsychosocial assessment of a pediatric chronic somatic pain sample (N = 98, 65 females, 7–18 years). Stimulus–response tests were applied at pain regions and intra-subject control sites to cutaneous stimuli (simple and dynamic touch, punctate pressure and cool) and deep pressure stimuli (using a handheld pressure algometer, and, in a subset, manually inflated cuff). Validated psychological, pain-related and functional measures were administered. Cutaneous allodynia, usually regional, was elicited by at least one stimulus in 81% of cases, most frequently by punctate pressure. Central sensitization, using a composite measure of deep pressure pain threshold and temporal summation of pain, was implied in the majority (59.2%) and associated with worse sleep impairment and psychological functioning. In regression analyses, depressive symptoms were the only significant predictor of pain intensity. Functional interference was statistically predicted by deep pressure pain threshold and depressive symptoms. Manually inflated cuff algometry had comparable sensitivity to handheld pressure algometry for deep pressure pain threshold but not temporal summation of pain. SST complemented standard biopsychosocial assessment of pediatric chronic pain; use of SST may facilitate the understanding of disordered neurobiology.

Bilateral Neonatal Suppurative Sialadenitis Progressing to Abscess Formation in a Preterm Neonate

Aims We report a case of bilateral neonatal suppurative sialadenitis (NSS) in an extremely low birth weight infant (ELBW). Methods The infant developed bilateral sub-mandibular swelling at 3 weeks of age. NSS with abscess was confirmed with ultrasound. Despite intravenous antibiotic therapy the masses increased in size and developed abscesses. Results Unilaterally the abscess discharged via Wharton’s duct necessitating intubation to protect the airway. The abscess remnant was incised and drained. Culture grew a methicillin sensitive staphyloccocus aureus. The NSS resolved following two weeks of antibiotics. Conclusion We wish to highlight the importance of early recognition of this rare condition in preterm neonates.

Iron Refractory Iron Deficiency Anaemia: A Rare Cause of Iron Deficiency Anaemia

We describe the case of a 17-month-old boy with a hypochromic microcytic anaemia, refractory to oral iron treatment. After exclusion of dietary and gastrointestinal causes of iron deficiency, a genetic cause for iron deficiency was confirmed by finding two mutations in the TMPRSS6 gene, consistent with a diagnosis of iron-refractory iron deficiency anaemia (IRIDA).

A qualitative study of the language of satisfaction in children with pain

Background

Measures of satisfaction are essential to understanding patient experience, in general, and particularly with pain management.

Objectives

(A) To identify the words children commonly use to communicate satisfaction, in general, and for pain management and (B) to determine if this vocabulary matches their caregivers.

Methods

A study of child-caregiver pairs seen at a paediatric emergency department (PED) from July to November 2014 was conducted. Children were interviewed using ten open-ended questions. Grounded theory was employed for data coding and analysis. Caregivers completed a written survey.

Results

A total of 105 child interviews were completed (n=53 females, mean age 9.91, SD 3.71, age range 4 to 16); 105 caregiver surveys were completed (n=80 females). Children (n=99) most commonly used 'good', 'better' and 'happy' to express satisfaction with pain management (27%, 21% and 22%, respectively), with PED care (31%, 14% and 33%) and in general (13%, 5% and 49%). Children (n=99) used the words 'sad', 'bad' and 'not good' to communicate dissatisfaction with pain management (21%, 7% and 11%, respectively) and with PED care (21%, 13% and 12%). Only 56% of children (55/99) were familiar with the word 'satisfaction'. Children's word choices were similar to their caregivers' word choices, 14% (14/99) of the time.

Conclusion

Children use simpler words than their caregivers, including good, better and happy, when communicating satisfaction. A child's vocabulary is seldom the same as the vocabulary their caregiver uses, therefore caregiver vocabulary should not be used as a surrogate for paediatric patients. The word 'satisfaction' should be avoided, as most children lack understanding of the term.

Reaching poor populations with cancer prevention and early detection programs

The American Cancer Society (ACS), Philadelphia Division, through its Nurses' Education Committee (NEC), accepted the challenge to provide cancer prevention and early detection programs to several culturally diverse populations to directly reach the underserved, the working poor, and healthcare professionals who care for the poor. Populations selected included (1) students enrolled in nursing-assistant programs, (2) committed members of the ACS's NEC, (3) registered nurses employed by the local department of public health, and (4) a group of female immigrants from Russia.

Mechanisms of multidrug resistance in HL60 cells. Analysis of resistance associated membrane proteins and levels of mdr gene expression

HL60 cells isolated for resistance to Adriamycin do not contain P-glycoprotein, as determined with immunological probes. These cells, however, are multidrug resistant and defective in the cellular accumulation of drug. In view of these findings, we have examined in greater detail certain properties of the HL60/Adr cells and have compared these properties to an HL60 drug-resistant isolate (HL60/Vinc) which contains high levels of P-glycoprotein. The results of these studies demonstrated that verapamil induces a major increase in cellular drug accumulation in both HL60/Adr and HL60/Vinc isolates. An 125I-labeled photoaffinity analog of verapamil labeled P-glycoprotein contained in membranes of HL60/Vinc cells. In contrast, this agent did not label any protein selectively associated with drug resistance in membranes of the HL60/Adr isolate. The photoactive dihydropyridine calcium channel blocker [3H]azidopine and [125I]NASV, a photoaffinity analog of vinblastine, labelled P-glycoprotein in membranes from HL60/Vinc cells, whereas in experiments with the HL60/Adr isolate there was no detectable labeling of a drug resistance associated membrane protein. Additional studies have been carried out to analyze membrane proteins of HL60/Adr cells labeled with the photoaffinity agent 8-azido-alpha-[32P]ATP (AzATP32). The results demonstrate that this agent labeled a resistance associated membrane protein of 190 kilodaltons (P190). P190 is essentially absent in membranes of drug-sensitive cells. Labeling of P190 with AzATP32 in membranes of resistant cells was blocked completely when incubations were carried out in the presence of excess unlabeled ATP. Additional studies were carried out to analyze mdr gene amplification and expression in sensitive and resistant cells. Experiments carried out with human 5',mdr1 (1.1 kb) and mdr3 (1.0 kb) cDNAs demonstrate that both of these sequences were highly amplified in the HL60/Vinc isolate. Only the mrd1 gene sequence however, was overexpressed. In contrast, there was no detectable amplification or overexpression of mdr1 or mdr3 sequences in HL60/Adr cells. The results of this study thus identify a new nucleotide binding protein which is overexpressed in membranes of HL60 cells isolated for resistance to Adriamycin. P190, which exhibits properties distinct from P-glycoprotein, possibly functions in the energy-dependent drug efflux system contained in the HL60/Adr resistant isolate.

Multiple mechanisms of adriamycin resistance in the human leukemia cell line CCRF-CEM

CEM cells exhibiting a 25-fold (C25X) or 80-fold (C80X) increase in resistance to adriamycin were isolated and characterized. C25X cells were cross-resistant to daunomycin and etoposide (VP-16) but not to vincristine or colchicine. These cells were not defective in the cellular accumulation of drug and did not contain detectable levels of P-glycoprotein. Continued exposure of C25X cells to adriamycin resulted in increased levels of resistance and additional phenotypic changes. These cells (C80X) now contained high levels of P-glycoprotein and were cross-resistant to a variety of agents including vincristine and colchicine. A fluorometric assay for DNA unwinding was used to measure levels of drug-induced DNA breaks in sensitive and C25X resistant cells. Studies carried out with VP-16, 4'9-acridinyl-aminomethanesulfon-m-anisidide (m-AMSA), adriamycin, or daunomycin showed that the level of drug-induced DNA strand breakage in resistant cells was considerably less than that occurring in drug-treated sensitive cells. These studies, therefore, show that treatment of CEM cells with adriamycin resulted in a nuclear alteration that contributed to drug resistance. They also demonstrate that prolonged treatment of cells with adriamycin resulted in membrane alterations that affect cellular drug accumulation. Adriamycin resistance in CEM cells can thus occur as a result of at least two distinct mechanisms.

Mechanisms of multidrug resistance in HL60 cells: evidence that a surface membrane protein distinct from P-glycoprotein contributes to reduced cellular accumulation of drug

HL60 cells exhibiting a 140-fold increase in resistance to vincristine contain three surface membrane proteins with molecular weights of 210,000 (P210), 180,000 (P180), and 150,000 (P150) which are highly phosphorylated in vivo and in an in vitro system in the presence of Mn2+ and [gamma-32P]ATP. These phosphorylated proteins are either absent or present in very low levels in membranes of drug-sensitive cells. Growth of the vincristine-resistant isolate in the absence of drug results in a decrease in the level of resistance and a major reduction in the phosphorylation of P210 and P180. The phosphorylation of P150 is not altered in the revertant which still exhibits substantial levels of resistance. Further studies show that P210 and P180 are highly reactive with a monoclonal antibody against P-glycoprotein. These two proteins are present in only very low levels in revertant cells. The monoclonal antibody exhibits no reactivity with P150. In HL60 cells isolated for a 25-fold increase in vincristine resistance proteins reactive with P-glycoprotein monoclonal antibody are essentially absent. P150 is however highly phosphorylated in these cells. Additional experiments using lectin binding of 32P-labeled proteins demonstrates that P150 has properties distinct from P210 and P180. Analysis of drug uptake patterns in the vincristine-resistant isolates and the revertant shows that resistance is related to a reduced intracellular accumulation of drug. Reduced accumulation of vincristine is also found in HL60 cells isolated for resistance to Adriamycin. These cells are devoid of P-glycoprotein but contain phosphorylated P150. These results suggest that proteins P150, P180, and P210 may contribute to multidrug resistance in HL60 cells through a mechanism which involves reduced cellular accumulation of drug. P180 and P210 are structurally related whereas P150 is distinct from these two proteins.

Adriamycin resistance in HL60 cells in the absence of detectable P-glycoprotein

Previous studies have shown that the development of multi-drug resistance in cell lines treated with chemotherapeutic agents is closely associated with the overexpression of a 170-180 kilodalton surface membrane glycoprotein (P-glycoprotein). In the present study a monoclonal antibody against the P-glycoprotein was used to determine if this protein is overexpressed in multi-drug resistant HL60 cells. Using either indirect immunofluorescent staining or immunoblot analysis P-glycoprotein could not be detected in HL60 cells isolated for resistance to adriamycin. In contrast HL60 cells isolated for resistance to vincristine contain the P-glycoprotein and the amount of this material increases with increasing levels of resistance. These studies thus demonstrate adriamycin resistance in P-glycoprotein negative HL60 cells. Furthermore adriamycin and vincristine are found to have distinct effects in inducing overexpression of P-glycoprotein in the HL60 cell line. This information could be useful in the development of therapeutic strategies for the treatment of certain forms of cancer.

A new Legionella species, Legionella feeleii species nova, causes Pontiac fever in an automobile plant

From 15 to 21 August 1981, Pontiac fever affected 317 automobile assembly plant workers. Results of serologic tests were negative for Mycoplasma, Chlamydia, respiratory tract viruses, and previously described legionellae. A gram-negative, rod-shaped organism (WO-44C) that did not grow on blood agar, required L-cysteine for growth, and contained large amounts of branched-chain fatty acids was isolated from a water-based coolant. The organism did not react with antisera against other legionellae, and on DNA hybridization the organism was less than 10% related to other Legionella species. Geometric mean titers found by indirect fluorescent antibody testing to WO-44C were significantly higher in ill employees than in controls (p = 0.0001). Attack rates by department decreased linearly with the department's distance from the implicated coolant system. The etiologic agent apparently was a new Legionella species; we propose the name Legionella feeleii species nova (AATC 35072). This is the first outbreak of nonpneumonic legionellosis in which the etiologic agent is not L. pneumophila, serogroup 1.

Substrate stabilization of lysozyme to thermal and guanidine hydrochloride denaturation

The thermal and guanidine hydrochloride (GdnHCl) denaturation of lysozyme has been investigated at various concentrations of tri-N-acetylglucosamine ((GlcNAc)3), a trisaccharide which binds specifically at the active site of native lysozyme. The presence of (GlcNAc)3 leads to a readily observable stabilization of the protein to thermal and GdnHCl denaturation. An analysis of guanidine hydrochloride denaturation curves shows that the stability of lysozyme is increased by 495 cal/mol by the presence of 3 x 10(-4) M (GlcNAc)3. The midpoint of the thermal denaturation curve, T 1/2, is increased 1.6 and 5.3 degrees C by 2.02 x 10(-4) M and 1.38 x 10(-3) M (GlcNAc)3, respectively. This corresponds to an increase in the stability of lysozyme of 385 and 1275 cal/mol. These results are in excellent agreement with predictions based on an equation derived by Schellman ((1975) Biopolymers 14, 999-1018) to take into account the effect of ligand binding on the melting temperature of a protein. delta T 1/2 = TT0R divided by delta HD ln (1 + KB[S]) where T and T0 are T1/2 values in the presence and absence of (GlcNAc)3, delta HD is the enthalpy of denaturation in the presence of (GlcNAc)3, KB in the equilibrium constant for the binding of (GlcNAc)3 to lysozyme, and [S] is the free concentration of (GlcNAc)3. Thus, the increased stability of an enzyme in the presence of its substrate, coenzyme, or any small molecule that it binds specifically results because binding to the native state shifts the unfolding equilibrium and decreases the concentration of unfolded states of the enzyme. It is suggested that this may be a more important factor than substrate-induced conformational changes in acccounting for the decreased rates of protein catabolism frequently observed in vivo at elevated substrate concentrations.

Effect of cardiac arrest on cerebral circulation. An experimental investigation

The effect of 2 to 15 min of cardiac arrest on cerebral circulation was investigated in dogs and Rhesus monkeys. When circulatory arrest lasted longer than 5 minutes, angiographic changes of the no-reflow phenomenon were observed between 3 and 4 h after resuscitation in dogs but not in monkeys. These findings were (1) marked prolongation of the arterial phase in both intracranial and extracranial arteries; followed by (2) occasional evidence of dilatation of the proximal intracranial arteries with non-filling of the distal intracranial arteries; and (3) faint demonstration of the venous phase. Carbon black perfusion results were (1) diffuse lack of perfusion at the arteriolar-capillary level and (2) multifocal areas of filling defects. Regional cortical blood flow measurement in monkeys disclosed a significant decrease in flow starting from 3 h after re-establishment of circulation for those in which longer than 5 min of arrest was induced.