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Huang Y, Sompii-Montgomery L, Patti J, Pickering A, Yasin S, Do T, Baker E, Gao D, Abdul-Aziz R, Behrens EM, Canna S, Clark M, Co DO, Collins KP, Eberhard B, Friedman M, Graham TB, Hahn T, Hersh AO, Hobday P, Holland MJ, Huggins J, Lu PY, Mannion ML, Manos CK, Neely J, Onel K, Orandi AB, Ramirez A, Reinhardt A, Riskalla M, Santiago L, Stoll ML, Ting T, Grom AA, Towe C, Schulert GS. Disease Course, Treatments, and Outcomes of Children With Systemic Juvenile Idiopathic Arthritis-Associated Lung Disease. Arthritis Care Res (Hoboken) 2024; 76:328-339. [PMID: 37691306 DOI: 10.1002/acr.25234] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/17/2023] [Accepted: 09/07/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE Systemic juvenile idiopathic arthritis-associated lung disease (SJIA-LD) is a life-threatening disease complication. Key questions remain regarding clinical course and optimal treatment approaches. The objectives of the study were to detail management strategies after SJIA-LD detection, characterize overall disease courses, and measure long-term outcomes. METHODS This was a prospective cohort study. Clinical data were abstracted from the electronic medical record, including current clinical status and changes since diagnosis. Serum biomarkers were determined and correlated with presence of LD. RESULTS We enrolled 41 patients with SJIA-LD, 85% with at least one episode of macrophage activation syndrome and 41% with adverse reactions to a biologic. Although 93% of patients were alive at last follow-up (median 2.9 years), 37% progressed to requiring chronic oxygen or other ventilator support, and 65% of patients had abnormal overnight oximetry studies, which changed over time. Eighty-four percent of patients carried the HLA-DRB1*15 haplotype, significantly more than patients without LD. Patients with SJIA-LD also showed markedly elevated serum interleukin-18 (IL-18), variable C-X-C motif chemokine ligand 9 (CXCL9), and significantly elevated matrix metalloproteinase 7. Treatment strategies showed variable use of anti-IL-1/6 biologics and addition of other immunomodulatory treatments and lung-directed therapies. We found a broad range of current clinical status independent of time from diagnosis or continued biologic treatment. Multidomain measures of change showed imaging features were the least likely to improve with time. CONCLUSION Patients with SJIA-LD had highly varied courses, with lower mortality than previously reported but frequent hypoxia and requirement for respiratory support. Treatment strategies were highly varied, highlighting an urgent need for focused clinical trials.
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Affiliation(s)
- Yannan Huang
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Jessica Patti
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Shima Yasin
- University of Iowa Carver College of Medicine, Iowa City
| | - Thuy Do
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Elizabeth Baker
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Denny Gao
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rabheh Abdul-Aziz
- University at Buffalo, Oishei Children's Hospital, Buffalo, New York
| | - Edward M Behrens
- The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia
| | - Scott Canna
- The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia
| | - Matthew Clark
- Prisma Health Children's Hospital Upstate and University of South Carolina School of Medicine-Greenville, Greenville
| | | | - Kathleen P Collins
- University of Tennessee Health Science Center College of Medicine, Memphis
| | | | - Monica Friedman
- Orlando Health Arnold Palmer Hospital for Children, Orlando, Florida
| | - Thomas B Graham
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Timothy Hahn
- Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Aimee O Hersh
- University of Utah School of Medicine, Salt Lake City
| | | | | | - Jennifer Huggins
- Cincinnati Children's Hospital Medical Center and University Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | - Cynthia K Manos
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Karen Onel
- Hospital for Special Surgery and Weill Cornell Medical Center, New York City, New York
| | | | | | - Adam Reinhardt
- Boys Town National Research Hospital, Boys Town, Nebraska
| | | | - Laisa Santiago
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Tracy Ting
- Cincinnati Children's Hospital Medical Center and University Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexei A Grom
- Cincinnati Children's Hospital Medical Center and University Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher Towe
- Cincinnati Children's Hospital Medical Center and University Cincinnati College of Medicine, Cincinnati, Ohio
| | - Grant S Schulert
- Cincinnati Children's Hospital Medical Center and University Cincinnati College of Medicine, Cincinnati, Ohio
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Barter KM, Fuchs C, Graham TB, Pagano LM, Vater M. Anti-NMDAR Encephalitis Clinical Practice Guideline: Improving Time to Diagnosis, Treatment, and Hospital Length of Stay. Neurol Clin Pract 2024; 14:e200218. [PMID: 38173540 PMCID: PMC10759001 DOI: 10.1212/cpj.0000000000200218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/03/2023] [Indexed: 01/05/2024]
Abstract
Background and Objectives A clinical practice guideline (CPG) was created to standardize evaluation and treatment for patients with suspected anti-methyl-d-aspartate receptor (NMDAR) autoimmune encephalitis (AE), the most common AE in children. The objective of this study was to evaluate the CPG effect on time to diagnosis, treatment, and hospital length of stay (LOS). Methods Patients with an inpatient consult to pediatric rheumatology for AE during a 4-year period (period 2) after CPG implementation were identified. Data were extracted and compared with data over the preceding 4-year period (period 1). Results During period 1, fewer patients underwent diagnostic testing than during period 2 (34 vs 80). Number of patients diagnosed with AE did not differ from period 1 to that from period 2 (NMDAR AE 9 vs 8; seronegative AE 4 vs 5). The average time to diagnostic evaluation with lumbar puncture decreased from 5.4 to 1.5 days (p = 0.0082), and time to treatment decreased from 7.6 to 3.9 days (p = 0.018). LOS showed a trend toward improvement (40.4-29.2 days (p = 0.23)). Discussion Creation of a CPG for patients with suspected AE was associated with an improved time to diagnostic evaluation and treatment. With the CPG, more patients underwent AE testing, though total diagnoses remained the same.
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Affiliation(s)
- Kelsey M Barter
- Division of Pediatric and Developmental Neurology, Department of Neurology (KMB), Washington University School of Medicine in St. Louis, MO; Division of Child and Adolescent Psychiatry (CF), Departments of Psychiatry and Behavioral Sciences and Pediatrics; Division of Pediatric Rheumatology (TBG); Division of Pediatric Neurology (LMP); and Division of Pediatric Rheumatology (MV), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Catherine Fuchs
- Division of Pediatric and Developmental Neurology, Department of Neurology (KMB), Washington University School of Medicine in St. Louis, MO; Division of Child and Adolescent Psychiatry (CF), Departments of Psychiatry and Behavioral Sciences and Pediatrics; Division of Pediatric Rheumatology (TBG); Division of Pediatric Neurology (LMP); and Division of Pediatric Rheumatology (MV), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Thomas B Graham
- Division of Pediatric and Developmental Neurology, Department of Neurology (KMB), Washington University School of Medicine in St. Louis, MO; Division of Child and Adolescent Psychiatry (CF), Departments of Psychiatry and Behavioral Sciences and Pediatrics; Division of Pediatric Rheumatology (TBG); Division of Pediatric Neurology (LMP); and Division of Pediatric Rheumatology (MV), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Lindsay M Pagano
- Division of Pediatric and Developmental Neurology, Department of Neurology (KMB), Washington University School of Medicine in St. Louis, MO; Division of Child and Adolescent Psychiatry (CF), Departments of Psychiatry and Behavioral Sciences and Pediatrics; Division of Pediatric Rheumatology (TBG); Division of Pediatric Neurology (LMP); and Division of Pediatric Rheumatology (MV), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - McKenzie Vater
- Division of Pediatric and Developmental Neurology, Department of Neurology (KMB), Washington University School of Medicine in St. Louis, MO; Division of Child and Adolescent Psychiatry (CF), Departments of Psychiatry and Behavioral Sciences and Pediatrics; Division of Pediatric Rheumatology (TBG); Division of Pediatric Neurology (LMP); and Division of Pediatric Rheumatology (MV), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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Tesher MS, Graham TB, Ting T, Kashikar-Zuck S, Lynch N, Wroblewski K, Weiss JE. Juvenile Fibromyalgia in Patients With Juvenile Idiopathic Arthritis: Utility of the Pain and Symptom Assessment Tool. Arthritis Care Res (Hoboken) 2022; 74:2085-2090. [PMID: 34197032 DOI: 10.1002/acr.24739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/08/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the proportion of children with juvenile idiopathic arthritis (JIA) who met criteria for comorbid juvenile fibromyalgia (FM) using the Pain and Symptom Assessment Tool (PSAT), and to identify clinical and demographic differences among JIA patients with and without juvenile FM. METHODS Patients ages 11-17 years with JIA were recruited from 4 North American pediatric rheumatology centers. Each patient completed the PSAT. Additional clinical and disease activity measures included pain visual analog scale, patient global assessment of disease activity (PtGA) and physician global assessment of disease activity (PhGA), the Functional Disability Inventory (FDI), and the Pain Catastrophizing Scale in children. RESULTS Of 129 patients, 11 met criteria for juvenile FM. FDI scores were markedly higher in patients who tested positive for juvenile FM, with a mean of 24.8 compared to 6.9 in patients without juvenile FM (P < 0.001). Pain catastrophizing scores were also significantly higher, by ~14 points, in patients with juvenile FM. There was a significant tendency for patients to give higher disease activity scores than physicians, which was more marked among patients with juvenile FM. In patients with juvenile FM, PtGA scores exceeded PhGA scores by a mean of 3.7, compared to a mean of 0.7 among patients without juvenile FM (P < 0.001). CONCLUSION A minority of JIA patients (8.5%) met criteria for juvenile FM. This group demonstrated markedly more functional impairment. PtGA scores were strikingly higher than PhGA scores among patients with JIA who met juvenile FM criteria, suggesting that providers might consider a more expansive approach to chronic pain and non-musculoskeletal symptom assessment and treatment in JIA patients.
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Affiliation(s)
| | | | - Tracy Ting
- Cincinnati Children's Hospital, Cincinnati, Ohio
| | | | - Niccola Lynch
- University of Maryland School of Medicine, Baltimore
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Krout JC, Rees AB, Goldin AN, Moran CP, Graham TB, Lawrenz JM, Halpern JL, Schwartz HS, Holt GE. Chronic Recurrent Multifocal Osteomyelitis: A Review of the Noninfectious Inflammatory Bone Disease and Lessons for More Timely Diagnosis. Orthopedics 2022; 46:e149-e155. [PMID: 35876774 DOI: 10.3928/01477447-20220719-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an idiopathic autoinflammatory disease of the bone that typically occurs in children and adolescents. CRMO is characterized by recurrent periods of exacerbation and remission of symptomatic, osteolytic/sclerotic sterile bone lesions and is often a diagnosis of exclusion. Treatment consists of multimodal anti-inflammatory medication management by rheumatology and rarely involves surgery. This review summarizes the clinical presentation, pathophysiology, diagnosis, and management of this disease and highlights the role of the orthopedic surgeon. With increased familiarity with CRMO, clinicians will be able to diagnose and treat the condition in a more timely manner. [Orthopedics. 202x;4x(x):xx-xx.].
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Goettel AM, DeClercq J, Choi L, Graham TB, Mitchell AA. Efficacy and Safety of Abatacept, Adalimumab, and Etanercept in Pediatric Patients With Juvenile Idiopathic Arthritis. J Pediatr Pharmacol Ther 2021; 26:157-162. [PMID: 33603579 DOI: 10.5863/1551-6776-26.2.157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 06/10/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The lack of randomized controlled trials comparing biologics for the treatment of juvenile idiopathic arthritis (JIA) has led to wide variation in treatment approaches. The objective of this study is to compare the efficacy and safety of abatacept, adalimumab, and etanercept in JIA patients treated at a tertiary pediatric institution. METHODS This was a single-center, retrospective chart review of patients initiated on abatacept, adalimumab, or etanercept from December 1, 2015, to August 31, 2018, at Monroe Carell Jr. Children's Hospital at Vanderbilt (VCH). The primary outcome was the change in the Physician Global Assessment (PGA) score after 4 to 6 months of biologic therapy. Secondary outcomes included change in laboratory markers of JIA disease activity, change in the number of joints with active disease or limitation of motion, reduction in corticosteroid dose, adverse effects, adherence among patients who have their medications filled at the institution's specialty pharmacy, and reason for discontinuation of therapy. RESULTS A total of 139 patients were included, with a median age of 13 years. Most patients, 80.6%, experienced a reduction in their PGA score after starting biologic therapy. There was not a statistically significant difference among the agents (p = 0.64). Adverse effects were reported in only 26.6% of patients, with the most frequent being injection site reactions or pain (n = 35). Ultimately, 32% of patients discontinued biologic therapy with a lack of efficacy being the most common reason. CONCLUSIONS Abatacept, adalimumab, and etanercept were not significantly different in efficacy and safety for the treatment of JIA at this single institution.
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Abstract
Objectives Depression and medication nonadherence are important in managing chronic diseases, but little is known about these factors in childhood-onset systemic lupus erythematosus (cSLE). The objectives of this cross-sectional study were to estimate prevalence of depression and medication nonadherence, describe demographic and disease characteristics associated with depression and medication nonadherence, and evaluate the association between depression and medication nonadherence in cSLE patients. Methods Patients with cSLE ( n = 51) completed validated screening questionnaires to identify depression and medication nonadherence, Patient Health Questionnaire-9 and Medication Adherence Self-Report Inventory, respectively. Demographic and disease characteristics were obtained via chart abstraction, and compared between groups of depression or medication nonadherence status. A multivariable linear regression model adjusting for propensity scores was conducted to evaluate the association between depression and medication nonadherence. Results The prevalence of a positive depression screen was 58.8%, and seven patients reported suicidal ideation (13.7%). The prevalence of self-reported medication nonadherence was 19.7%. No statistically significant differences for demographic and disease characteristics were found between patients with a positive vs. negative depression screen. Patients reporting medication nonadherence were more likely to have longer disease duration (4.8 vs. 2.6 years, p = 0.035). As the severity of depression symptoms increased, the degree of medication nonadherence also increased (beta = -1.89; p = 0.011). Conclusions The prevalence of depression and medication nonadherence is high in cSLE, and these factors have a direct relationship. Interventions that better recognize and treat depression and increase rates of medication adherence are needed to improve outcomes in cSLE.
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Affiliation(s)
- A M Davis
- 1 Division of Pediatric Rheumatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.,2 Vanderbilt University Medical Center, Nashville, TN, USA
| | - T B Graham
- 1 Division of Pediatric Rheumatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.,2 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Y Zhu
- 3 Department of Biostatistics, Vanderbilt University, Nashville, TN, USA.,4 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - M L McPheeters
- 4 Vanderbilt University School of Medicine, Nashville, TN, USA.,5 Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
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Brunner HI, Bishnoi A, Barron AC, Houk LJ, Ware A, Farhey Y, Mongey AB, Strife CF, Graham TB, Passo MH. Disease outcomes and ovarian function of childhood-onset systemic lupus erythematosus. Lupus 2016; 15:198-206. [PMID: 16686258 DOI: 10.1191/0961203306lu2291oa] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The objective of this study was to determine the medical outcomes including the ovarian function childhood-onset SLE (cSLE). The medical records of all patients diagnosed with cSLE in the Greater Cincinnati area between 1981 and 2002 were reviewed. Patient interviews were performed to obtain additional information on current medication regimens, disease activity [SLE Disease Activity Index (SLEDAI-2k)], and damage [Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI)]. The occurence of premature ovarian failure (POF) and reduction of the ovarian reserve was assessed by timed gonadotropin levels. There were 77 patients (F: M = 70: 7, 53% Caucasian, 45% African-American and 2% Asian) with a mean age at diagnosis of 14.6 years. Nine patients died (88.3% survival) during the mean follow-up of 7.1 years (standard deviation [SD] 5.6) and 88% of the patients continued to have active disease (SLEDAI-2k mean/SD: 6.6/6.7), with 42% of them having disease damage (SDI mean/SD: 1.62/2.1); Non-Caucasian patients had higher disease activity (mean SLEDAI-2k: 10 versus 3.4; P < 0.0001) and more disease damage (mean SDI: 2.1 versus 1.2; P < 0.02) than Caucasian patients. Cyclophosphamide was given to 47% of the patients during the course of their disease and associated with the presence of significantly reduced ovarian reserve (RR = 2.8; 95% CI: 1.7-4.8; P = 0.026). Patient mortality and disease damage with cSLE continue to be high. Although overt POF with cyclophosphamide exposure is rare, it is a risk factor for significantly decreased ovarian reserve cSLE.
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Affiliation(s)
- H I Brunner
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, William Rowe Division of Rheumatology, OH 45229, USA.
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Bleesing J, Prada A, Siegel DM, Villanueva J, Olson J, Ilowite NT, Brunner HI, Griffin T, Graham TB, Sherry DD, Passo MH, Ramanan AV, Filipovich A, Grom AA. The diagnostic significance of soluble CD163 and soluble interleukin-2 receptor α-chain in macrophage activation syndrome and untreated new-onset systemic juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2007; 56:965-71. [PMID: 17328073 DOI: 10.1002/art.22416] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Macrophage activation syndrome is characterized by an overwhelming inflammatory reaction driven by excessive expansion of T cells and hemophagocytic macrophages. Levels of soluble interleukin-2 receptor alpha (sIL-2Ralpha) and soluble CD163 (sCD163) may reflect the degree of activation and expansion of T cells and macrophages, respectively. This study was undertaken to assess the value of serum sIL-2Ralpha and sCD163 in diagnosing acute macrophage activation syndrome complicating systemic juvenile idiopathic arthritis (JIA). METHODS Enzyme-linked immunosorbent assay was used to assess sIL-2Ralpha and sCD163 levels in sera from 7 patients with acute macrophage activation syndrome complicating systemic JIA and 16 patients with untreated new-onset systemic JIA. The results were correlated with clinical features of established macrophage activation syndrome, including ferritin levels. RESULTS The median level of sIL-2Ralpha in the patients with macrophage activation syndrome was 19,646 pg/ml (interquartile range [IQR] 18,128), compared with 3,787 pg/ml (IQR 3,762) in patients with systemic JIA (P = 0.003). Similarly, the median level of sCD163 in patients with macrophage activation syndrome was 23,000 ng/ml (IQR 14,191), compared with 5,480 ng/ml (IQR 2,635) in patients with systemic JIA (P = 0.017). In 5 of 16 patients with systemic JIA, serum levels of sIL-2Ralpha or sCD163 were comparable with those in patients with acute macrophage activation syndrome. These patients had high inflammatory activity associated with a trend toward lower hemoglobin levels (P = 0.11), lower platelet counts, and significantly higher ferritin levels (P = 0.02). Two of these 5 patients developed overt macrophage activation syndrome several months later. CONCLUSION Levels of sIL-2Ralpha and sCD163 are promising diagnostic markers for macrophage activation syndrome. They may also help identify patients with subclinical macrophage activation syndrome.
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Affiliation(s)
- Jack Bleesing
- Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
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Villanueva J, Lee S, Giannini EH, Graham TB, Passo MH, Filipovich A, Grom AA. Natural killer cell dysfunction is a distinguishing feature of systemic onset juvenile rheumatoid arthritis and macrophage activation syndrome. Arthritis Res Ther 2004; 7:R30-7. [PMID: 15642140 PMCID: PMC1064882 DOI: 10.1186/ar1453] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2004] [Revised: 09/21/2004] [Accepted: 09/27/2004] [Indexed: 12/27/2022] Open
Abstract
Macrophage activation syndrome (MAS) has been reported in association with many rheumatic diseases, most commonly in systemic juvenile rheumatoid arthritis (sJRA). Clinically, MAS is similar to hemophagocytic lymphohistiocytosis (HLH), a genetic disorder with absent or depressed natural killer (NK) function. We have previously reported that, as in HLH, patients with MAS have profoundly decreased NK activity, suggesting that this abnormality might be relevant to the pathogenesis of the syndrome. Here we examined the extent of NK dysfunction across the spectrum of diseases that comprise juvenile rheumatoid arthritis (JRA). Peripheral blood mononuclear cells (PBMC) were collected from patients with pauciarticular (n = 4), polyarticular (n = 16), and systemic (n = 20) forms of JRA. NK cytolytic activity was measured after co-incubation of PBMC with the NK-sensitive K562 cell line. NK cells (CD56+/T cell receptor [TCR]-αβ-), NK T cells (CD56+/TCR-αβ+), and CD8+ T cells were also assessed for perforin and granzyme B expression by flow cytometry. Overall, NK cytolytic activity was significantly lower in patients with sJRA than in other JRA patients and controls. In a subgroup of patients with predominantly sJRA, NK cell activity was profoundly decreased: in 10 of 20 patients with sJRA and in only 1 of 20 patients with other JRA, levels of NK activity were below two standard deviations of pediatric controls (P = 0.002). Some decrease in perforin expression in NK cells and cytotoxic T lymphocytes was seen in patients within each of the JRA groups with no statistically significant differences. There was a profound decrease in the proportion of circulating CD56bright NK cells in three sJRA patients, a pattern similar to that previously observed in MAS and HLH. In conclusion, a subgroup of patients with JRA who have not yet had an episode of MAS showed decreased NK function and an absence of circulating CD56bright population, similar to the abnormalities observed in patients with MAS and HLH. This phenomenon was particularly common in the systemic form of JRA, a clinical entity strongly associated with MAS.
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MESH Headings
- Adolescent
- Adult
- Arthritis, Juvenile/blood
- Arthritis, Juvenile/classification
- Arthritis, Juvenile/immunology
- Autoimmune Diseases/blood
- Autoimmune Diseases/immunology
- CD56 Antigen/analysis
- CD8-Positive T-Lymphocytes/immunology
- Child
- Child, Preschool
- Coculture Techniques
- Cytotoxicity Tests, Immunologic
- Cytotoxicity, Immunologic
- Female
- Flow Cytometry
- Granzymes
- Humans
- Immunologic Deficiency Syndromes/blood
- Immunologic Deficiency Syndromes/immunology
- K562 Cells/immunology
- Killer Cells, Natural/chemistry
- Killer Cells, Natural/immunology
- Leukocytes, Mononuclear/immunology
- Lymphohistiocytosis, Hemophagocytic/immunology
- Macrophage Activation
- Male
- Membrane Glycoproteins/analysis
- Perforin
- Pore Forming Cytotoxic Proteins
- Serine Endopeptidases/analysis
- Syndrome
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Affiliation(s)
- Joyce Villanueva
- Division of Hematology/Oncology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Susan Lee
- Division of Hematology/Oncology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Edward H Giannini
- William S Rowe Division of Rheumatology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Thomas B Graham
- William S Rowe Division of Rheumatology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Murray H Passo
- William S Rowe Division of Rheumatology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexandra Filipovich
- Division of Hematology/Oncology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexei A Grom
- William S Rowe Division of Rheumatology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Affiliation(s)
- S Kashikar-Zuck
- Division of Psychology, Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Kashikar-Zuck S, Vaught MH, Goldschneider KR, Graham TB, Miller JC. Depression, coping, and functional disability in juvenile primary fibromyalgia syndrome. The Journal of Pain 2002; 3:412-9. [PMID: 14622745 DOI: 10.1054/jpai.2002.126786] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study describes pain characteristics, coping, depression, and functional disability in children with juvenile primary fibromyalgia syndrome (JPFS) and compares them with a group of children with nonmalignant chronic back pain (CBP). Subjects were 18 female subjects (9 to 19 years of age) diagnosed with JPFS and 18 matched control subjects with CBP. Visual Analog Pain Rating Scales, the Pain Coping Questionnaire, the Children's Depression Inventory, and Functional Disability Inventory were administered. Results indicated that both JPFS and CBP groups reported significant disruption in functional abilities and school attendance as a result of chronic pain. Both groups reported mildly elevated symptoms of depression overall, but there was a subgroup of JPFS subjects who reported severe levels of depression. The JPFS group had suffered from pain for significantly longer than the CBP group before being referred for specialty care. However, pain duration was not significantly related to depression, functional disability, or pain coping efficacy. The levels of functional disability were similar in both groups, but the JPFS group reported somewhat more school absences. The longer time to receive specialty care and identification of a subgroup of depressed subjects at risk for long-term psychosocial consequences are of particular concern in JPFS.
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Affiliation(s)
- Susmita Kashikar-Zuck
- Division of Psychology, Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 45229, USA.
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12
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Gylys-Morin VM, Graham TB, Blebea JS, Dardzinski BJ, Laor T, Johnson ND, Oestreich AE, Passo MH. Knee in early juvenile rheumatoid arthritis: MR imaging findings. Radiology 2001; 220:696-706. [PMID: 11526269 DOI: 10.1148/radiol.2203000461] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the magnetic resonance (MR) imaging findings in the knee in early juvenile rheumatoid arthritis. MATERIALS AND METHODS MR imaging (1.5 T) was performed in the more symptomatic knee in 30 children with juvenile rheumatoid arthritis with a symptom duration 1 year or less. Conventional, fast spin-echo, three-dimensional gradient-echo, and gadolinium-enhanced T1-weighted images were assessed. Two radiologists independently read the images, and a third resolved disagreements. These images were compared with knee radiographs in 27 children. RESULTS Mean maximal synovial thickness was 4.8 mm +/- 2.4 (SD). Mean synovial volume was 15.4 mL +/- 10.8. Suprapatellar joint effusions were seen in 26 (87%) of 30 knees, meniscal hypoplasia in 11 (37%) of 30 knees, and abnormal epiphyseal marrow in eight (27%) of 30 knees. Three knees had articular cartilage contour irregularity, fissures, and/or thinning. One knee had a bone erosion. Knee radiographs showed suprapatellar fullness in 78% of the knees, joint space narrowing in one knee, and no bone abnormalities. CONCLUSION Synovial hypertrophy and joint effusions are the most frequent MR imaging findings of knees in early juvenile rheumatoid arthritis. Early in the disease, radiographically occult cartilage and bone erosions are uncommonly seen at MR imaging. The potential relationship of synovitis to cartilage abnormalities deserves further study.
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Affiliation(s)
- V M Gylys-Morin
- Department of Radiology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039, USA.
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Thompson SD, Luyrink LK, Graham TB, Tsoras M, Ryan M, Passo MH, Glass DN. Chemokine Receptor CCR4 on CD4+ T Cells in Juvenile Rheumatoid Arthritis Synovial Fluid Defines a Subset of Cells with Increased IL-4:IFN-γ mRNA Ratios. J Immunol 2001; 166:6899-906. [PMID: 11359851 DOI: 10.4049/jimmunol.166.11.6899] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To understand the mechanisms that promote recruitment and survival of T cells within the pediatric inflamed joint, we have studied the expression of CCR4 and CCR5 on synovial fluid T cells and matched peripheral blood samples from juvenile rheumatoid arthritis (JRA) patients using three-color flow cytometric analysis. Thymus- and activation-regulated chemokine and macrophage-derived chemokine, ligands for CCR4, were measured by ELISA in JRA synovial fluid, JRA plasma, adult rheumatoid arthritis synovial fluid, and normal plasma. IL-4 and IFN-gamma mRNA production was assessed in CD4+/CCR4+ and CD4+/CCR4(-) cell subsets. We found accumulations of both CCR4+ and CCR5+ T cells in JRA synovial fluids and a correlation for increased numbers of CCR4+ T cells in samples collected early in the disease process. Thymus- and activation-regulated chemokine was detected in JRA synovial fluid and plasma samples, but not in adult rheumatoid arthritis synovial fluid or control plasma. Macrophage-derived chemokine was present in all samples. CD4+/CCR4+ synovial lymphocytes produced more IL-4 and less IFN-gamma than CD4+/CCR4(-) cells. These findings suggest that CCR4+ T cells in the JRA joint may function early in disease in an anti-inflammatory capacity through the production of type 2 cytokines and may play a role in determining disease phenotype.
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MESH Headings
- Adolescent
- Adult
- Arthritis, Juvenile/genetics
- Arthritis, Juvenile/immunology
- Arthritis, Juvenile/pathology
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/metabolism
- Chemokine CCL17
- Chemokine CCL22
- Chemokines, CC/metabolism
- Child
- Child, Preschool
- Cytokines/biosynthesis
- Cytokines/genetics
- Female
- Flow Cytometry
- Humans
- Immunophenotyping
- Interferon-gamma/biosynthesis
- Interferon-gamma/genetics
- Interleukin-4/biosynthesis
- Interleukin-4/genetics
- Ligands
- Macrophages/immunology
- Macrophages/metabolism
- Male
- RNA, Messenger/biosynthesis
- Receptors, CCR4
- Receptors, Chemokine/biosynthesis
- Receptors, Chemokine/genetics
- Receptors, Chemokine/metabolism
- Synovial Fluid/immunology
- Synovial Fluid/metabolism
- T-Lymphocyte Subsets/immunology
- T-Lymphocyte Subsets/metabolism
- T-Lymphocyte Subsets/pathology
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Affiliation(s)
- S D Thompson
- William S. Rowe Division of Rheumatology, Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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14
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Abstract
OBJECTIVES This study was undertaken to examine the role of magnetic resonance imaging (MRI) in the management of patients with juvenile rheumatoid arthritis (JRA). METHODS A Medline search was performed to identify all publications pertaining to MRI in JRA. Further searches and identification of articles from bibliographies identified articles pertaining to plain radiograph imaging in JRA and MRI in adult rheumatoid arthritis. RESULTS Studies in both children and adults have shown superiority of MRI to plain radiography in detecting synovial hypertrophy and articular cartilage abnormalities. Several studies in adults have shown a good correlation of MR images with gross anatomic as well as histological findings at arthroscopy. Biochemical changes that occur before structural changes within the joint may even be detectable with magnetic resonance spectroscopy. CONCLUSIONS MRI holds promise for the assessment of disease progression in JRA and may be useful in serial evaluation, as in clinical trials.
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Affiliation(s)
- T B Graham
- Special Treatment Center for Juvenile Arthritis, Children's Hospital Medical Center, Cincinnati, OH, USA
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15
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Graham TB, Glass DN. Juvenile rheumatoid arthritis: ethnic differences in diagnostic types. J Rheumatol 1997; 24:1677-9. [PMID: 9292786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
Outcome assessment has been a focus of recent research in rheumatic diseases and in pediatric rheumatology. The establishment of a preliminary core set of outcome variables for juvenile rheumatoid arthritis patients and a preliminary definition of improvement using these variables have been important steps toward standardization of outcome assessment. A population-based epidemiologic study has added to our knowledge of long-term outcome in juvenile arthritis and confirms the chronicity of disease that was found in previous studies. Standardization of outcome assessment in pediatric systemic lupus erythematosus has not been achieved to the same extent as in juvenile rheumatoid arthritis, but renal survival and overall mortality are important outcomes in this disease that are easily quantified. Recent studies of pediatric systemic lupus erythematosus demonstrate similarities with respect to organ involvement and overall survival between adult and pediatric lupus patients.
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Affiliation(s)
- T B Graham
- Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Abstract
Hantavirus pulmonary syndrome, first documented in 1993, is caused by Sin Nombre virus (SNV), which is carried by the Peromyscus species. In 1994, high SNV antibody prevalence was identified in deer mice from two California Channel Islands. We sampled two locations on three islands to estimate mouse population density and SNV prevalence. Population flux and SNV prevalence appear to vary independently.
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Affiliation(s)
- T B Graham
- USGS, Biological Resources Division, Moab, Utah, USA
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18
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Graham TB, Giannini EH. Juvenile rheumatoid arthritis--assessment. Indian J Pediatr 1996; 63:283-91. [PMID: 10830003 DOI: 10.1007/bf02751520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The assessment of overall health status of a child with juvenile rheumatoid arthritis (JRA) is complex and multi-dimensional. The general physical examination is complemented by a rheumatological evaluation that includes determination of articular indices of inflammation and duration of inactivity stiffness. Laboratory assessment plays a critical role in monitoring side effects of pharmacologic management, but is limited in its ability to portray accurately the degree of active inflammation. Newly measureable indicators of inflammatory activity, such as serum cytokine and soluble cytokine receptors will likely become part of routine laboratory assessment in the future. Radiographs remain a useful tool for assessing disease progression, but may be replaced in the future by magnetic resonance imaging. In recent years, rheumatologists have realized that measurement of overall physical and psycho-social functional ability, quality of life, and pain are major descriptors to consider during routine follow-up. They are also critical in the assessment of long-term clinical effectiveness. The importance of nutritional assessment has also been realized. This section seeks to describe some of the methodologic approaches currently used to assess the variables mentioned above, and includes a brief discussion of the evolving instrumentation which attempts to measure variables of a more cognitive or subjective aspect.
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Affiliation(s)
- T B Graham
- William S. Rowe Division of Rheumatology, Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH 45229-2899, USA
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Hanes TE, Page DL, Graham TB, Robinson WA, Atwood GF. Regional myocardial infarction of low-flow type in a neonate with tricuspid atresia. Arch Pathol Lab Med 1977; 101:86-8. [PMID: 576395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Clinical and anatomical data are presented on a neonate with tricuspid atresia, who died at 16 hours with a regional, nontransmural myocardial infarcti after clinical documentation of akinesis. A partially occlusive intimal lesion associated with acute angulation of the right coronary artery was noted in an area of fibrosis that included the atretic tricuspid valve. Low-flow myocardial infarction was found in the posterior part of the left ventricle in an area supplied by the right coronary artery distal to the arterial lesion.
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