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.

Canadian Rheumatology Association Recommendations for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis

OBJECTIVE

To develop Canadian recommendations for the screening, monitoring, and treatment of uveitis associated with juvenile idiopathic arthritis (JIA).

METHODS

Recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT approach. A working group of 14 pediatric rheumatologists, 6 ophthalmologists, 2 methodologists, and 3 caregiver/patient representatives reviewed recent American College of Rheumatology (ACR)/Arthritis Foundation (AF) recommendations and worked in pairs to develop evidence-to-decision (EtD) tables. A survey to assess agreement and recommendations requiring group discussion was completed. EtD tables were presented, discussed, and voted upon at a virtual meeting, to produce the final recommendations. A health equity framework was applied to all aspects of the adolopment process including the EtD tables, survey responses, and virtual meeting discussion.

RESULTS

The survey identified that 7 of the 19 recommendations required rigorous discussion. Seventy-five percent of working group members attended the virtual meeting to discuss controversial topics as they pertained to the Canadian environment, including timing to first eye exam, frequency of screening, escalation criteria for systemic and biologic therapy, and the role of nonbiologic therapies. Equity issues related to access to care and advanced therapeutics across Canadian provinces and territories were highlighted. Following the virtual meeting, 5 recommendations were adapted, 2 recommendations were removed, and 1 was developed de novo.

CONCLUSION

Recommendations for JIA-associated uveitis were adapted to the Canadian context by a working group of pediatric rheumatologists, ophthalmologists with expertise in the management of uveitis, and parent/patient input, taking into consideration cost, equity, and access.

Hydroxychloroquine-induced hyperpigmentation in a 14-year-old female with systemic lupus erythematosus

Hydroxychloroquine (HCQ)-induced hyperpigmentation is uncommon but is increasingly recognized. To our knowledge, HCQ-induced hyperpigmentation has not been reported in the pediatric age group. Herein, we present the case of a 14-year-old girl with systemic lupus erythematosus, who developed hyperpigmentation on her shins and dorsum of the left foot, approximately 3 years after initiating treatment with HCQ. Physicians who treat children with HCQ for reasons such as rheumatologic disorders, dermatologic disorders and, more recently, coronavirus disease-19 should be aware of this less-known side effect of HCQ.

Diagnosis and management of ADA2 deficient polyarteritis nodosa

Deficiency of ADA2 (DADA2) is a recently described systemic inflammatory vasculopathy caused by mutations in the CERC1 gene that often, but not always, clinically resembles polyarteritis nodosa (PAN). The condition was originally characterized by livedoid rash, systemic inflammation, variable hypogammaglobulinemia, and early-onset stroke. The phenotypic spectrum has expanded to include patients with immunodeficiency syndromes and bone marrow dysfunction, which are not typical features of PAN. Exploration into the pathogenesis and treatment options of DADA2 has added to our understanding of this condition, but more studies are needed. The purpose of this article is to review the various clinical phenotypes of DADA2, and raise awareness among rheumatologists to consider DADA2 when evaluating patients presenting with PAN-like disease.

Serum anti-Müllerian hormone dynamics in mares following immunocontraception with anti-zona pellucida or -GnRH vaccines

Circulating anti-Müllerian hormone concentration (AMH) is positively correlated to the number of small growing follicles in the mare and may reflect ovarian function. Dynamics of AMH during immunocontraception have not previously been investigated. This study aimed to compare serum AMH in mares following treatment with native porcine zona pellucida (pZP), recombinant pZP3 and pZP4 (reZP) or gonadotrophin releasing hormone (GnRH) vaccines, and saline-treated controls. Stored sera collected during two previous studies examining ovarian activity in mares during zona pellucida (ZP) or GnRH immunocontraception were analysed for serum AMH. Data were compared among treatment groups using mixed-effects linear regression and one-way ANOVA with post hoc testing. Correlations between AMH and previously reported clinical variables were estimated using Spearman's rho. Mares immunized against GnRH showed variable but detectable AMH throughout successive breeding and non-breeding seasons that were not significantly different to unvaccinated control mares. Mares treated with pZP demonstrated marked, reversible suppression of AMH. Mares immunized using reZP showed an intermediate effect. In the ZP study, AMH was positively correlated to serum progesterone concentrations, mean ovarian volumes and antral follicle counts, whereas no correlations between AMH and serum progesterone concentrations, mean ovarian volumes, or the presence of one or more follicles ≥20 mm in diameter were detected in the GnRH study. In conclusion, marked suppression of AMH during pZP immunocontraception, but not during GnRH immunocontraception, suggested enhanced suppression of ovarian follicular development and, or follicular function during pZP immunocontraception. Serum AMH concentrations may provide a novel tool for the assessment of ovarian function during ZP-based immunocontraception.

Comrades marathon for short-term experiential learning as perceived by physiotherapy students: A short report

This  study  described  the  learning  experiences  of physiotherapy students during the 2009 comrades marathon. A quali-tative  approach  using  focus  group  discussions  was  employed  for  this study.The population for this study was all the 43 B.Sc. physiotherapy final year students of the university of limpopo, who provided physio-therapy services at the 2009 comrades Marathon. forty (93%) students participated in this study. All the participants were black with majo-rity 23 (58%) of them from the limpopo province. Twenty one (52%) of the participants were females with ages ranging between 21 and 30 years. The field trip provided both sport specific and general learning experiences. participants had the opportunity to handle sports injuries and athletes, work and learn as a team and were quite independent. This trip also provided participants the opportunity experiencing workplace communication and interaction, the reality of the real workplace experience of heavy workload, experience of prejudice, time management and an unsafe environment.Despite organizational challenges of the trip, the event provided an opportunity for the participants to practice sport physiotherapy. Participants appreciated the opportunity to experience the dynamics of team and collaborative learning. To ensure effective use of this event for experiential learning, it is recommended that proper guidance and support be provided by the faculty.

The use of deslorelin implants for the long-term contraception of lionesses and tigers

Contraception is an essential tool for controlling reproduction in captive and free-ranging lions. This paper describes the treatment and contraception of 23 captive and 40 free-ranging lionesses (Panthera leo) and four captive tigers (Panthera tigris) in South Africa using 3 × 4.7 mg, 2 × 4.7 mg, 9.4 mg or 4.7 + 9.4 mg deslorelin implants. Thirty-one lionesses were treated more than once at 11- to 60-month intervals. In Brazil, two lionesses were treated with 9.4-mg implants and faecal progesterone and oestradiol concentrations were monitored for 920 days. All combinations of deslorelin showed the length of contraception to be around 30 months with one 3 × 4.7 mg treatment lasting 40 months in one captive lioness. The mean time taken to reconception was 30.1 months for the 3 × 4.7 mg combination. The faecal analyses of the lionesses in Brazil reflected quiescent ovarian activity for periods of 17 and 30 months, respectively, when small oestradiol peaks but no progesterone peaks started to appear. This confirmed the field observations in South Africa. No side effects occurred although several of the lionesses were treated repeatedly for up to 8 years. Deslorelin (Suprelorin) is a safe and effective means of controlling reproduction in captive or free-ranging populations of lions. Where contraception is to be maintained, the implementation of implants at 24-month intervals is recommended.

Repeated use of the GnRH analogue deslorelin to down-regulate reproduction in male cheetahs (Acinonyx jubatus)

The GnRH analogue deslorelin, as a subcutaneous implant, was initially developed in Australia as an ovulation-inducing agent in mares. Its uses, for the suppression of reproduction in the domestic dog and cat and in other species, including humans, have been developed subsequently. Such implants have been used as a contraceptive modality in a variety of wild carnivores, both males and females. This paper describes the use of deslorelin implants as a contraceptive agent for cheetah males maintained in a semi-captive environment and housed in various camps together with females. Annually, male cheetahs were treated for 1 (n = 2), 2 (n = 7), 3 (n = 9), 4 (n = 3) or 5 (n = 1) consecutive years with an implant containing 4.7, 5.0 or 6.0 mg of deslorelin. On the first day of treatment and then on an annual basis, blood testosterone concentrations were analysed, testicular measurements were taken, appearance of penile spikes was determined, and semen was collected and evaluated. Pregnancy rates of mated or inseminated females were determined. A dose of 6 mg of deslorelin suppressed reproduction for at least 1 year, whereas with 4.7 and 5 mg of deslorelin, 3 of 17 males had a few non-motile spermatozoa in their ejaculates. All testosterone concentrations were basal at 1 year post-implant and no side effects were observed. We concluded that deslorelin implantation, at a dose of 6 mg, was a safe and reliable method of annual contraception in male cheetahs.

Induction of contraception in some African wild carnivores by downregulation of LH and FSH secretion using the GnRH analogue deslorelin

The GnRH analogue deslorelin, in long-acting biocompatible implants, was used as a contraceptive in 31 cheetahs (13 females and 18 males), 21 African wild dogs (15 females and 6 males), 10 lionesses and four leopards (three females and one male). A dose of 12 or 15 mg deslorelin was administered to lions, whereas 6 mg deslorelin was administered to the other species. Monitoring consisted of observations, measurement of plasma progesterone and testosterone concentrations, vaginal cytology and evaluation of semen and sex organs. Deslorelin induced contraception in lionesses for 12-18 months, and in female cheetahs and leopards for a minimum of 12 months after treatment. Two male cheetahs had no viable spermatozoa or detectable plasma testosterone 21 months after treatment with deslorelin. Female wild dogs responded less consistently and one bitch conceived 4 weeks after implantation. However, in nine bitches, mating could be postponed until the next breeding season. Male dogs responded consistently and the contraception was effective for approximately 12 months. Although lionesses and cheetahs may become attractive to males for a few days after treatment, mating was not observed. No side-effects or behavioural changes were noted, indicating that deslorelin is a safe drug to use for the contraception of the species described. Males remain fertile for the first 6 weeks after the insertion of implants and should be separated from cyclic females during this period.

Control of reproduction and sex related behaviour in exotic wild carnivores with the GnRH analogue deslorelin: preliminary observations

The GnRH analogue deslorelin, in long-acting implants, was used in an attempt to temporarily control reproduction or aggression in wild carnivores in southern Africa and the USA. In the southern African study, 6 mg deslorelin was administered to cheetahs (eight females, four males), one female leopard and wild dogs (six females, one male) housed in groups, and 12 mg deslorelin was administered to two lionesses. None of the animals became pregnant after deslorelin administration apart from one wild dog that was mated at the initial treatment-induced oestrus. Two wild dogs and one lioness came into oestrus 12 and 18 months after deslorelin administration, respectively, thus demonstrating that the anti-fertility effects of deslorelin are reversible. Two lionesses and four cheetahs underwent oestrus without allowing mating 2-14 days after treatment. Simultaneous administration of progestins to three bitches and one lioness did not suppress oestrus. Male cheetahs had no spermatozoa on day 82 after treatment and did not impregnate two untreated females. Of three untreated female wild dogs housed with treated males, only the first female to enter oestrus (21 days after deslorelin administration) became pregnant. One month after treatment, plasma testosterone concentrations of male dogs were at basal values. In the USA study, three male sea otters that had been treated with 6 mg deslorelin ceased antagonistic behaviour and blood testosterone concentrations and size of the testes were still sharply reduced 24 months after treatment. Male red (n = 7) and grey (n = 5) wolves received 6 mg deslorelin in December 1998 but no effects on seasonal spermatogenesis and behaviour were observed. In a black-footed cat, sperm production, libido and aggressiveness decreased in response to treatment with 3 mg deslorelin and penile spines were not observed within 3 months after treatment, but were observed again 4-6 months later. Treatment of female red (n = 5) and grey (n = 5) wolves with deslorelin in December 1999 triggered preseason oestrus and mating, which were followed by one abortion and one successful pregnancy. Contraception was achieved in female Fennec foxes (n = 7) and two lionesses, which was observed in the foxes by an absence of increases in faecal progesterone concentrations. In two male bush dogs, administration of 3 mg deslorelin once or twice was insufficient to suppress reproductive function or behaviour.