Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Dayside response of the magnetosphere to a small shock compression: Van Allen Probes, Magnetospheric MultiScale, and GOES-13

Observations from Magnetospheric MultiScale (~8 Re) and Van Allen Probes (~5 and 4 Re) show that the initial dayside response to a small interplanetary shock is a double-peaked dawnward electric field, which is distinctly different from the usual bipolar (dawnward and then duskward) signature reported for large shocks. The associated E × B flow is radially inward. The shock compressed the magnetopause to inside 8 Re, as observed by Magnetospheric MultiScale (MMS), with a speed that is comparable to the E × B flow. The magnetopause speed and the E × B speeds were significantly less than the propagation speed of the pulse from MMS to the Van Allen Probes and GOES-13, which is consistent with the MHD fast mode. There were increased fluxes of energetic electrons up to several MeV. Signatures of drift echoes and response to ULF waves also were seen. These observations demonstrate that even very weak shocks can have significant impact on the radiation belts.

Identification badge lanyards as infection control risk: a cross-sectional observation study with epidemiological analysis

Staphylococcus aureus cultures from name badge lanyards were phenotypically and genotypically indistinguishable from the wearer's nasal carrier strains by pulsed-field gel electrophoresis and antibiogram. Lanyards had a mean age of 22 months and hygiene was poor with only 9% ever having been laundered. Molecular analysis showed that 26% of S. aureus nasal carriers shared an indistinguishable strain on their lanyard. Lanyards should not be recommended for staff in frontline clinical care.

An Approach to Optimise Therapeutic Vancomycin Dosage in a Haemodialysis Population

Haemodialysis patients are at risk of gram-positive bacteraemia and commonly require intravenous vancomycin. Intravenously administered vancomycin is primarily excreted by the kidney and exhibits complex pharmacokinetics in haemodialysis patients; achieving therapeutic levels can be challenging. An audit in our unit showed current practises of vancomycin administration resulted in a high proportion of sub-therapeutic levels. A new protocol was developed with fixed weight-based loading and subsequent dosing guided by pre-dialysis levels, target levels were 10-20mg/L. Its effectiveness was prospectively evaluated between 24th September 2012, and 8th February 2013. During this period 25 patients commenced vancomycin, 15 were included. In total, 112 vancomycin levels were taken, 94 (84%) were therapeutic, this was a significant improvement compared to previous practise (odds ratio 5.4, CI 3.1-9.4, p<0.0001). In conclusion, our study shows this protocol can consistently and reliably achieve therapeutic vancomycin levels.

How visual perceptual grouping influences foot placement

Everybody would agree that vision guides locomotion; but how does vision influence choice when there are different solutions for possible foot placement? We addressed this question by investigating the impact of perceptual grouping on foot placement in humans. Participants performed a stepping stone task in which pathways consisted of target stones in a spatially regular path of foot falls and visual distractor stones in their proximity. Target and distractor stones differed in shape and colour so that each subset of stones could be easily grouped perceptually. In half of the trials, one target stone swapped shape and colour with a distractor in its close proximity. We show that in these 'swapped' conditions, participants chose the perceptually groupable, instead of the spatially regular, stepping location in over 40% of trials, even if the distance between perceptually groupable steps was substantially larger than normal step width/length. This reveals that the existence of a pathway that could be traversed without spatial disruption to periodic stepping is not sufficient to guarantee participants will select it and suggests competition between different types of visual input when choosing foot placement. We propose that a bias in foot placement choice in favour of visual grouping exists as, in nature, sudden changes in visual characteristics of the ground increase the uncertainty for stability.

Upper limit on the inner radiation belt MeV electron intensity

No instruments in the inner radiation belt are immune from the unforgiving penetration of the highly energetic protons (tens of MeV to GeV). The inner belt proton flux level, however, is relatively stable; thus, for any given instrument, the proton contamination often leads to a certain background noise. Measurements from the Relativistic Electron and Proton Telescope integrated little experiment on board Colorado Student Space Weather Experiment CubeSat, in a low Earth orbit, clearly demonstrate that there exist sub-MeV electrons in the inner belt because their flux level is orders of magnitude higher than the background, while higher-energy electron (>1.6 MeV) measurements cannot be distinguished from the background. Detailed analysis of high-quality measurements from the Relativistic Electron and Proton Telescope on board Van Allen Probes, in a geo-transfer-like orbit, provides, for the first time, quantified upper limits on MeV electron fluxes in various energy ranges in the inner belt. These upper limits are rather different from flux levels in the AE8 and AE9 models, which were developed based on older data sources. For 1.7, 2.5, and 3.3 MeV electrons, the upper limits are about 1 order of magnitude lower than predicted model fluxes. The implication of this difference is profound in that unless there are extreme solar wind conditions, which have not happened yet since the launch of Van Allen Probes, significant enhancements of MeV electrons do not occur in the inner belt even though such enhancements are commonly seen in the outer belt.

KEY POINTS

Quantified upper limit of MeV electrons in the inner beltActual MeV electron intensity likely much lower than the upper limitMore detailed understanding of relativistic electrons in the magnetosphere.

A selective blocking method to control the overgrowth of Pt on Au nanorods

A method for the preparation of smooth deposits of Pt on Au nanorods is described, involving sequential deposition steps with selective blocking of surface sites that reduces Pt-on-Pt deposition. The Au-Pt nanorods prepared by this method have higher long-term stability than those prepared by standard Pt deposition. Electrochemical data show that the resulting structure has more extended regions of Pt surface and enhanced activity toward the carbon monoxide oxidation and oxygen reduction reactions.

Angle-resolved XPS analysis and characterization of monolayer and multilayer silane films for DNA coupling to silica

We measure silane density and Sulfo-EMCS cross-linker coupling efficiency on aminosilane films by high-resolution X-ray photoelectron spectroscopy (XPS) and atomic force microscopy (AFM) measurements. We then characterize DNA immobilization and hybridization on these films by (32)P-radiometry. We find that the silane film structure controls the efficiency of the subsequent steps toward DNA hybridization. A self-limited silane monolayer produced from 3-aminopropyldimethylethoxysilane (APDMES) provides a silane surface density of ~3 nm(-2). Thin (1 h deposition) and thick (19 h deposition) multilayer films are generated from 3-aminopropyltriethoxysilane (APTES), resulting in surfaces with increased roughness compared to the APDMES monolayer. Increased silane surface density is estimated for the 19 h APTES film, due to a ∼32% increase in surface area compared to the APDMES monolayer. High cross-linker coupling efficiencies are measured for all three silane films. DNA immobilization densities are similar for the APDMES monolayer and 1 h APTES. However, the DNA immobilization density is double for the 19 h APTES, suggesting that increased surface area allows for a higher probe attachment. The APDMES monolayer has the lowest DNA target density and hybridization efficiency. This is attributed to the steric hindrance as the random packing limit is approached for DNA double helices (dsDNA, diameter ≥ 2 nm) on a plane. The heterogeneity and roughness of the APTES films reduce this steric hindrance and allow for tighter packing of DNA double helices, resulting in higher hybridization densities and efficiencies. The low steric hindrance of the thin, one to two layer APTES film provides the highest hybridization efficiency of nearly 88%, with 0.21 dsDNA/nm(2). The XPS data also reveal water on the cross-linker-treated surface that is implicated in device aging.

Uncertainty plus prior equals rational bias: an intuitive Bayesian probability weighting function

Empirical research has shown that when making choices based on probabilistic options, people behave as if they overestimate small probabilities, underestimate large probabilities, and treat positive and negative outcomes differently. These distortions have been modeled using a nonlinear probability weighting function, which is found in several nonexpected utility theories, including rank-dependent models and prospect theory; here, we propose a Bayesian approach to the probability weighting function and, with it, a psychological rationale. In the real world, uncertainty is ubiquitous and, accordingly, the optimal strategy is to combine probability statements with prior information using Bayes' rule. First, we show that any reasonable prior on probabilities leads to 2 of the observed effects; overweighting of low probabilities and underweighting of high probabilities. We then investigate 2 plausible kinds of priors: informative priors based on previous experience and uninformative priors of ignorance. Individually, these priors potentially lead to large problems of bias and inefficiency, respectively; however, when combined using Bayesian model comparison methods, both forms of prior can be applied adaptively, gaining the efficiency of empirical priors and the robustness of ignorance priors. We illustrate this for the simple case of generic good and bad options, using Internet blogs to estimate the relevant priors of inference. Given this combined ignorant/informative prior, the Bayesian probability weighting function is not only robust and efficient but also matches all of the major characteristics of the distortions found in empirical research.

High-resolution X-ray photoelectron spectroscopy of mixed silane monolayers for DNA attachment

The amine density of 3-aminopropyldimethylethoxysilane (APDMES) films on silica is controlled to determine its effect on DNA probe density and subsequent DNA hybridization. The amine density is tailored by controlling the surface reaction time of (1) APDMES, or (2) n-propyldimethylchlorosilane (PDMCS, which is not amine terminated) and then reacting it with APDMES to form a mixed monolayer. High-resolution X-ray photoelectron spectroscopy (XPS) is used to quantify silane surface coverage of both pure and mixed monolayers on silica; the XPS data demonstrate control of amine density in both pure APDMES and PDMCS/APDMES mixed monolayers. A linear correlation between the atomic concentration of N atoms from the amine and Si atoms from the APDMES in pure APDMES films allows us to calculate the PDMCS/APDMES ratio in the mixed monolayers. Fluorescence from attached DNA probes and from hybridized DNA decreases as the percentage of APDMES in the mixed monolayer is decreased by dilution with PDMCS.

The safety profile of anti-tumour necrosis factor therapy in inflammatory bowel disease in clinical practice: analysis of 620 patient-years follow-up

BACKGROUND

Anti-TNF agents are now widely used in Crohn's disease (CD), and in ulcerative colitis (UC).

AIM

To review the safety profile of anti-TNF agents in all patients treated with infliximab in Edinburgh from 1999 to 2007.

METHODS

Complete data were available on 202/207 patients comprising 157 CD, 42 UC and three coeliac disease. Median follow-up was 2.4 years (1.0-4.9) with a total of 620 patient-years follow-up. About 19.1% of CD patients were subsequently treated with adalimumab.

RESULTS

Seven deaths (3.3%) occurred in follow-up; only one death was <1 year post-infliximab (at day 72, from lung cancer). A total of six malignancies (three haematological, three bronchogenic) and six cases of suspected demyelination (three with confirmed neurological disease) were reported. In the 90 days following infliximab, 95 adverse events (36 serious) occurred in 58/202 (28.7%) patients. In all, 42/202 (20.8%) had an infectious event (22 serious) and 27/202 (13.4%) of patients had an infusion reaction: 19 acute (four serious) and eight delayed (three serious).

CONCLUSIONS

Serious infections, malignancies and neurological disease complicate anti-TNF use in clinical practice. Although evidence for causality is unclear, potential mechanisms and predisposing factors need to be explored. In individual patients, the risk/benefit analysis needs to be carefully assessed and discussed prior to commencement of therapy.

The use of adalimumab in the management of refractory Crohn's disease

BACKGROUND

Adalimumab is a humanized monoclonal antibody targeting tumour necrosis factor-alpha. Recent clinical trials have demonstrated its efficacy in Crohn's disease; however, experience in clinical practice remains limited.

AIM

To investigate the efficacy and safety of adalimumab in the clinical setting.

METHODS

The clinical outcomes of patients with medically refractory Crohn's disease treated with adalimumab in the Western General Hospital Edinburgh, over a 3-year period (2003-2006), were studied.

RESULTS

Twenty-two (14 females; age at therapy: 32.6 years) patients were treated using an 80/40 mg induction regimen followed by fortnightly 40 mg treatment. All had proven refractory/intolerant to corticosteroids and immunosuppression. Twenty patients had had previous infliximab infusions - of these eight (36%), six (27%), three (14%) had previous infusion reactions, no response and lost response to infliximab, respectively. Over a period of 1.0 years (IQR: 0.62-2.5), Kaplan-Meier analyses showed that 68% (seven nonresponders) were in clinical remission and 67% (five surgery - discounting oral CD) avoided further surgery for active disease. 59% required dose escalation to 40 mg weekly (0.55 years; IQR: 0.22-1.4). Three (50%) primary nonresponders to infliximab achieved remission. Two patients developed serious infective complications and one patient developed lung cancer.

CONCLUSIONS

Adalimumab is efficacious in refractory Crohn's disease, with benefit observed in infliximab primary nonresponders. However, many patients require escalation of dosing regimen.

Influence of natural vs. anthropogenic stresses on water resource sustainability: a case study

Climate change has been identified as a major influence on basin water balances. However, land use and water use practices have also been identified as players. This case study was completed to better understand a changing water balance affecting a major basin in Alberta. The Beaver River basin is located in east central Alberta. Much of the basin has been developed for agricultural use; however, a number of heavy oil operations also exist. Both sectors use surface and groundwater. Evidence exists that the basin hydrology has changed since the mid-1970s. Coincidently, it was at this time that much of the land was cleared for agricultural development and commercial-scale oil development began. Oil industry use of water was suspected as the main cause for the changes observed. To investigate this further, data from regional hydrometric and meteorological stations were assessed along with water well hydrographs and historical satellite images. A significant correlation was found between basin responses and a climate phenomenon known as the Pacific decadal oscillation. Although the correlation between the Pacific decadal oscillation and basin hydrology appeared strong, deforestation for agricultural development also seemed to have an effect. Use of the local water resources was found to be of minor significance.

Serotonin syndrome:case report and current concepts

Selective serotonin reuptake inhibitors (SSRI's) are increasingly being used as the first line therapeutic agent for the depression. It is therefore not unusual to see a case of overdose with these agents. More commonly an adverse drug reaction may be seen among the older patients who are particularly vulnerable to the serotonin syndrome due to multiple co-morbidity and polypharmacy. The clinical picture of serotonin syndrome (SS) is non-specific and there is no confirmatory test. SS may go unrecognized because it is often mistaken for a viral illness, anxiety, neurological disorder or worsening psychiatric condition.

NOD2/CARD15, TLR4 and CD14 mutations in Scottish and Irish Crohn's disease patients: evidence for genetic heterogeneity within Europe?

NOD2/caspase recruitment domain (CARD)15 variants are identified in up to 50% of Crohn's disease (CD) patients. Functional variants of toll-like receptor-4 (TLR4) and CD14 genes may also be relevant to disease pathophysiology. We aimed to assess the contribution of NOD2/CARD15, TLR4 and CD14 variants in Scottish and Irish CD patients. In all, 612 patients with well-characterised inflammatory bowel disease (252 Scottish CD, 247 Scottish UC, 113 Irish CD) and 304 controls were genotyped for variants of NOD2/CARD15 (1007fsinsC, G908R, R702W, P268S), TLR4 (A299G) and CD14 (T-159C). Genotype-phenotype analyses were performed. Variant 1007fsinsC (P=0.003) and G908R (P=0.008) but not R702W (P=0.269) alleles were more prevalent in Scottish CD (4.7, 1.8 and 7.1%, respectively) than Scottish control (2.3, 0.3 and 5.4%). CD allelic frequencies were lower than the series from Europe (P<0.00001) and North America (P<0.00001) but not Scandinavia (P<0.7). Associations were identified with age at diagnosis (P=0.002), ileal disease (P<0.02), penetrating disease (P=0.04) and inflammatory joint disease (P<0.02). TLR4 and CD14 variants did not differ between CD and controls. In conclusion, we present compelling evidence for genetic heterogeneity within Europe. These NOD2/CARD15 variants have a minor contribution in Scottish and Irish CD patients, consistent with an emerging pattern from Northern Europe.

Oxidative stress and vascular damage in hypertension

Oxidative stress, a state of excessive reactive oxidative species activity, is associated with vascular disease states such as hypertension. In this review, we discuss the recent advances in the field of reactive oxidative species-mediated vascular damage in hypertension. These include the identification of redox-sensitive tyrosine kinases, the characterization of enzymatic sources of superoxide production in human blood vessels, and their relationship with vascular damage in atherosclerosis and hypertension. Finally, recent developments in the search for strategies to attenuate vascular oxidative stress are reviewed.

The power of survivor advocacy: making car trunks escapable

Survivor advocates are powerful workers for injury prevention. Some of the major prevention successes have been due in large part to their efforts. This case history examines the four year campaign to prevent entrapment in car trunks (or boot) through the routine installation of interior trunk releases. It traces how a life altering event began a cluster of activities leading to product redesign and regulation to prevent injury. The following elements were key: data and the lack thereof, identification of possible solutions, newsworthy tragedies and media advocacy, politics and sympathetic lawmakers, an agency with regulatory authority, manufacturers, and trade associations. Survivors can assist the injury field because the personal and the professional complement each other in advocacy. Public health professionals can assist survivor advocates by sharing research, data and organizational skills, and by helping to secure grants.

Hope suspended: morality, politics and war in central Africa

The Great Lakes tragedy from 1994-8 has demonstrated the impact of a new consensus in favour of conditional relief for the protection and assistance of disaster victims. This paper attempts to catalogue the failures of the international humanitarian community, African leaders and donor governments to act effectively in defence of humanitarian principles throughout the crisis. The paper places special emphasis on the events in eastern Zaire during 1996-7 that have, so far, received limited treatment, and, it contends, led to the loss of hundreds of thousands of lives. The paper argues that the new orthodoxy of developmental relief, as adopted by UN and NGO humanitarian agencies in the Great Lakes, has acted more in support of the geopolitical and economic agendas of Northern governments and African leaders than in defence of disaster victims. The paper points out that the evidence of the Great Lakes tragedy suggests that the adoption of these approaches has sanctioned the abandonment of ideas about universal rights of protection for non-combatants at the moment when they are most at risk, with catastrophic results for those most vulnerable to abuse.

Postinfarction ventricular septal defect associated with long-term steroid therapy

Two cases of postinfarction ventricular septal rupture in patients on long-term steroid therapy are presented and the favourable outcome in both cases described. A possible association between steroid therapy and subsequent postinfarction septal rupture is discussed.

Status epilepticus secondary to fluoxetine

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