Abstract
Objective
Myositis-specific autoantibodies have defined distinct phenotypes of patients with juvenile myositis (JIIM). We assessed the frequency and clinical significance of anti-melanoma ...differentiation-associated gene 5 (MDA5) autoantibody-associated JIIM in a North American registry.
Methods
Retrospective examination of the characteristics of 35 JIIM patients with anti-MDA5 autoantibodies was performed, and differences from other myositis-specific autoantibody groups were evaluated.
Results
Anti-MDA5 autoantibodies were present in 35/453 (7.7%) of JIIM patients and associated with older age at diagnosis, and lower serum creatine kinase and aldolase levels. Patients with anti-MDA5 autoantibodies had more frequent weight loss, adenopathy, arthritis, interstitial lung disease (ILD), and less frequent falling compared with anti-transcriptional intermediary factor 1 (TIF1), anti-nuclear matrix protein 2 (NXP2) and myositis-specific autoantibody/myositis-associated autoantibody-negative patients. They had a different season of diagnosis and less frequent mechanic’s hands and ILD compared with those with anti-synthetase autoantibodies. Anti-MDA5 patients received fewer medications compared with anti-TIF1, and corticosteroid treatment was shorter compared with anti-TIF1 and anti-nuclear matrix protein 2 autoantibody groups. The frequency of remission was higher in anti-MDA5 than anti-synthetase autoantibody-positive JIIM. In multivariable analyses, weight loss, arthritis and arthralgia were most strongly associated with anti-MDA5 autoantibody-positive JIIM.
Conclusion
Anti-MDA5 JIIM is a distinct subset, with frequent arthritis, weight loss, adenopathy and less severe myositis, and is also associated with ILD. Anti-MDA5 is distinguished from anti-synthetase autoantibody-positive JIIM by less frequent ILD, lower creatine kinase levels and differing seasons of diagnosis. Anti-MDA5 has comparable outcomes, but with the ability to discontinue steroids more rapidly and less frequent flares compared with anti-TIF1 autoantibodies, and more frequent remission compared with anti-synthetase JIIM patients.
Objective
This open‐label, 24‐week study was conducted to evaluate the safety and efficacy of abatacept in patients with refractory juvenile dermatomyositis (DM).
Methods
Ten patients ≥7 years of age ...with moderate disease activity were enrolled in a 24‐week study to examine the safety of subcutaneous abatacept and patient responses to the treatment. The primary endpoint was the International Myositis Assessment and Clinical Studies (IMACS) group Definition Of Improvement (DOI). Secondary endpoints included safety, changes in the core set activity measures (CSMs) of the IMACS group and the Pediatric Rheumatology International Trials Organization, and improvements in disease activity based on the American College of Rheumatology (ACR)/EULAR response criteria for juvenile DM. Radiologists blinded with regard to participant data assessed magnetic resonance images (MRIs) of patient thigh muscles. Interferon (IFN)–regulated gene score was performed on whole‐blood RNA samples using a NanoString assay, and cytokines were assessed using a Luminex assay.
Results
Five patients achieved DOI at week 12, and 9 patients achieved DOI at week 24, including 2 patients with minimal, 4 patients with moderate, and 3 patients with major improvement by the 2016 ACR/EULAR response criteria for juvenile DM when patients were assessed using the CSMs of the IMACS Group. Improvements from baseline were seen in all CSMs at weeks 12 and 24, except in muscle enzymes. Daily glucocorticoid doses decreased from a mean of 16.7 mg at baseline to 10.2 mg at week 24 (P = 0.002). Average MRI muscle edema scores decreased from a mean baseline score of 5.3 to 2.3 at week 24 (P = 0.01). Six patients had down‐trending IFN‐regulated gene scores and galectin‐9 expression at week 24. Decreases in IFN‐regulated gene scores and in levels of interferon‐γ‐inducible protein 10kDa, galectin‐9, and interleukin‐2 correlated with improvements in disease activity and in muscle edema shown on MRI. Eleven grade 2 or 3 treatment‐emergent adverse events were observed.
Conclusion
This open‐label study demonstrated that abatacept may be beneficial for patients with treatment‐refractory juvenile DM.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract
Objective
To compare muscle ultrasound (MUS) parameters in patients with juvenile JDM and healthy controls, and examine their association with JDM disease activity measures and MRI.
Methods
...MUS of the right mid-rectus femoris was performed in 21 patients with JDM meeting probable or definite Bohan and Peter criteria and 28 demographically matched healthy control subjects. MUS parameters were quantitated by digital image processing and correlated with JDM disease activity measures and semi-quantitative thigh MRI short tau inversion recovery (STIR) and T1 scores.
Results
Rectus femoris MUS echogenicity was increased (median 47.8 vs 38.5, P = 0.002) in patients with JDM compared with controls. Rectus femoris MUS echogenicity correlated with Physician Global Activity (PGA), Manual Muscle Testing (MMT), and Childhood Myositis Assessment Scale (CMAS) (rs 0.4–0.54). Some MUS parameters correlated with functional quantitative measures of muscle strength: resting RF area on MUS strongly correlated with knee extension quantitative muscle testing (rs 0.76), and contracted area correlated with proximal MMT, knee extension quantitative muscle testing, and CMAS (rs 0.71–0.80). MUS echogenicity correlated with both STIR and T1 MRI (rs 0.43), and T1 MRI correlated inversely with RF contracted area (rs -0.49) on MUS. There were differences in pre- and post-exercise vascular power and colour Doppler on MUS in patients with JDM vs controls, with the percentage change of post-exercise vascular power Doppler lower in JDM compared with controls (7.1% vs 100.0%).
Conclusions
These data suggest MUS may be a valuable imaging modality to assess JDM disease activity and damage.
Objective As many as half of all patients with gouty arthritis have some degree of renal impairment. The goal of this systematic review is to provide physicians with a comprehensive examination of ...available data on the risks and benefits of gouty arthritis treatment options when used in patients with chronic kidney disease (CKD). Methods We conducted a systematic literature review to determine what information is available to guide treatment decisions in this patient population. PubMed was searched for English-language articles indexed through July 2011 containing the terms “gout” or “hyperuricemia” and synonyms for renal impairment in combination with drug names. Publications were deemed relevant if they reported results from clinical studies, case reports, or prescribing practices of the drug of interest in patients with gouty arthritis and CKD. Results Nonsteroidal anti-inflammatory drugs and colchicine are oftentimes not considered appropriate in patients with CKD. Corticosteroids may be an effective alternative in this population; however, their efficacy has not been confirmed in randomized controlled trials and these agents can cause serious side effects. Allopurinol can be used for the prophylactic management of chronic hyperuricemia in patients with CKD, but the recommended decreased dosage may limit efficacy and serious hypersensitivity reactions may preclude its use. Febuxostat and pegloticase are new treatment options for chronic urate-lowering prophylaxis; however, the safety of these drugs in patients with advanced CKD has not yet been reported. Conclusions There is currently an unmet need for additional treatment options for the management of gouty arthritis in patients with CKD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objective
Nonsteroidal anti‐inflammatory drugs (NSAIDs) are principal pharmacologic agents for symptom relief in patients with arthritis and other inflammatory conditions. Cardiovascular risk is ...associated with all NSAIDs, excluding aspirin. Selective inhibition of cyclo‐oxygenase‐2 (COX)‐2 could produce a relative reduction in endothelial production of prostacyclin, while leaving the platelet production of thromboxane A2 (TXA2) intact. It has been speculated that this imbalance of homeostatic prostanoids might increase the risk for thrombotic events.
The goal of this review is to provide physicians guidelines to mitigate cardiovascular and nephrotoxicity of NSAIDs.
Methods
We conducted a systematic literature review to determine what information is available to guide treatment decisions in this patient population.
Results
Selective inhibition of COX‐2 could produce a relative reduction in endothelial production of prostacyclin, while leaving the platelet production of TXA2 intact. Increasing degrees of selectivity for COX‐2 are associated with augmented cardiovascular risk, whereas increasing degrees of selectivity for cyclo‐oxygenase‐2 (COX‐1) are associated with augmented gastrointestinal risk. Some NSAIDs (such as ibuprofen) can interfere with the cardioprotective effects of aspirin by competitively binding to COX‐1 enzyme, resulting in increased TXA2 production Naproxen may differ from other NSAIDs in sustaining functionally important degrees of inhibition of platelet cyclooxygenase‐1 activity throughout the dosing interval.
Conclusion
It is of paramount importance to consider individual health factors when choosing therapy with NSAIDs.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Idiopathic inflammatory myopathies (IIM) are a group of autoimmune diseases characterised by myositis-related autoantibodies plus infiltration of leucocytes into muscles and/or the skin, leading to ...the destruction of blood vessels and muscle fibres, chronic weakness and fatigue. While complement-mediated destruction of capillary endothelia is implicated in paediatric and adult dermatomyositis, the complex diversity of complement
in IIM pathology was unknown.
We elucidated the gene copy number (GCN) variations of total
,
and
and
in 1644 Caucasian patients with IIM, plus 3526 matched healthy controls using real-time PCR or Southern blot analyses. Plasma complement levels were determined by single radial immunodiffusion.
The large study populations helped establish the distribution patterns of various
GCN groups. Low GCNs of
(
=2+3) and
deficiency (
=0+1) were strongly correlated with increased risk of IIM with OR equalled to 2.58 (2.28-2.91), p=5.0×10
for
, and 2.82 (2.48-3.21), p=7.0×10
for
deficiency. Contingency and regression analyses showed that among patients with
deficiency, the presence of
became insignificant as a risk factor in IIM except for inclusion body myositis (IBM), by which 98.2% had
with an OR of 11.02 (1.44-84.4). Intragroup analyses of patients with IIM for C4 protein levels and IIM-related autoantibodies showed that those with anti-Jo-1 or with anti-PM/Scl had significantly lower C4 plasma concentrations than those without these autoantibodies.
deficiency is relevant in dermatomyositis,
is important in IBM and both
deficiency and
contribute interactively to risk of polymyositis.
Abstract
Objective
We examined features of clinically amyopathic JDM (CAJDM), in which patients have characteristic rashes with little to no evidence of muscle involvement, to determine whether this ...is a distinct phenotype from JDM.
Methods
Demographic, clinical, laboratory and treatment data from 12 (9 hypomyopathic, 3 amyopathic) patients meeting modified Sontheimer criteria for CAJDM and from 60 matched JDM patients meeting Bohan and Peter criteria were examined. Differences were evaluated by Fisher's exact and Mann-Whitney tests, random forests and logistic regression analysis.
Results
Nine (75%) CAJDM patients had anti-p155/140 (transcriptional intermediary factor 1), one (8.3%) anti-melanoma differentiation-associated gene 5 autoantibodies and two (16.7%) were myositis autoantibody negative. CAJDM patients were younger at diagnosis and frequently had mild disease at onset. CAJDM patients had less frequent myalgias, arthritis, contractures, calcinosis, dysphagia, abdominal pain and fatigue. The muscle, skeletal and overall clinical scores were lower in CAJDM. Serum muscle enzymes were less frequently increased in CAJDM, and peak values were lower. CAJDM patients received fewer medications compared with JDM patients. Only 50% of CAJDM patients received oral prednisone, but the maximum dose and treatment duration did not differ from JDM. At a median follow-up of 2.9 years, CAJDM patients had no documented functional disability, and none developed weakness, calcinosis, interstitial lung disease or lipodystrophy. Multivariable modelling revealed a lower skeletal score and less frequent myalgias as the most important factors in distinguishing CAJDM from JDM.
Conclusion
CAJDM may be distinguished from JDM, in that they often have p155/140 (transcriptional intermediary factor 1) autoantibodies, have fewer systemic manifestations and receive less therapy.
We previously reported that 6 to 12 weeks of dual-chamber (DDD) pacing results in clinical and hemodynamic improvement in obstructive hypertrophic cardiomyopathy (HCM). This study examines the ...long-term results of DDD pacing in obstructive HCM.
DDD devices were implanted in 84 patients (mean age, 49 +/- 16 years) with obstructive HCM and severe drug-refractory symptoms. At a mean follow-up of 2.3 +/- 0.8 years (maximum, 3.5 years), the New York Heart Association (NYHA) functional class had improved significantly (1.6 +/- 0.6 versus 3.2 +/- 0.5, P < .00001). Symptoms were eliminated in 28 patients (33%), improved in 47 patients (56%), but remained unchanged in 7 patients (8%). Two patients died suddenly (97% cumulative 3-year survival rate). In 74 patients with significant left ventricular outflow tract (LVOT) obstruction at rest, the LVOT gradients were significantly reduced at follow-up (27 +/- 31 versus 96 +/- 41 mm Hg, P < .00001). Symptoms and provokable LVOT gradients were also reduced in all 10 patients without significant resting but with provokable LVOT obstruction. Persistence of the LVOT obstruction and symptoms was attributed to inability to pre-excite the interventricular septum (n = 8) and onset of atrial fibrillation (n = 7). Fifty patients had two cardiac catheterization evaluations, 3 +/- 1 and 16 +/- 4 months after implantation of a pacemaker. In this subgroup, the NYHA functional class improved from 3.2 +/- 0.5 at baseline to 1.8 +/- 0.7 at the initial evaluation (P < .00001), but with a further significant improvement at the second evaluation: 1.4 +/- 0.6, P < .001. This symptomatic improvement was associated with progressive reduction of LVOT gradient at the two evaluations: baseline, 100 +/- 47 mm Hg; first evaluation, 41 +/- 36 mm Hg (P < .0001); and second evaluation, 29 +/- 34 mm Hg (P < .01). Despite the presence of left bundle branch block, DDD pacing reduced LVOT obstruction significantly in 15 patients (LVOT gradient, baseline 89 +/- 36 mm Hg versus 18 +/- 26 mm Hg at follow-up, P < .0001). There was a weak but significant correlation between the reduction in LVOT gradients accomplished by AV pacing before implantation of DDD device and the eventual reduction in LVOT gradients recorded at the follow-up evaluation (r = .38, P = .0017). Echocardiography demonstrated significant thinning of the anterior septum and distal anterior LV wall in the absence of deterioration of LV systolic function.
(1) Although most of the improvement of symptoms and hemodynamic indexes occurs during the first few months of DDD pacing, further changes are often observed a year later; (2) DDD pacing is associated with an excellent prognosis in a subgroup of severely disabled patients, many of whom present with syncope or presyncope; (3) baseline pacing studies are not essential to identify patients who may benefit from pacing; (4) preexisting left bundle branch block is compatible with severe LVOT obstruction, and DDD pacing is also beneficial in this subgroup; (5) DDD pacing reduces both resting and provokable LVOT obstruction; (6) additional therapy, for example, radiofrequency ablation of the AV node, may be necessary in some patients either to preexcite the interventricular septum or to control atrial fibrillation; and (7) although LV hypertrophy has been considered a primary feature of HCM, pacing appears to reverse LV wall thickness in a significant subset of adult HCM patients.
The role of fluoro‐2‐deoxyglucose (FDG) positron emission tomography (PET) in the diagnosis, staging, and monitoring of neoplastic conditions is well established. The clinical utility of PET/CT has ...now expanded to the diagnosis of autoimmune, inflammatory, infectious, as well as non‐neoplastic conditions, such as the vasculitides, atherosclerosis, and granulomatous conditions, including sarcoidosis and inflammatory bowel disease, in addition to a variety of neurologic disorders. The availability of new PET radiotracers is expected to expand PET/CT applications to a variety of other clinical domains. New radioligands for studying inflammation and neurodegenerative processes are under development. Here, we discuss the evolving potential role of PET imaging for the evaluation and monitoring of miscellaneous conditions, including osteoarthritis, interstitial lung disease, vascular thromboses, and osteoporosis.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
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