The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of ...children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA).
The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting.
One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups.
Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.
Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP ...include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.
Tofacitinib is an oral Janus kinase inhibitor. This trial assessed the efficacy and safety of tofacitinib versus placebo in patients with polyarticular course juvenile idiopathic arthritis (JIA).
...This double-blind, withdrawal phase 3 trial enrolled patients with polyarticular course JIA (extended oligoarthritis, rheumatoid factor-positive or rheumatoid factor-negative polyarthritis, or systemic JIA without active systemic features) aged 2 years to younger than 18 years, and was done at 64 centres of the Paediatric Rheumatology International Trials Organisation and Pediatric Rheumatology Collaborative Study Group networks in 14 countries. Patients with psoriatic arthritis or enthesitis-related arthritis were enrolled for exploratory endpoints. During part 1 of the study, patients received oral open-label tofacitinib (weight-based doses; 5 mg twice daily or lower) for 18 weeks. Patients achieving at least JIA/American College of Rheumatology 30 response were randomly assigned (1:1) using an Interactive Response Technology system to continue tofacitinib or switch to placebo in part 2 of the study for 26 weeks. The primary endpoint was JIA flare rate by week 44 in part 2 in patients with polyarticular course JIA; the intention-to-treat principle was applied. Safety was evaluated throughout part 1 and part 2 of the study in all patients who received one dose or more of study medication. This trial is registered with ClinicalTrials.gov, NCT02592434.
Between June 10, 2016, and May 16, 2019, of 225 patients enrolled, 184 (82%) patients had polyarticular course JIA, 20 (9%) had psoriatic arthritis, and 21 (9%) had enthesitis-related arthritis. 147 (65%) of 225 patients received concomitant methotrexate. In part 2, 142 patients with polyarticular course JIA were assigned to tofacitinib (n=72) or placebo (n=70). Flare rate by week 44 was significantly lower with tofacitinib (21 29% of 72 patients) than with placebo (37 53% of 70 patients; hazard ratio 0·46, 95% CI 0·27–0·79; p=0·0031). In part 2 of the study, adverse events occurred in 68 (77%) of 88 patients receiving tofacitinib and 63 (74%) of 85 in the placebo group. Serious adverse events occurred in one (1%) and two (2%), respectively. In the entire tofacitinib exposure period, 107 (48%) of 225 patients had infections or infestations. There were no deaths during this study.
The results of this pivotal trial show that tofacitinib is an effective treatment in patients with polyarticular course JIA. New oral therapies are particularly relevant for children and adolescents, who might prefer to avoid injections.
Pfizer.
Objective
To compare the capacity of the 2004 diagnostic guidelines for hemophagocytic lymphohistiocytosis (HLH‐2004) with the capacity of the preliminary diagnostic guidelines for systemic juvenile ...idiopathic arthritis (JIA)–associated macrophage activation syndrome (MAS) to discriminate MAS complicating systemic JIA from 2 potentially confusable conditions, represented by active systemic JIA without MAS and systemic infection.
Methods
International pediatric rheumatologists and hemato‐oncologists were asked to retrospectively collect clinical information from patients with systemic JIA–associated MAS and confusable conditions. The ability of the guidelines to differentiate MAS from the control diseases was evaluated by calculating the sensitivity and specificity of each set of guidelines and the kappa statistics for concordance with the physician's diagnosis. Owing to the fact that not all patients were assessed for hemophagocytosis on bone marrow aspirates and given the lack of data on natural killer cell activity and soluble CD25 levels, the HLH‐2004 guidelines were adapted to enable the diagnosis of MAS when 3 of 5 of the remaining items (3/5‐adapted) or 4 of 5 of the remaining items (4/5‐adapted) were present.
Results
The study sample included 362 patients with systemic JIA and MAS, 404 patients with active systemic JIA without MAS, and 345 patients with systemic infection. The best capacity to differentiate MAS from systemic JIA without MAS was found when the preliminary MAS guidelines were applied. The 3/5‐adapted HLH‐2004 guidelines performed better than the 4/5‐adapted guidelines in distinguishing MAS from active systemic JIA without MAS. The 3/5‐adapted HLH‐2004 guidelines and the preliminary MAS guidelines with the addition of ferritin levels ≥500 ng/ml discriminated best between MAS and systemic infections.
Conclusion
The preliminary MAS guidelines showed the strongest ability to identify MAS in systemic JIA. The addition of hyperferritinemia enhanced their capacity to differentiate MAS from systemic infections. The HLH‐2004 guidelines are likely not appropriate for identification of MAS in children with systemic JIA.
Purpose
The survival benefit from detecting additional breast cancers by preoperative magnetic resonance imaging (MRI) continues to be controversial.
Methods
We followed a cohort of 4454 women ...diagnosed with non-metastatic breast cancer (stage I–III) from 2/2005–6/2010 in five registries of the breast cancer surveillance consortium (BCSC). BCSC clinical and registry data were linked to Medicare claims and enrollment data. We estimated the cumulative probability of breast cancer-specific and all-cause mortality. We tested the association of preoperative MRI with all-cause mortality using a Cox proportional hazards model.
Results
917 (20.6%) women underwent preoperative MRI. No significant difference in the cumulative probability of breast cancer-specific mortality was found. We observed no significant difference in the hazard of all-cause mortality during the follow-up period after adjusting for sociodemographic and clinical factors among women with MRI (HR 0.90; 95% CI 0.72–1.12) compared to those without MRI.
Conclusion
Our findings of no breast cancer-specific or all-cause mortality benefit supplement prior results that indicate a lack of improvement in surgical outcomes associated with use of preoperative MRI. In combination with other reports, the results of this analysis highlight the importance of exploring the benefit of preoperative MRI in patient-reported outcomes such as women’s decision quality and confidence levels with decisions involving treatment choices.
Juvenile idiopathic arthritis Weiss, Jennifer E; Ilowite, Norman T
The Pediatric clinics of North America,
04/2005, Letnik:
52, Številka:
2
Journal Article
Recenzirano
Juvenile idiopathic arthritis (JIA), a term referring to a group of disorders characterized by chronic arthritis, is the most common chronic rheumatic illness in children and is a significant cause ...of short- and long-term disability. This article discusses the classification, differential diagnosis, and treatment of JIA.
Kawasaki disease (KD) is a multisystem vasculitis of unknown etiology, with coronary artery aneurysms occurring in 25% of untreated cases. With conventional treatment of intravenous immunoglobulin ...(i.v.IG) and high dose aspirin (ASA) only 4% of patients develop coronary artery aneurysms. Children who are unresponsive present a challenge. Tumor necrosis factor-alpha levels peak during the acute and subacute phase of KD, especially in children who develop coronary artery aneurysms. We describe a 3-year-old male with KD and giant coronary artery aneurysms, unresponsive to multiple doses of i.v.IG and methylprednisolone, who was treated with infliximab. After the first dose he defervesced and his laboratory measures improved.
BackgroundEfficacy and safety of intravenous (IV) tocilizumab (TCZ) have been shown in patients (pts) with pcJIA.1ObjectivesDetermine appropriate dosing regimens of SC TCZ in pcJIA.MethodsPts were ...aged 1–17 y with pcJIA, inadequate response/intolerance to MTX and TCZ-naive or receiving TCZ IV with adequate disease control. TCZ SC was administered open label by body weight (BW)–based dosing modeled on IV dosing in pcJIA and SC dosing in adult rheumatoid arthritis: pcJIA pts <30kg received TCZ 162mg every 3 wks (Q3W) and pts ≥30kg received TCZ 162mg Q2W for 52 wks. Safety, efficacy (exploratory) and model-computed pharmacokinetic (PK) and pharmacodynamic (PD) parameters were assessed.Results52 pts were enrolled; 27 <30kg and 25 ≥30kg BW; 85% and 56% were TCZ naive. Since no notable difference in steady state PK occurred in naive vs non-naive pts, pooled data are shown. Median Cmin was similar between BW groups and higher than with TCZ IV (TCZ IV median Cmin: 3.2 μg/mL for 10mg/kg <30kg BW and 7.3 μg/mL for 8mg/kg ≥30kg BW) ensuring adequate exposure from SC doses. Median Cmax was lower from SC than IV dosing. Changes in PD parameters for TCZ-naive pts were consistent with those for TCZ IV. JADAS-71 generally improved (Table), with trends consistent with those for TCZ IV. Infections were the most frequent adverse event (AE), reported in 36 pts; 2 serious infections occurred in 1 pt. Injection site reactions occurred in 15% pts in the <30kg group and 44% pts in the ≥30kg group. The most common symptoms were erythema, swelling, hematoma, pain and pruritus. No serious hypersensitivity, AE leading to withdrawal, opportunistic infection, serious hepatic AE or death occurred. Overall there were 4 serious AEs in 3 pts (7.9/100 pt-y, consistent with that for TCZ IV).TCZ 162mg SC Q3W,TCZ 162mg SC Q2W, BW <30kg (n=27)BW ≥30kg (n=25) Model-computed steady state PK parameters, median range Cmin, μg/mL13.4 0.2, 52.312.7 0.2, 23.8 Cmax, μg/mL62.4 39.4, 121.129.7 7.6, 50.3 AUC12weeks, μg/mL×day2998 1465, 77081933 324, 3098Change from baseline to week 52a in PD markers and efficacy, median range; TCZ-naive pts IL-6, pg/mL27.3 3.5, 173.9, n=1112.2 −6.2, 30.9, n=9 sIL-6R, ng/mL612.1 399.4, 808.4, n=14429.3 245.5, 585.6, n=11 CRP, mg/L−1.3 −17.0, 0.5, n=21−0.8 −22.9, 0.0, n=12 ESR, mm/h−11.0 −40.0, 0.0, n=21−6.0 −35.0, 0.0, n=12 JADAS-71−16.8 −40.3, −4.4, n=21−12.9 −48.1, −2.3, n=12aWeek 51 for Q3W group. AUC, area under the concentration curve; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IL-6, interleukin-6; sIL-6R, soluble IL-6 receptor.ConclusionsThe BW-based TCZ SC dosing regimens for pcJIA provided adequate exposure to support efficacy comparable to that for TCZ IV, with an acceptable benefit-risk profile.References Brunner HI et al. Ann Rheum Dis 2014;74:1110–7. Disclosure of InterestF. De Benedetti Grant/research support from: Novartis, Roche, Pfizer, SOBI, AbbVie, Novimmune, BMS, Sanofi, N. Ruperto Consultant for: AbbVie, Amgen, Alter, AstraZeneca, Baxalta Biosimilars, Biogenidec, Boehringer, BMS, Celgene, CrescendoBio, EMD Serono, Hoffmann-La Roche, Italfarmaco, Janssen, MedImmune, Medac, Novartis, Novo Nordisk, Pfizer, Sanofi Aventis, Servier, Takeda, UCB Biosciences GmbH, Speakers bureau: AbbVie, Amgen, Alter, AstraZeneca, Baxalta Biosimilars, Biogenidec, Boehringer, BMS, Celgene, CrescendoBio, EMD Serono, Hoffmann-La Roche, Italfarmaco, Janssen, MedImmune, Medac, Novartis, Novo Nordisk, Pfizer, Sanofi Aventis, Servier, Takeda, UCB Biosciences GmbH, D. Lovell Grant/research support from: NIH, NIAMS, Consultant for: Astra-Zeneca, Bristol Meyers Squibb, AbbVie, Pfizer, Roche, Novartis, UBC, Forest Research Institute, Horizon, Johnson & Johnson, Biogen, Takeda, Genentech, GlaxoSmithKline, Boehringer Ingelheim, Celgene, Janssen, A. Ramanan Speakers bureau: Roche, AbbVie, R. Cuttica Consultant for: Roche, Novartis, Lilly, GlaxoSmithKline, Bristol-Myers Squibb, Janssen, Speakers bureau: Roche, Novartis, Lilly, GlaxoSmithKline, Bristol-Myers Squibb, Janssen, J. Weiss: None declared, M. Henrickson: None declared, H. Schmeling Grant/research support from: Janssen, Pfizer, UCB Biosciences GmbH, J. Anton Grant/research support from: Roche, K. Minden Grant/research support from: AbbVie, Pfizer, Roche, Speakers bureau: AbbVie, Pfizer, Roche, Genzyme, Pharm-Allergan, J. Hsu Employee of: Roche, K. Bharucha Employee of: Genentech, S. Wimalasundera Employee of: Roche Products Ltd., A. Kadva Employee of: Genentech, R. Upmanyu Employee of: Roche Products Ltd., N. Mallalieu Shareholder of: Roche, Employee of: Roche, A. Martini Consultant for: Abbvie, Boehringer, Celgene, CrescendoBio, Janssen, MedImmune, Novartis, NovoNordisk, Pfizer, Sanofi Aventis, Vertex, Servier, Speakers bureau: Abbvie, Boehringer, Celgene, CrescendoBio, Janssen, MedImmune, Novartis, NovoNordisk, Pfizer, Sanofi Aventis, Vertex, Servier, H. Brunner: None declared
Arsenic is a known carcinogen specifically linked to skin cancer occurrence in regions with highly contaminated drinking water or in individuals who took arsenic-containing medicines. Presently, it ...is unknown whether such effects occur at environmental levels found in the United States. To address this question, the authors used data collected on 587 basal cell and 284 squamous cell skin cancer cases and 524 controls interviewed as part of a case-control study conducted in New Hampshire between 1993 and 1996. Arsenic was determined in toenail clippings using instrumental neutron activation analysis. The odds ratios for squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) were close to unity in all but the highest category. Among individuals with toenail arsenic concentrations above the 97th percentile, the adjusted odds ratios were 2.07 (95% confidence interval (CI): 0.92, 4.66) for SCC and 1.44 (95% CI: 0.74, 2.81) for BCC, compared with those with concentrations at or below the median. While the risks of SCC and BCC did not appear elevated at the toenail arsenic concentrations detected in most study subjects, the authors cannot exclude the possibility of a dose-related increase at the highest levels of exposure experienced in the New Hampshire population.
A study was conducted to evaluate toenail arsenic concentrations as a biologic marker of drinking water arsenic exposure. Study subjects were controls in a US population-based case-control study of ...nonmelanoma skin cancer, randomly selected from drivers' license records (those < 65 years of age) and Medicare enrollment files (those > or = 65 years of age). Between 1994 and 1997, a total of 540 controls were interviewed and toenail samples of sufficient weight were collected from 506 (93.7%) of these. Beginning in 1995, a sample of tap water was taken from the participants' homes; a total of 217 (98.6%) water samples were obtained from the 220 subjects interviewed. Arsenic determinations were made from toenail samples using neutron activation analysis. Water samples were analyzed using hydride-generation magnet sector inductively coupled mass spectrometry. Among 208 subjects with both toenail and water measurements, the correlation (r) between water and nail arsenic was 0.65 (p < 0.001) among those with water arsenic concentrations of 1 microg/liter or higher and 0.08 (p = 0.31) among those with concentrations below 1 microg/liter (overall r = 0.46, p < 0.001). Our data suggest that toenail samples provide a useful biologic marker for quantifying low-level arsenic exposure.
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