TNF‐α promoter gene polymorphisms in Spanish children with persistent oligoarticular and systemic‐onset juvenile idiopathic arthritis

OBJECTIVE

To explore the possible association/s of the first reported tumour necrosis factor (TNF-alphaTNF-) alpha promoter gene polymorphisms -308, -238, -376 and -163 (G-->A) with systemic (SoJIA) and oligoarticular subtypes of juvenile idiopathic arthritis (JIA); and to test the association between these polymorphisms and the class I/class II HLA alleles in our population.

METHODS

The patient group comprised 29 oligoarticular and 26 systemic Caucasian Spanish children with JIA; 68 healthy volunteers from the same ethnic group and geographical region served as controls. HLA alleles were determined using low-resolution polymerase chain reaction (PCR). TNF-alpha promoter gene polymorphisms were screened using PCR denaturing gradient gel electrophoresis (PCR-DGGE), followed, if positive, by restriction fragment length polymorphism (RFLP) analysis for identification.

RESULTS

No statistical association was found between the four polymorphisms studied and JIA. However, the -308 G-->A polymorphism (TNF A2) tended to be more frequent in patients with SoJIA than in the oligoarticular group. TNF A2 was strongly associated with the extended haplotype A1B8DR3 (p = 0.003), and the tandem polymorphism -238/-376 in the presence of B18 and DR3.

CONCLUSION

The TNF A2 allele was more frequent in SoJIA than in the oligoarticular group. TNF A2 can help to create a more inflammatory milieu in this JIA subtype, in combination with other polymorphisms involved in regulatory sequences of key molecules in the inflammatory response. The association of the -308 and -238/-376 polymorphisms with specific alleles of the HLA is reconfirmed.

Tarsitis as an initial manifestation of juvenile spondyloarthropathy

OBJECTIVE

The aim of this study was to determine the frequency of tarsitis as one of the first symptoms of juvenile spondyloarthropathy (JSpA) and to analyze whether patients with tarsitis at onset differ from those without it.

METHODS

A retrospective chart review was performed, from January 1996 to September 2007, at a paediatric rheumatology unit of a tertiary university hospital.

RESULTS

Tarsitis was detected in one-third of the children diagnosed with JSpA. They had fever and received antibiotics due to a suspected infection more frequently than those without tarsitis. Inflammatory low back pain was extremely unusual among these patients.

CONCLUSION

There were some differences between children diagnosed with JSpA initially affected with tarsitis and those without it. Patients with tarsitis as one of the first symptoms were often misdiagnosed as soft tissue infections.

Evolution of Drug use After Enforcing a Protocol in a Medium Stay Unit. Results Four Years Later

Aims:

Comorbidity between drug misuse and mental disorders affects negatively in the prognosis of psychistric illness, so it’s important to guarantee drug abstinence at least during hospitalization. This is even more significant in a medium stay unit because patients are more serious and resistant to treatment.

In February 2003, a multidisciplinary group was formed to evaluate the situation of drug use in a psychiatric hospital and a drug screening protocol was then created.

We evaluate if with the protocol, drug use decreases during hospitalization in a medium stay unit in a psychiatric hospital.

Methods:

We first compared drug use (positive results in urine samples) from 2000 to 2002 (before protocol: urine samples collected when there’s drug misuse suspicion) with the period after the protocol was enforced (from 2003 to 2006). Afterwards, we analyzed if drug use during hospitalization continues decreasing in 2007.

In the protocol urine samples are collected when there’s a past misuse history, consumption suspicion, randomly and every time they leave for home.

Results:

It is proved that drug use decreases during hospitalization since the new protocol came into force. Drug use continues reducing since the enforcement of the drug screening protocol.

Conclusion:

The introduction and exhaustive completion of a protocol designed to decrease drug misuse in a psychiatric hospitalization unit, provokes a high reduction of drug use, and each year, the reduction of drug misuse is higher. So we think it’s convenient to generalize this kind of measures.

Efficacy of a Drug Screening Protocol

Aims:

Comorbidity between drug misuse and mental disorders affects negatively in the prognosis of psychiatric illness, so it’s important to guarantee drug abstinence during hospitalization.

The Hospital of Zamudio contains short and medium stay units. Patients are referred to medium stay units when disorders are more serious or the symptoms are resistant to treatment.

In February 2003, a multidisciplinary group was formed to evaluate the situation of drug use in a psychiatric hospital and a drug screening protocol was then created.

We evaluate if the enforcement of the protocol, has decreased drug use during hospitalization.

Methods:

It’s compared, retrospectively, drug use (positive results in urine samples) since the screening drug protocol was enforced (2003) to 2007. Urine samples are collected when there’s a past misuse history, consumption suspicion, randomly and every time the patient leave for home. It’s also compared the differences between short and medium stay units.

Results:

It’s proved that drug use decreases during hospitalization since the new protocol came into force in a medium stay unit. This drug protocol is not useful in a short stay unit.

Conclusions:

The introduction and completion of this protocol provokes a high reduction of drug use in a medium stay unit. This design seems not to be adequate to short stay units. Probably, collecting urine samples when patients came into a short unit gives false positive results because these patients don’t come from other hospitalization units as in the case of medium stay unit.

Differences Between Patients of a Medium Stay Unit Depending on the Derivation Unit

Aims:

The medium stay unit of the hospital of Zamudio is a psychiatric hospitalization unit where serious patients are admitted, specially those with psychotic and affective disorders. The complexity of the pathology extends the average stay of hospitalization with an average of 60 days to improve.

There are 2 derivation units from which medium stay takes patients:

•

Methods:

It is analyzed, retrospecitvely, the profile of patients in a medium stay unit comparing the derivation unit they come from in 2007.

Results and conlusions:

There are no statistically significant differences in the number of patients derived from the diverse units.

The sociodemographic and administrative profile of the patients is similar in both groups: a single middle aged (between 45-50 years old) that is hospitalized knowlingly (63%). The average stay at hospital is 55 days.

Attending to the clinical profile we concluded that patients derived from the Hospital of Zamudio suffer from Bipolar disorder as main diagnosis. The rest of disorders remain similar comparing both units.

Biological and phylogenetic characterization of virulent Newcastle disease virus circulating in Mexico

In 2002-2003, velogenic Newcastle Disease Virus outbreaks, closely related to the Mexican isolates, were confirmed in the United States (U.S.) in southern California, Arizona, Nevada, and Texas. In this report, virulent NDVs isolated in Mexico between 1998 and 2006 were subjected to biologic characterization, using standard pathogenicity tests, and to phylogenetic analysis. Chicken embryo mean death time (MDT) test results ranged from 39.7 to 61.5 hours, and intracerebral pathogenicity index (ICPI) values were between 1.59 and 1.94, compared to a possible maximum value of 2.0. These isolates showed a dibasic amino acid motif at the fusion protein cleavage site sequence required for host systemic replication. Phylogenetic analysis indicated that the Mexican virulent NDVs belong to the class II, genotype V viruses and can be clearly divided in two groups as follows: isolates from 1998 to 2001 with close epidemiologic relationship with the latest U.S. NDV outbreaks, and phylogenetically distinct viruses, isolated from 2004 to 2006, which showed higher virulence. The assessment of the evolution of viruses from Mexico and other neighboring countries will aid in the U.S surveillance efforts for early detection of highly virulent NDV.

Prevention of murine lupus disease in (NZBxNZW)F1 mice by sirolimus treatment

Sirolimus is a new immunosuppressive drug used to avoid allograft rejection. The immunosuppressive effect of sirolimus is due to inhibition of the mammalian target of rapamycin, necessary for the proliferation and clonal expansion of activated T-cells. Because T-cells play a central role in the pathogenesis of autoimmune disease developed in (NZBxNZW)F1 mice, we evaluated the therapeutic use of sirolimus in such mice. (NZBxNZW)F1 female mice received 1mg/kg/day of sirolimus from 12 to 37 weeks of age. The development of autoimmune disease was evaluated by measuring the serum levels of auto-antibodies (autoAbs) and their immunoglobulin isotypes, prevalence of glomerulonephritis and mortality rates. Sirolimus directly inhibited production of autoAbs, glomerular deposits of immunoglobulins and development of proteinuria; also the survival of these mice was prolonged. Our results demonstrate the beneficial effects of sirolimus in preventing the development of lupus disease in (NZBxNZW)F1 female mice.

Cyclosporine A in juvenile idiopathic arthritis. Results of the PRCSG/PRINTO phase IV post marketing surveillance study

OBJECTIVE

To investigate the clinical use patterns, clinical effect and safety of cyclosporine A (CSA) in juvenile idiopathic arthritis (JIA) in the setting of routine clinical care.

METHODS

An open-ended, phase IV post marketing surveillance study was conducted among members of the Pediatric Rheumatology Collaborative Study Group (PRCSG) and of the Paediatric Rheumatology International Trials Organisation (PRINTO) to identify patients with polyarticular course JIA who had received CSA during the course of their disease.

RESULTS

A total of 329 patients, half of whom had systemic JIA, were collected in 21 countries. Data were collected during 1240 routine clinic visits. CSA was started at a mean of 5.8 years after disease onset and was given at a mean dose of 3.4 mg/kg/day. The drug was administered in combination with MTX in 61% and along with prednisone in 65% of the patients who were still receiving CSA. Among patients who were still receiving CSA therapy at the last reported visit, remission was documented in 9% of the patients, whereas in 61% of the patients the disease activity was rated as moderate or severe. The most frequent reason for discontinuation of CSA was insufficient therapeutic effect (61% of the patients); only 10% of the patients stopped CSA because of remission. In 17% of the patients, side effects of therapy was given as the primary reason for discontinuation.

CONCLUSION

This survey suggests that CSA may have a less favourable efficacy profile than MTX and etanercept, whereas the frequency of side effects may be similar. The exact place of CSA in the treatment of JIA can only be established via controlled clinical trial.

Organochlorine compounds in liver and concentrations of vitellogenin and 17beta-estradiol in plasma of sea bass fed with a commercial or with a natural diet

Results from previous experiments directed to determine the effect of different nutritional factors or the effect of xenobiotics on hormonal control of reproduction, lead to the hypothesis that hormonal perturbations repeatedly observed in sea bass (Dicentrarchus labrax) broodstock feeding commercial diets could have been caused by the presence of aryl hydrocarbon receptor (AhR) ligands, such as dioxins, furans and polychlorinated biphenyls (PCBs) in the diet. To evaluate this hypothesis, dioxins and related compounds were analysed in liver of female sea bass fed with a commercial or with a natural diet consisting of trash fish (bogue, Boops boops), and concentrations of vitellogenin (VTG) and 17beta-estradiol (E2) were determined in plasma obtained previously in monthly samplings of these animals. As observed in other experiments, females fed with a commercial diet exhibited lower VTG and higher E2 plasma levels than females fed with the natural diet. In liver, sea bass fed with the commercial diet exhibited a profile clearly dominated by high-chlorinated dioxins while in fish fed with the natural diet this profile was dominated by low chlorinated furans. However, typical AhR ligands, such as 2,3,7,8-tetrachlorodibenzo-p-dioxin showed no differences between groups or, as is the case of planar PCBs, showed higher concentrations in the liver of fish fed with the natural diet. These results do not permit to explain the observed hormonal alterations by a possible antiestrogenic effect caused by dioxins and related compounds.

A new role for BMP5 during limb development acting through the synergic activation of Smad and MAPK pathways

In an attempt to identify new genes implicated in the control of programmed cell death during limb development, we have generated a cDNA library from the regressing interdigital tissue of chicken embryos. We have analyzed 804 sequences from this library and identified 23 genes involved in apoptosis in different models. One of the genes that came up in the screening was the Bone Morphogenetic Protein family member, Bmp5, that has not been previously involved in the control of apoptosis during limb development. In agreement with a possible role in the control of cell death, Bmp5 exhibited a regulated pattern of expression in the interdigital tissue. Transcripts of Bmp5 and BMP5 protein were abundant within the cytoplasm of the fragmenting apoptotic interdigital cells in a way suggesting that delivery of BMPs into the tissue is potentiated during apoptosis. Gain-of-function experiments demonstrated that BMP5 has the same effect as other interdigital BMPs inducing apoptosis in the undifferentiated mesoderm and growth in the prechondrogenic mesenchyme. We have characterized both Smad proteins and MAPK p38 as intracellular effectors for the action of BMPs in the developing limb autopod. Activation of Smad signaling involves the receptor-regulated genes Smad1 and -8, and the inhibitory Smad6, and results in both the upregulation of gene transcription and protein phosphorylation with subsequent nuclear translocation. MAPK p38 is also quickly phosphorylated after BMP stimulation in the limb mesoderm. Treatment with the inhibitor of p38, SB203580, revealed that there are interdigital genes induced by BMPs in a p38-dependent manner (DKK, Snail and FGFr3), and genes induced in a p38-independent manner (BAMBI, Msx2 and Smads). Together, our results suggest that Smad and MAPK pathways act synergistically in the BMP pathway controlling limb development.

Lymphoproliferative disorders in paediatric rheumatic diseases. A report of two cases

Lymphoproliferative disorders (LPD) are reported with a much lower frequency in children with rheumatic diseases than in their adult counterparts. We describe 2 patients who developed a lymphoma during the course of the disease. The first is a 16-year-old girl diagnosed with systemic juvenile idiopathic arthritis 6 years before who developed a mucosa-associated lymphoid tissue (MALT) lymphoma. The second report involves a boy diagnosed with systemic lupus erythematosus at 9 years of age who developed a Hodgkin's lymphoma 9 years after the disease onset. In spite of the low frequency of LPD in children with rheumatic diseases, these processes do occur.

Analysis of the molecular cascade responsible for mesodermal limb chondrogenesis: Sox genes and BMP signaling

Here, we have studied how Sox genes and BMP signaling are functionally coupled during limb chondrogenesis. Using the experimental model of TGFbeta1-induced interdigital digits, we dissect the sequence of morphological and molecular events during in vivo chondrogenesis. Our results show that Sox8 and Sox9 are the most precocious markers of limb cartilage, and their induction is independent and precedes the activation of BMP signaling. Sox10 appears also to cooperate with Sox9 and Sox8 in the establishment of the digit cartilages. In addition, we show that experimental induction of Sox gene expression in the interdigital mesoderm is accompanied by loss of the apoptotic response to exogenous BMPs. L-Sox5 and Sox6 are respectively induced coincident and after the expression of Bmpr1b in the prechondrogenic aggregate, and their activation correlates with the induction of Type II Collagen and Aggrecan genes in the differentiating cartilages. The expression of Bmpr1b precedes the appearance of morphological changes in the prechondrogenic aggregate and establishes a landmark from which the maintenance of the expression of all Sox genes and the progress of cartilage differentiation becomes dependent on BMPs. Moreover, we show that Ventroptin precedes Noggin in the modulation of BMP activity in the developing cartilages. In summary, our findings suggest that Sox8, Sox9, and Sox10 have a cooperative function conferring chondrogenic competence to limb mesoderm in response to BMP signals. In turn, BMPs in concert with Sox9, Sox6, and L-Sox5 would be responsible for the execution and maintenance of the cartilage differentiation program.

Evaluation of ILAR classification criteria for juvenile idiopathic arthritis in Spanish children

OBJECTIVE

To evaluate the proposed International League of Associations for Rheumatology (ILAR) classification criteria for juvenile idiopathic arthritis in a cohort of Spanish children.

METHODS

One hundred twenty-five patients with chronic arthritis were categorized according to one of the traditional classifications and the proposed ILAR classification system after at least 6 months of disease. The traditional classifications included the European League Against Rheumatism (EULAR) criteria for pauciarticular, polyarticular rheumatoid factor (RF) negative, and systemic juvenile chronic arthritis (JCA), as well as for RF+ polyarthritis; the Vancouver criteria for juvenile psoriatic arthritis (JPsA); and the European Spondylarthropathy Study Group (ESSG) preliminary criteria for juvenile spondyloarthropathy (JSpA).

RESULTS

The ILAR criteria classified 106/125 patients (84.8%). All patients with systemic and polyarticular JCA, RF+ polyarthritis, and definite juvenile psoriatic arthritis were reclassified in the corresponding ILAR category. In contrast, only 80% of pauciarticular JCA and 47% of JSpA patients could be allocated to the ILAR oligoarthritis (47/59 patients, 35 persistent and 12 extended) and enthesitis related arthritis (ErA. 8/17 patients) categories. Two children with probable PsA were reclassified in the RF- polyarthritis category. Nineteen patients (15.2%) were allocated to the ILAR "other arthritis" group, 13/19 because they did not fulfill criteria for any of the other categories (12 due to family history of psoriasis and one because of family history of HLA-B27 associated disease). The remaining 6 patients met criteria for 2 categories, RF- polyarthritis and either ErA (n = 5) or PsA (n = 1). No differences other than family history of psoriasis were found in any of the variables studied between pauciarticular JCA patients classified in the oligoarthritis (n = 47) and those in the "other arthritis" (n = 11) ILAR categories.

CONCLUSION

The proposed ILAR criteria allocated 84.8% of the patients classified by traditional criteria. Family history of psoriasis (n = 12) and polyarticular onset of disease in patients with ErA (n = 5) were responsible for most of the exclusions from other ILAR categories.

The European Spanish version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation of 2 health related quality of life instruments into the European Spanish language. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with Juvenile Idiopathic Arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from an underlying disease. The Spanish CHQ was fully validated with 3 forward and 3 backward translations, while the Spanish CHAQ, already published, was revalidated. A total of 149 subjects were enrolled: 80 patients with JIA (28% systemic arthritis, 34% polyarthritis, 17% extended oligoarthritis, and 21% persistent oligoarthritis) and 69 healthy children. The CHAQ appropriately distinguished healthy subjects from JIA patients, with those classified in the systemic arthritis, polyarthritis and extended oligoarthritis categories having a higher degree of disability and pain, as well as a lower overall well-being than their healthy peers. The CHQ was also able to discriminate healthy subjects from JIA patients, with those allocated in the systemic arthritis, polyarthritis and extended oligoarthritis categories having a lower physical and psychosocial well-being than their healthy counterparts. In conclusion, the European Spanish version of the CHAQ-CHQ is a reliable and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Role of FGFs in the control of programmed cell death during limb development

We have investigated the role of FGFs in the control of programmed cell death during limb development by analyzing the effects of increasing and blocking FGF signaling in the avian limb bud. BMPs are currently considered as the signals responsible for cell death. Here we show that FGF signaling is also necessary for apoptosis and that the establishment of the areas of cell death is regulated by the convergence of FGF- and BMP-mediated signaling pathways. As previously demonstrated, cell death is inhibited for short intervals (12 hours) after administration of FGFs. However, this initial inhibition is followed (24 hours) by a dramatic increase in cell death, which can be abolished by treatments with a BMP antagonist (Noggin or Gremlin). Conversely, blockage of FGF signaling by applying a specific FGF-inhibitor (SU5402) into the interdigital regions inhibits both physiological cell death and that mediated by exogenous BMPs. Furthermore, FGF receptors 1, 2 and 3 are expressed in the autopodial mesoderm during the regression of the interdigital tissue, and the expression of FGFR3 in the interdigital regions is regulated by FGFs and BMPs in the same fashion as apopotosis. Together our findings indicate that, in the absence of FGF signaling BMPs are not sufficient to trigger apoptosis in the developing limb. Although we provide evidence for a positive influence of FGFs on BMP gene expression, the physiological implication of FGFs in apoptosis appears to result from their requirement for the expression of genes of the apoptotic cascade. We have identified MSX2 and Snail as candidate genes associated with apoptosis the expression of which requires the combined action of FGFs and BMPs.