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.

Youth preferences for cigar brands: rates of use and characteristics of users

OBJECTIVE

Youth use of cigars has increased in the USA. Understanding brand preference among youth could help explain the attraction to cigars, and develop prevention strategies. This study reports on youth characteristics associated with preferences for cigar brands.

DESIGN

Data are presented on 5006 students in grades 7-12 (ages 12-18 years) in classrooms administered the cigar use reasons evaluation (CURE), a questionnaire assessing alternative tobacco use (cigars, bidis, and kreteks).

SETTING

Twelve middle and high schools across Massachusetts.

MAIN OUTCOME MEASURES

Preferred brands of cigars.

RESULTS

Cigar smoking was reported by 16.4% of the sample. The brands preferred by over 5% of cigar users were Phillies (overall prevalence: 31.0%, 95% confidence interval (CI) 27.9% to 34.3%), Black & Mild (12.3%, 95% CI 9.8% to 15.4%), Garcia y Vega (11.4%, 95% CI 9.3% to 13.8%), Swisher Sweets (9.6%, 95% CI 7.6% to 12.2%), Backwoods (6.1%, 95% CI 4.6% to 8.1%), and non-listed brands (16.4%, 95% CI 14.0% to 19.0%). Male cigar smokers were significantly more likely than females to prefer five brands: Backwoods, Dutch Masters, Garcia y Vega, Phillies, and Swisher Sweets, while females were more likely to prefer Black & Mild and non-listed brands. Brand preferences were also distinguished by self, friends' and siblings' tobacco use, race/ethnicity, parents' education and cigar use, GPA (grade point average), college plans, and community type. Urban students were more likely to prefer Black & Mild; students whose parents smoke cigars preferred non-listed brands.

CONCLUSIONS

Youth prefer certain brands, most notably Phillies. Particular brands are preferred by particular youth subgroups, raising the possibility of selective marketing toward these groups.

Interaction between two isoforms of the NF2 tumor suppressor protein, merlin, and between merlin and ezrin, suggests modulation of ERM proteins by merlin

The product of the neurofibromatosis type II (NF2) tumor suppressor gene, merlin, is closely related to the ezrin-radixin-moesin (ERM) family, a group of proteins believed to link the cytoskeleton to the plasma membrane. Mutation in the NF2 locus is associated with Schwann cell tumors (schwannomas). The two predominant merlin isoforms, I and II, differ only in the carboxy-terminal 16 residues and only isoform I is anti-proliferative. Merlin lacks an actin-binding domain conserved among ezrin, radixin and moesin. Because merlin, ezrin and moesin are co-expressed in Schwann cells, and all homodimerize, we have examined whether merlin and ezrin dimerize with one another. We found by immunoprecipitation and yeast two-hybrid assays that both merlin isoforms interact with ezrin. The interaction occurs in a head-to-tail orientation, with the amino-terminal half of one protein interacting with the carboxy-terminal half of the other. The two merlin isoforms behave differently in their interaction with ezrin. Isoform I binds only ezrin whose carboxy-terminus is exposed, whereas isoform II binds ezrin regardless of whether ezrin is in the open or closed conformation. The heterodimerization of merlin is a much stronger interaction than the interaction between either merlin isoform and ezrin, and can inhibit merlin-ezrin binding. This suggests that, in vivo, merlin dimerization could regulate merlin-ERM protein interaction, and could thus indirectly regulate other interactions involving ERM proteins.

Interaction between two isoforms of the NF2 tumor suppressor protein, merlin, and between merlin and ezrin, suggests modulation of ERM proteins by merlin

The product of the neurofibromatosis type II (NF2) tumor suppressor gene, merlin, is closely related to the ezrin-radixin-moesin (ERM) family, a group of proteins believed to link the cytoskeleton to the plasma membrane. Mutation in the NF2 locus is associated with Schwann cell tumors (schwannomas). The two predominant merlin isoforms, I and II, differ only in the carboxy-terminal 16 residues and only isoform I is anti-proliferative. Merlin lacks an actin-binding domain conserved among ezrin, radixin and moesin. Because merlin, ezrin and moesin are co-expressed in Schwann cells, and all homodimerize, we have examined whether merlin and ezrin dimerize with one another. We found by immunoprecipitation and yeast two-hybrid assays that both merlin isoforms interact with ezrin. The interaction occurs in a head-to-tail orientation, with the amino-terminal half of one protein interacting with the carboxy-terminal half of the other. The two merlin isoforms behave differently in their interaction with ezrin. Isoform I binds only ezrin whose carboxy-terminus is exposed, whereas isoform II binds ezrin regardless of whether ezrin is in the open or closed conformation. The heterodimerization of merlin is a much stronger interaction than the interaction between either merlin isoform and ezrin, and can inhibit merlin-ezrin binding. This suggests that, in vivo, merlin dimerization could regulate merlin-ERM protein interaction, and could thus indirectly regulate other interactions involving ERM proteins.

Folacin and iron status and hematological findings in black and Spanish-American adolescents from urban low-income households

The folacin and iron status of 193 adolescents from urban low-income households was evaluated. Red blood cell folacin concentrations were less than 140 ng/ml in 42% of the subjects and 140 to 159 ng/ml in 13%. Of the serum folacin values, 45% were less than 6 ng/ml, and 15% were below 3 ng/ml. Serum folacin levels decreased with increasing age (p less than 0.01) and sexual maturity (p less than 0.05). Transferrin saturation was low (less than 16%) in 12% of the females and 2% of the males. Transferrin saturation levels for females declined as age increased in contrast to an increase over age in males (p less than 0.01). Eleven percent of the females and 3% of the males were classified as anemic (less than 12 g/dl). Mean cell Hb concentration was low (less than 32%) in 24% of the females and 7% of the males. Of all subjects, 17% had low mean cell volumes (less than 81 mum 3). These findings demonstrate folacin and iron status is less than adequate in a significant proportion of this adolescent population group.

Vitamin B12 status of elderly persons from urban low-income households

Vitamin B12 status was evaluated in 111 noninstitutional elderly persons (age range, 60-87 years) living in an urban poverty area. The sample was predominantly black (90 subjects); the rest were Spanish Americans. Serum vitamin B12 levels were all normal (greater than 200 pg/ml) and ranged from 226 to 1200 pg/ml (mean +/- SD = 700 +/- 191 pg/ml). The findings indicate that vitamin B12 deficiency was not a problem in this elderly population.