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.

[Treatment of pigmentation disorders in association with systemic diseases]

Pigmentation disorders are a frequent skin problem and incorporate a broad spectrum of diseases, caused by an abnormal melanin pigmentation or also non-melanin pigmentation of the skin. Both hypermelanosis and hypomelanosis can be hereditary or acquired. This article summarizes the treatment approaches that are used in the majority of acquired pigmentation disorders of the skin. The following forms of hypermelanosis are addressed: lentiginosis, hyperpigmentation due to endocrine disorders or other systemic diseases, drug-induced hyperpigmentation. Acquired hypomelanoses include postinflammatory hypomelanosis, chemical depigmentation, idiopathic guttate hypomelanosis and punctate leucoderma. With reference to non-melanin pigmentation, the exogenous pigmentation due to chemicals, metals and drug exposure are discussed. The treatment is primarily based on finding the cause of the alterations to the pigment. The affected area, age and ethnic origin are also important factors. The spectrum of therapeutic options is broad: topical agents, chemical peeling, systemic agents, laser and light-based treatment. As some of these treatment procedures can have side effects, the availability of a protocol that contains information on the drug concentration, dose, parameters for laser treatment and the number of sessions is important. For every disorder the specific dermatological treatment is presented even when some pigmentation alterations that occur in association with systemic diseases, are cured by the treatment of the primary disease. Most diseases are exacerbated by exposure to UV light. Therefore, sun protection is recommended and a cosmetic coverage is indicated.

Zertifizierung: „Teledermatologie (DDA)“

Telemedizin (E-Health) ist die Verwendung von Telekommunikationstechnologien zum Austausch medizinischer Informationen für Diagnostik, Konsultation, Therapie und Lehre. Das Fachgebiet der Dermatologie eignet sich aufgrund seiner morphologisch-bildbasierten Diagnostik in besonderer Weise für telemedizinische Anwendungen, die als „Teledermatologie“ bezeichnet werden. Diese bieten ein erhebliches Potenzial sowohl für Diagnostik, Prävention, Therapiebegleitung und Nachsorge von Krankheiten der Haut und für den Austausch (Teledermatologisches Konsil) mit anderen Ärzten und Angehörigen der Gesundheitsberufe. Spezifische Fortbildungsangebote für Dermatologen in der Teledermatologie fehlten bisher.

Die Deutsche Dermatologische Akademie (DDA) hat daher mit dem Zertifikat „Teledermatologie (DDA)“ ein wichtiges Fortbildungsangebot auf diesem zukunftsträchtigen Teilgebiet der Dermatologie geschaffen.

Die Fortbildungsinhalte für die Zertifizierung „Teledermatologie (DDA)“ werden flexibel in von der DDA zertifizierten Modulen vermittelt, die insgesamt mindestens 8 Stunden umfassen sollten; diese können im Rahmen dermatologischer Fortbildungsveranstaltungen angeboten werden.

Die Module sollen interaktiv gestaltet sein; bestimmend sind die praxisorientierte Präsentation des Wissens und die kollegiale Diskussion mit ausgewiesenen Experten. Zum Erhalt des Zertifikats ist einmal alle 5 Jahre die Teilnahme an einem Qualitätszirkel (2 Stunden) vorgesehen, in dem aktuelle Entwicklungen komprimiert dargestellt und anhand von Falldiskussionen thematisiert werden.

[Light-based inflammatory acne treatments]

Light-based acne treatments may represent a new emerging treatment for acne that does not increase the risk of bacterial resistance and they may be potentially effective with a favorable safety profile. Current data show that photodynamic therapy reduces inflammatory lesions and significantly improves acne. However, there is no consensus on the optimal implementation in the treatment of acne. In addition to topically applied photodynamic therapy, intense pulsed light, pulsed dye lasers, potassium-titanyl-phosphate lasers, infrared diode lasers, broad-spectrum continuous-wave light sources (red light, blue-red light) have been introduced as alternative treatments. Since well-designed studies to evaluate their efficacy versus traditional medical therapies are lacking and standardized regimens have not been agreed upon, procedures including laser, intense pulsed light, and photodynamic therapy should currently not be considered first-line treatment for inflammatory acne.

Die Deutsche Dermatologische Akademie und ihre Zertifikate

Neben Facharzt- und Zusatzbezeichnungen der Ärztekammern gibt es eine Fülle von Spezialkenntnissen, die mit den offiziellen Titeln nicht abgebildet werden.

Qualifikationsbelege in Form von Zertifikaten können als Kompetenznachweis gegenüber hilfesuchenden Patienten sowie in den Medien Bedeutung haben, wie auch in juristischen Fragen wie Haftung, für die Kostenerstattung und zum Marketing genutzt werden.

Hierzu wurden in der DDA (Deutsche Dermatologische Akademie) eine Reihe von Themen identifiziert, die für solche Zusatzweiterbildungen und Zertifizierungen von Interesse sind, für die nun Curricula existieren und Fortbildungsveranstaltungen danach ausgerichtet werden können. Nach ca. 10 Jahren sollte eine Rezertifizierung erfolgen. Auch unser Assistenzpersonal soll von diesen Weiterbildungen profitieren, daher werden spezielle Curricula und Zertifikate auch für sie aufgelegt.

[The 308 nm Excimer laser for the treatment of psoriasis and inflammatory skin diseases]

Overall, the 308 nm Excimer laser enables not only a more effective and safer UVB therapy than classical UV phototherapy, but also targeted irradiation in higher doses with a lower cumulative load, which results in faster healing of mainly circumscribed skin changes. This also applies to therapy-resistant residual lesions which, despite systemic therapy, did not diminish. Combination therapies usually improve the result and enable the dose of UVB and systemic medication to be reduced. Excimer laser therapy can be used for an increasing number of skin diseases, especially those that respond to phototherapy or photochemotherapy.

[The 308 nm Excimer laser : Treatment of vitiligo and hypopigmentation]

Use of the 308 nm Excimer laser to treat hypopigmentation and vitiligo is usually superior to conventional ultraviolet (UV) therapy with regard to results and safety. It is particularly advantageous because specific areas of skin can be targeted without burdening the rest of the skin. Fewer sessions with lower cumulative doses are required. Various combination therapies can improve the outcome; selection criteria such as early initiation of treatment and more frequent sessions with shorter intervals make it easier to decide which patients should be treated and how to achieve the greatest benefit.

[Laser treatment of basal cell carcinoma]

With a clear increase in the incidence and a continuously earlier onset, the main risk factors for the development of basal cell carcinoma are still exposure to sunlight, fair skin, immunosuppression, carcinogens such as arsenic, chronic irritations and certain genodermatoses. Treatment options for localized resectionable basal cell carcinoma include micrographically controlled surgery, simple excision, curettage, laser ablation, cryosurgery, imiquimod, 5‑fluorouracil, photodynamic treatment and radiotherapy. Non-surgical treatment options are more suited for cases in which surgical procedures lead to disfigurement or functional impairments or for patients with a high surgical risk. Laser treatment, ablative and non-ablative as monotherapy or in combination can represent a meaningful treatment option in selected cases. In recent years there has been an increase in knowledge about the indications and effects of laser treatment of basal cell carcinoma; nevertheless, further studies with a high level of evidence are necessary.

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

[Undesired treatment effects in behavior group therapy: Frequency and spectrum]

BACKGROUND

Psychotherapy not only has positive but also negative effects, which is especially true for group psychotherapy due to psychodynamic and interactional processes.

METHODS

Using the UE-G questionnaire 71 patients who participated in cognitive behavioral group psychotherapy reported on negative experiences in the context of the group therapy. The answers were then validated in a qualitative interview.

RESULTS

Of the patients 98.6% reported about at least one negative experience and 43.7% about severe or extremely severe negative experiences. Most prominent was the induction of hopelessness and demoralization by what patients saw and heard from other patients in the group.

CONCLUSION

Burdensome and therefore undesired treatment effects are regularly seen in group psychotherapy, because of treatment or patient related factors. In any case they must be taken into account during treatment, in the training of group psychotherapists and in quality control.

Pharmacological management of unipolar depression

OBJECTIVE

To be used in conjunction with 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of pharmacological treatments in depression derived from a literature review.

METHOD

Using our previous Clinical Practice Guidelines [Malhi et al. Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand 2009;119(Suppl. 439):27-46] as a foundation, these clinician guidelines target key practical considerations when prescribing pharmacotherapy. A comprehensive review of the literature was conducted using electronic database searches (PubMed, MEDLINE), and the findings have been synthesized and integrated alongside clinical experience.

RESULTS

The pharmacotherapy of depression is an iterative process that often results in partial and non-response. Beyond the initiation of antidepressants, the options within widely used strategies, such as combining agents and switching between agents, are difficult to prescribe because of the paucity of pertinent research. However, there is some evidence for second-line strategies, and a non-prescriptive algorithm can be derived that is based broadly on principles rather than specific steps.

CONCLUSION

Depression is by its very nature a heterogeneous illness that is consequently difficult to treat. Invariably, situation-specific factors often play a significant role and must be considered, especially in the case of partial and non-response. Consulting with colleagues and trialling alternate treatment paradigms are essential strategies in the management of depression.

[Off-label use of alitretinoin]

Oral alitretinoin (9-cis retinoic acid) is an endogenous retinoid related to vitamin A. Studies have shown that oral alitretinoin is effective and well-tolerated in the treatment of severe chronic hand eczema, so that it is approved for this indication. This review summarizes new studies and clinical experience on the off-label use of alitretinoin.

Getting depression clinical practice guidelines right: time for change?

OBJECTIVE

As part of a series of papers ['Chronobiology of mood disorders' Malhi & Kuiper. Acta Psychiatr Scand 2013;128(Suppl. 444):2-15; and 'It's time we managed depression: The emerging role of chronobiology' Malhi et al. Acta Psychiatr Scand 2013;128(Suppl. 444):1] examining chronobiology in the context of depression, this article examines recent western clinical practice guidelines (CPGs) for the treatment of depression with respect to the recommendations they make, in particular as regards chronobiological treatments, and briefly considers the implications of their methodology and approach.

METHOD

Five international treatment guidelines, which had been published in the past 5 years, were identified, representing North American and European views. Chosen guidelines were reviewed by the authors, and the relevant recommendations were distributed for discussion and subsequent synthesis.

RESULTS

Most current guidelines do not address chronobiology in detail. Chronotherapeutic recommendations are tentative, although agomelatine is considered as an option for major depression and bright light therapy for seasonal affective disorder. Sleep deprivation is not routinely recommended.

CONCLUSION

Recommendations are limited by the lack of reliable therapeutic markers for chronotherapeutics. Current evidence supports use of light therapy in seasonal depression, but in non-seasonal depression there is insufficient evidence to support reliance on chronotherapeutics over existing treatment modalities.

Asymmetric distribution of anionic phospholipids in supported lipid bilayers

Lipid bilayers with a controlled content of anionic lipids are a prerequisite for the quantitative study of hydrophobic-electrostatic interactions of proteins with lipid bilayers. Here, the asymmetric distribution of zwitterionic and anionic lipids in supported lipid bilayers is studied by neutron reflectometry. We prepare POPC/POPS (3:1) unilamellar vesicles in a high-salt-concentration buffer. Initially, no fusion of the vesicles to a SiO(2) surface is observed over hours and days. Once the isotonic buffer is exchanged with hypotonic buffer, vesicle fusion and bilayer formation occur by osmotic shock. Neutron reflectivity on the bilayers formed this way reveals the presence of anionic lipids (d(31)-POPS) in the outer bilayer leaflet only, and no POPS is observed in the leaflet facing the SiO(2) substrate. We argue that this asymmetric distribution of POPS is induced by the electrostatic repulsion of the phosphatidylserines from the negatively charged hydroxy surface groups of the silicon block. Such bilayers with controlled and high contents of anionic lipids in the outer leaflet are versatile platforms for studying anionic lipid protein interactions that are key elements in signal transduction pathways in the cytoplasmic leaflet of eukaryotic cells.

Guidelines on the safety of light-based home-use hair removal devices from the European Society for Laser Dermatology

In the past 5 years since their US introduction, there has been a rapid proliferation of light-based hair removal devices intended for home-use. In the last 2 years in Europe, sales already run into many tens of thousands of units with well-known multi-national companies entering the market. These guidelines provide a definition of light-based home-use technology, to inform healthcare professionals about home-use light-based technology and encourage manufacturers wishing to sell in Europe to adopt 'best practice'. The review presents the current status on standards and regulation issues and considers home-use safety issues, encompassing human, device and electrical safety, given risks to the eyes and skin from optical radiation both to the consumer and persons in the vicinity. Proposed technical measurement methodology is considered with focus on recognized critical parameters for the safe use of light-based hair removal technology including recording the technical performance and safety claims of a range of home-use hair removal devices. The literature review emphasizes potential adverse incidents and safety aspects of treating cosmetic conditions, such as unwanted hair growth. Although some regulations exist, they differ from region to region and there is a specific need for international common principles and guidelines relating to the manufacture, marketing and use of intense pulsed light and laser devices, including manufacturing standards for home-use products intended, amongst others, for cosmetic hair removal and photo-rejuvenation procedures. In these guidelines, the European Society for Laser Dermatology (ESLD) provides a professional view of what 'best practice' may imply for manufacturers and consumers alike.

[The role played by calcium in neuronal injury following neonatal hypoxia or convulsions]

AIM

Calcium plays a complex and pivotal role both in neuronal development and function, and in hypoxia/ ischemia-induced cell death. In this paper, we review current concepts of calcium function emphasizing the neonatal period.

DEVELOPMENT

Calcium enters the neuron through glutamate receptors (NMDA and AMPA) located on the neuronal membrane. After hypoxia or seizures, there is a conformational change of the receptors, with increased flow of calcium into the cytoplasm. Cytoplasmatic calcium triggers activation of several free-radical generation pathways, including the nitric oxide pathway, with a deleterious effect upon the neuron. Calcium then enters the neuronal nucleus, through specific receptors on the nuclear membrane. In our experience, hypoxia and neonatal seizures create nuclear membrane dysfunction, increasing the nitric-oxide-dependent flow of calcium into the nucleus. Nuclear calcium increase is critical for genetic transcription, pro-apoptotic gene activation and a cascade of biochemical and molecular events that lead to an increase of caspases and apoptotic neuronal death.

CONCLUSIONS

Calcium has a crucial role in neuronal damage after neonatal hypoxia or seizures. A better knowledge of the pathogenic mechanisms that lead to neuronal damage after neonatal hypoxia or seizures will assist in future development of efficacious neuroprotective therapies.

Expression of Bax and Bcl-2 proteins during hypoxia in cerebral cortical neuronal nuclei of newborn piglets: effect of administration of magnesium sulfate

This study tests the hypothesis that administration of magnesium sulfate, an antagonist of the NMDA receptor ion-channel, will prevent the hypoxia-induced alteration in the expression and the ratio of Bax and Bcl-2 proteins in cerebral cortical neuronal nuclear membranes. Anesthetized, ventilated and instrumented newborn piglets were divided into three groups: normoxic controls (Nx), untreated hypoxic (Hx), and magnesium sulfate-treated hypoxic (Mg-Hx) groups. Cerebral hypoxia was induced by lowering the FiO2 (0.05-0.07) for 1 h and the cerebral cortex was harvested immediately for isolation of neuronal nuclei and hypoxia was confirmed biochemically by a decrease in the tissue levels of ATP and phosphocreatine (PCr). Brain tissue PCr (micromol/g brain) was 2.74+/-0.77 (Nx), 0.38+/-0.09 (Hx, P<0.05 vs. Nx) and 0.69+/-0.60 (Mg-Hx, P<0.05 vs. Nx). The density of immunoblotted proteins was expressed as absorbance (Axmm(2)). The expression of Bax protein (Axmm(2)) was 222+/-31 (Nx), 279+/-32 (Hx), and 148+/-44 (Mg-Hx, P<0.05 vs. Hx). Bcl-2 protein expression was 77+/-1.0 (Nx), 37+/-5.0 (Hx) and 46+/-15 (Mg-Hx, P<0.05 vs. Nx). The ratio of Bax to Bcl-2 proteins increased more than twofold during hypoxia as compared to normoxia (7:1 Hx vs. 3:1 Nx). However, in the magnesium sulfate-treated group the Bax:Bcl-2 ratio was similar to normoxic controls. The data demonstrate that magnesium sulfate treatment prevents both the hypoxia-induced increase in Bax protein expression and the alteration of Bax:Bcl-2 protein ratios. We suggest that magnesium sulfate treatment before and during hypoxia may decrease hypoxia-induced programmed cell death by maintaining the normal ratio of Bax to Bcl-2 proteins.

["Open approach"--"progress" back the beginnings of septorhinoplasty]

Looking back at 150 years of the development of septorhinoplasty--50 of which I have experienced myself--one can conclude that recent developments go back to the nineteenth century. In the era of "minimal invasive surgery" the "open approach" to septorhinoplasty should no longer be indicated. The sublabial approach in the sense of minimal invasive surgery is recommended.

[Discordant growth of multiple fetuses in combination of HELLP syndrome and single umbilical artery in a triplet fetus]

We present a case of a triplet with HELLP-Syndromin the 31st gestation week. In ultrasound one of the fetuses was to small for gestational age and one of them showed an zero-flow in Doppler ultrasound. We decided to deliver by Caesarean section in the 31st gestation week. Growth-retardiation was found in two infants. One of them had a single umbilical artery in addition.