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Jansen MHA, Rondaan C, Legger GE, Minden K, Uziel Y, Toplak N, Maritsi D, van den Berg L, Berbers GAM, Bruijning P, Egert Y, Normand C, Bijl M, Foster HE, Koné-Paut I, Wouters C, Ravelli A, Elkayam O, Wulffraat NM, Heijstek MW. EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021. Ann Rheum Dis 2023; 82:35-47. [PMID: 35725297 DOI: 10.1136/annrheumdis-2022-222574] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/24/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Recent insights supporting the safety of live-attenuated vaccines and novel studies on the immunogenicity of vaccinations in the era of biological disease-modifying antirheumatic drugs in paediatric patients with autoimmune/inflammatory rheumatic diseases (pedAIIRD) necessitated updating the EULAR recommendations. METHODS Recommendations were developed using the EULAR standard operating procedures. Two international expert committees were formed to update the vaccination recommendations for both paediatric and adult patients with AIIRD. After a systematic literature review, separate recommendations were formulated for paediatric and adult patients. For pedAIIRD, six overarching principles and seven recommendations were formulated and provided with the level of evidence, strength of recommendation and Task Force level of agreement. RESULTS In general, the National Immunisation Programmes (NIP) should be followed and assessed yearly by the treating specialist. If possible, vaccinations should be administered prior to immunosuppressive drugs, but necessary treatment should never be postponed. Non-live vaccines can be safely given to immunosuppressed pedAIIRD patients. Mainly, seroprotection is preserved in patients receiving vaccinations on immunosuppression, except for high-dose glucocorticoids and B-cell depleting therapies. Live-attenuated vaccines should be avoided in immunosuppressed patients. However, it is safe to administer the measles-mumps-rubella booster and varicella zoster virus vaccine to immunosuppressed patients under specific conditions. In addition to the NIP, the non-live seasonal influenza vaccination should be strongly considered for immunosuppressed pedAIIRD patients. CONCLUSIONS These recommendations are intended for paediatricians, paediatric rheumatologists, national immunisation agencies, general practitioners, patients and national rheumatology societies to attain safe and effective vaccination and optimal infection prevention in immunocompromised pedAIIRD patients.
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Affiliation(s)
- Marc H A Jansen
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands .,RITA, European Reference Networks, Brussels, Belgium
| | - Christien Rondaan
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, Groningen, The Netherlands
| | - Geertje E Legger
- RITA, European Reference Networks, Brussels, Belgium.,Department of Paediatric Rheumatology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Kirsten Minden
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin, Berlin, Germany.,Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Yosef Uziel
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Natasa Toplak
- RITA, European Reference Networks, Brussels, Belgium.,Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, Ljubljana, Slovenia
| | - Despoina Maritsi
- Infectious Diseases, Immunology and Rheumatology Unit, Department of Paediatrics, Kyriakou Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Lotte van den Berg
- Dutch JIA Patient and Parent Organisation (JVN), Member of ENCA, Amsterdam, The Netherlands
| | - Guy A M Berbers
- Centre for Infectious Disease Control Netherlands, Laboratory for Infectious Diseases and Screening, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Patricia Bruijning
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yona Egert
- European Network Childhood Arthritis (ENCA) Patient Organisation, Judea and Samaria Area, Israel
| | - Christophe Normand
- MCI Secretariat, European Network for Children with Arthritis (ENCA), Geneva, Switzerland
| | - Marc Bijl
- Department of Internal Medicine and Rheumatology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Helen E Foster
- Population and Health Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Isabelle Koné-Paut
- Department of Paediatric Rheumatology and CEREMAIA, Hôpital Bicêtre, AP HP, Université Paris Saclay, Paris, France
| | - Carine Wouters
- Division of Paediatric Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Angelo Ravelli
- RITA, European Reference Networks, Brussels, Belgium.,Department of Rheumatology, Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Ori Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center and the Sackler faculty of medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas M Wulffraat
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,RITA, European Reference Networks, Brussels, Belgium
| | - Marloes W Heijstek
- RITA, European Reference Networks, Brussels, Belgium.,Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Toplak N, Wulffraat NM, Uziel Y. Editorial: Vaccination in children with immune-mediated diseases. Front Pediatr 2023; 11:1192407. [PMID: 37124191 PMCID: PMC10140601 DOI: 10.3389/fped.2023.1192407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Affiliation(s)
- Natasa Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Correspondence: Natasa Toplak
| | - Nicolaas M. Wulffraat
- Department of Pediatric Immunology & Rheumatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, Netherlands
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jansen MH, Rondaan C, Legger G, Minden K, Uziel Y, Toplak N, Maritsi D, van den Berg M, Berbers G, Bruijning P, Egert Y, Normand C, Bijl M, Foster H, Kone-Paut I, Wouters C, Ravelli A, Elkayam O, Wulffraat NM, Heijstek MW. Efficacy, Immunogenicity and Safety of Vaccination in Pediatric Patients With Autoimmune Inflammatory Rheumatic Diseases (pedAIIRD): A Systematic Literature Review for the 2021 Update of the EULAR/PRES Recommendations. Front Pediatr 2022; 10:910026. [PMID: 35874582 PMCID: PMC9298835 DOI: 10.3389/fped.2022.910026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background In 2011, the first European League Against Rheumatism (EULAR) vaccination recommendations for pediatric patients with autoimmune inflammatory rheumatic diseases (pedAIIRD) were published. The past decade numerous new studies were performed to assess the safety, efficacy and immunogenicity of vaccinations in pedAIIRD. A systematic literature review (SLR) was therefore performed to serve as the basis for the updated 2021 EULAR/PRES recommendations. Methods An SLR was performed according to the standard operating procedures for EULAR-endorsed recommendations. Primary outcomes were efficacy, immunogenicity and safety of vaccination in pedAIIRD. The search was performed in Medline, Embase and the Cochrane Library and included studies published from November 2010 until July 2020. Results The SLR yielded 57 studies which were included for critical appraisal and data extraction. Only 8 studies described the occurrence of vaccine-preventable infections after vaccination (efficacy), none of these studies were powered to assess efficacy. The majority of studies assessed (humoral) immune responses as surrogate endpoint for vaccine efficacy. Studies on non-live vaccines showed that these were safe and in general immunogenic. Biologic disease-modifying antirheumatic drugs (bDMARDs) in general did not significantly reduce seroprotection rates, except for B-cell depleting therapies which severely hampered humoral responses. Four new studies on human papilloma virus vaccination showed that this vaccine was safe and immunogenic in pedAIIRD. Regarding live-attenuated vaccinations, level 1 evidence of the measles mumps rubella (MMR) booster vaccination became available which showed the safety of this booster for patients treated with methotrexate. In addition, level 3 evidence became available that suggested that the MMR and varicella zoster virus (VZV) vaccination for patients on low dose glucocorticosteroids and bDMARDs might be safe as well. Conclusions The past decade, knowledge on the safety and immunogenicity of (live-attenuated) vaccines in pedAIIRD significantly increased. Data on efficacy (infection prevention) remains scarce. The results from this SLR are the basis for the updated EULAR/PRES vaccination recommendations in pedAIIRD.
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Affiliation(s)
- Marc H. Jansen
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
- RITA, European Reference Networks, Brussels, Belgium
| | - Christien Rondaan
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Geertje Legger
- RITA, European Reference Networks, Brussels, Belgium
- Department of Paediatric Rheumatology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Kirsten Minden
- Department of Paediatric Respiratory Medicine, Immunology and Critical Care Medicine, Deutsches Rheuma-Forschungszentrum Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, Germany
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Yosef Uziel
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Centre, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nataša Toplak
- RITA, European Reference Networks, Brussels, Belgium
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Despoina Maritsi
- Infectious Diseases, Immunology and Rheumatology Unit, Second Department of Paediatrics, Medical School, P. & A. Kyriakou Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Guy Berbers
- Centre for Infectious Disease Control, Laboratory for Infectious Diseases and Screening, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
| | - Patricia Bruijning
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yona Egert
- European Network for Children With Arthritis (ENCA), MCI Secretariat, Geneva, Switzerland
| | - Christophe Normand
- RITA, European Reference Networks, Brussels, Belgium
- European Network for Children With Arthritis (ENCA), MCI Secretariat, Geneva, Switzerland
| | - Marc Bijl
- Department of Rheumatology and Clinical Immunology, Martini Hospital Groningen, Groningen, Netherlands
| | - Helen Foster
- Population and Health Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Isabelle Kone-Paut
- RITA, European Reference Networks, Brussels, Belgium
- Department of Paediatric Rheumatology and CEREMAIA, Bicêtre University Hospital, Université Paris Saclay, Paris, France
| | - Carine Wouters
- Division of Paediatric Rheumatology University Hospitals Leuven, Leuven, Belgium
| | - Angelo Ravelli
- RITA, European Reference Networks, Brussels, Belgium
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Ori Elkayam
- Department of Rheumatology, Sackler Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas M. Wulffraat
- Department of Paediatric Immunology & Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
- RITA, European Reference Networks, Brussels, Belgium
| | - Marloes W. Heijstek
- RITA, European Reference Networks, Brussels, Belgium
- Department of Rheumatology & Clinical Immunology, University Medical Centre Utrecht, Utrecht, Netherlands
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Bizjak M, Heshin-Bekenstein M, Jansen MHA, Ziv A, Angevare S, Uziel Y, Wulffraat NM, Toplak N. Vaccinology in pediatric rheumatology: Past, present and future. Front Pediatr 2022; 10:1098332. [PMID: 36704144 PMCID: PMC9872015 DOI: 10.3389/fped.2022.1098332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023] Open
Abstract
With the introduction of biological disease-modifying antirheumatic drugs (bDMARDs), the treatment of pediatric patients with autoimmune/inflammatory rheumatic diseases (pedAIIRD) has advanced from the "Stone Age" to modern times, resulting in much better clinical outcomes. However, everything comes with a price, and use of new bDMARDs has resulted in an increased risk of infections. Therefore, preventing infections in pedAIIRD patients is one of the top priorities. The most effective preventive measure against infection is vaccination. The first study on humoral immunity after vaccination in pediatric rheumatology was published in 1974 and on safety in 1993. For many years, data about safety and immunogenicity in pedAIIRD patients were available only for non-live vaccines and the first studies on live-attenuated vaccines in pedAIIRD patients treated with immunosuppressive therapy were available only after 2007. Even today the data are limited, especially for children treated with bDMARDs. Vaccinations with non-live vaccines are nowadays recommended, although their long-term immunogenicity and efficacy in pedAIIRD patients are still under investigation. Vaccinations with live-attenuated vaccines are not universally recommended in immunosuppressed patients. However, measles-mumps-rubella booster and varicella zoster virus vaccination can be considered under specific conditions. Additional research is needed to provide more evidence on safety and immunogenicity, especially regarding live-attenuated vaccines in immunosuppressed patients with pedAIIRD. Due to the limited number of these patients, well-designed, prospective, international studies are needed. Further challenges were presented by the COVID-19 pandemic. This mini review article reviews past and present data and discusses the future of vaccinology in pediatric rheumatology.
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Affiliation(s)
- Masa Bizjak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Merav Heshin-Bekenstein
- Pediatric Rheumatology Service, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marc H A Jansen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Amit Ziv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Saskya Angevare
- European Network for Children with Arthritis, Geneva, Switzerland.,KAISZ, Amsterdam, Netherlands
| | - Yosef Uziel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel
| | - Nicolaas M Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, Netherlands
| | - Natasa Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Ververs FA, Eikendal ALM, Westenberg JJM, Van Der Geest RJ, Nuboer R, Wulffraat NM, Van Der Ent CK, Leiner T, Grotenhuis HB, Schipper HS. P3447Multimodal assessment and phenomapping of early atherosclerosis in children with chronic disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Childhood survival of chronic disease steadily increased over the last decades. However, accumulating evidence suggests that survivors are at risk for early atherosclerosis. The “Cardiovascular Disease in Children with chronic disease” (CDC) study has two aims. First, multimodal assessment of early atherosclerosis was performed in adolescents with chronic inflammatory- and metabolic disorders in order to develop new diagnostic approaches. As fatty streak formation starts in the abdominal aorta, aortic wall thickness (AWT) and pulse wave velocity (PWV) were measured using cardiovascular magnetic resonance imaging (MRI), and compared with traditional carotid intima-media thickness (cIMT) and echocardiography. Second, comprehensive risk profiling was performed, including phenomapping of early risk factors, in order to establish cardiovascular risk profiles in childhood.
Methods
113 adolescents aged 12–19 years old were enrolled*. The study population includes adolescents with juvenile idiopathic arthritis (JIA, n=19), cystic fibrosis (CF, n=24), obesity (n=20), corrected coarctation of the aorta (CoA, n=25), and corrected atrial septal defect as control group (ASD, n=25). The aorta was imaged on a 3.0 Tesla MR system using the 3D-T1-BB-VISTA sequence. Aortic PWV was assessed using velocity-encoded MRI. cIMT was measured in three directions for both the right- and left carotid artery using echography. Unbiased hierarchical clustering was performed on phenotypic data (phenomapping), including anthropomorphic-, metabolic-, and inflammatory parameters.
Results*
Aortic pulse wave velocity on MRI was highest in the obese group compared to controls (p=0.002), yet JIA patients (p=0.015), CoA patients (p=0.029), and CF patients (p=0.044) also showed increased PWV compared to controls. Aortic wall thickness was highest in obese adolescents (p=0.020) and in CF patients (p=0.043). cIMT was only increased in CoA patients (p=0.000). While PWV and AWT showed correlation with inflammatory- and metabolic parameters such as lymphocyte count (PWV, p=0.043), monocyte count (PWV, p=0.002; AWT, p=0.036), CRP (AWT, p=0.032), and QUICKI (PWV, p=0.026), cIMT correlated with systolic blood pressure (p=0.017). Phenomapping of risk factors will further define distinct cardiovascular risk profiles*.
Conclusion
Multimodal assessment of early atherosclerosis in children with chronic disease reveals differential vascular changes. While traditional cIMT is associated with increased systolic blood pressure in young CoA patients, aortic PWV and aortic wall thickness reflect early systemic inflammatory- and metabolic derangement. Phenomapping traditional risk factors alongside inflammatory- and metabolic parameters bears promise to establish early cardiovascular risk profiles in childhood chronic disease*.
*Patient inclusion finishes May 2019, followed by phenomapping of patient characteristics. At the ESC, final data will be presented.
Acknowledgement/Funding
Wilhelmina Children's Hospital Research Fund, Dutch Topsector Life Sciences and Health TKI fund, Nutricia Research fund. HS was supported by VENI-NWO.
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Affiliation(s)
- F A Ververs
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | - A L M Eikendal
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | | | | | - R Nuboer
- Meander Medical Center, Amersfoort, Netherlands (The)
| | - N M Wulffraat
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | - C K Van Der Ent
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | - T Leiner
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | - H B Grotenhuis
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | - H S Schipper
- University Medical Center Utrecht, Utrecht, Netherlands (The)
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Heijstek MW, Wulffraat NM. Response to: ‘Bivalent HPV vaccine safety depending on subtypes of juvenile idiopathic arthritis’ by Dr Akioka. Ann Rheum Dis 2014; 73:e76. [DOI: 10.1136/annrheumdis-2014-206446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Bellutti Enders F, Delemarre EM, Kuemmerle-Deschner J, van der Torre P, Wulffraat NM, Prakken BP, van Royen-Kerkhof A, van Wijk F. Autologous stem cell transplantation leads to a change in proinflammatory plasma cytokine profile of patients with juvenile dermatomyositis correlating with disease activity. Ann Rheum Dis 2014; 74:315-7. [DOI: 10.1136/annrheumdis-2014-206287] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Wulffraat NM, Ruperto N, Brunner HI, Oliveira S, Uziel Y, Nistala K, Cimaz R, Ferrandiz MA, Flato B, Gamir M, Kone-Paut I, Gaillez C, Lheritier K, Abrams K, Martini A, Lovell D. Canakinumab treatment shows maintained efficacy in systemic juvenile idiopathic arthritis patients. Pediatr Rheumatol Online J 2014. [PMCID: PMC4184294 DOI: 10.1186/1546-0096-12-s1-p68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Swart JF, de Roock S, Hofhuis FM, Rozemuller H, van den Broek T, Moerer P, Broere F, van Wijk F, Kuis W, Prakken BJ, Martens ACM, Wulffraat NM. Mesenchymal stem cell therapy in proteoglycan induced arthritis. Ann Rheum Dis 2014; 74:769-77. [PMID: 24395558 DOI: 10.1136/annrheumdis-2013-204147] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To explore the immunosuppressive effect and mechanism of action of intraperitoneal (ip) and intra-articular (ia) mesenchymal stem cell (MSC) injection in proteoglycan induced arthritis (PGIA). METHODS MSC were administered ip or ia after establishment of arthritis. We used serial bioluminescence imaging (BLI) to trace luciferase-transfected MSC. Mice were sacrificed at different time points to examine immunomodulatory changes in blood and secondary lymphoid organs. RESULTS Both ip and local ia MSC injection resulted in a beneficial clinical and histological effect on established PGIA. BLI showed that MSC ip and ia in arthritic mice are largely retained for several weeks in the peritoneal cavity or injected joint respectively, without signs of migration. Following MSC treatment pathogenic PG-specific IgG2a antibodies in serum decreased. The Th2 cytokine IL-4 was only upregulated in PG-stimulated lymphocytes from spleens in ip treated mice and in lymphocytes from draining lymph nodes in ia treated mice. An increase in production of IL-10 was seen with equal distribution. Although IFN-γ was also elevated, the IFN-γ/IL-4 ratio in MSC treated mice was opposite to the ratio in (untreated) active PGIA. CONCLUSIONS MSC treatment, both ip and ia, suppresses PGIA, a non-collagen induced arthritis model. MSC are largely retained for weeks in the injection region. MSC treatment induced at the region of injection a deviation of PG-specific immune responses, suggesting a more regulatory phenotype with production of IL-4 and IL-10, but also of IFN-γ, and a systemic decrease of pathogenic PG-specific IgG2a antibodies. These findings underpin the potential of MSC treatment in resistant arthritis.
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Affiliation(s)
- J F Swart
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S de Roock
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F M Hofhuis
- Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Rozemuller
- Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T van den Broek
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Moerer
- Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Broere
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - F van Wijk
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Kuis
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B J Prakken
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A C M Martens
- Department of Cell Biology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N M Wulffraat
- Department of Pediatric Immunology and Laboratory of Translational Immunology, Center for Molecular and Cellular Intervention (CMCI), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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Swart JF, De Roock S, Wulffraat NM. PReS-FINAL-2147: Immunological consequences of biologicals in juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2013. [PMCID: PMC4045744 DOI: 10.1186/1546-0096-11-s2-p159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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De Jager W, Vastert SJ, Mijnheer G, Prakken BJ, Wulffraat NM. PReS-FINAL-2181: Recombinant il-1ra restores the il-18-nk cell axis in steroid naive systemic juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2013. [PMCID: PMC4044177 DOI: 10.1186/1546-0096-11-s2-o16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Otten MH, Prince FHM, Armbrust W, ten Cate R, Hoppenreijs EPAH, Twilt M, Koopman-Keemink Y, Gorter SL, Dolman KM, Swart JF, van den Berg JM, Wulffraat NM, van Rossum MAJ, van Suijlekom-Smit LWA. Etanercept in juvenile idiopathic arthritis: Who will benefit? Pediatr Rheumatol Online J 2011. [PMCID: PMC3194423 DOI: 10.1186/1546-0096-9-s1-o28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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13
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Vastert SJ, De Jager W, Noordman BJ, Holzinger D, Kuis W, Prakken BJ, Wulffraat NM. Recombinant IL1-RA in the early phase of systemic onset JIA: before the onset of arthritis. Pediatr Rheumatol Online J 2011. [PMCID: PMC3194442 DOI: 10.1186/1546-0096-9-s1-o6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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14
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Swart JF, de Roock S, Hofhuis F, Kuis W, Prakken BJ, Martens AC, Slaper-Cortenbach I, Wulffraat NM. Mesenchymal stem cells and JIA. Pediatr Rheumatol Online J 2011. [PMCID: PMC3194725 DOI: 10.1186/1546-0096-9-s1-p65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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15
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Heijstek MW, Groot N, Scherpenisse M, Tacke C, Berbers G, van der Klis F, Wulffraat NM. Safety and immunogenicity of human papillomavirus vaccination in juvenile patients with rheumatic diseases. Pediatr Rheumatol Online J 2011. [PMCID: PMC3194438 DOI: 10.1186/1546-0096-9-s1-o41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Heijstek MW, Ott de Bruin LM, Bijl M, Borrow R, van der Klis F, Koné-Paut I, Fasth A, Minden K, Ravelli A, Abinun M, Pileggi GS, Borte M, Wulffraat NM. EULAR recommendations for vaccination in paediatric patients with rheumatic diseases. Ann Rheum Dis 2011; 70:1704-12. [PMID: 21813547 DOI: 10.1136/ard.2011.150193] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Evidence-based recommendations for vaccination of paediatric patients with rheumatic diseases (PaedRD) were developed by following the EULAR standardised procedures for guideline development. The EULAR task force consisted of (paediatric) rheumatologists/immunologists, one expert in vaccine evaluation, one expert in public health and infectious disease control, and one epidemiologist. A systematic literature review was conducted in MEDLINE, EMBASE, and abstracts of the EULAR and American College of Rheumatology meetings of 2008/9. The level of evidence and strength of recommendation were based on customary scoring systems. Delphi voting was applied to assess the level of agreement between task force members. 107 papers and eight abstracts were used. The majority of papers considered seasonal influenza (41) or pneumococcal (23) vaccination. 26 studies were performed specifically in paediatric patients, and the majority in adult rheumatoid arthritis and systemic lupus erythematosus patients. Fifteen recommendations were developed with an overall agreement of 91.7%. More research is needed on the safety and immunogenicity of (live-attenuated) vaccination in PaedRD, particularly in those using biologicals, and the effect of vaccination on prevention of infections.
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Affiliation(s)
- M W Heijstek
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Room KC 03.063.0, PO Box 85090, 3508 AB Utrecht, The Netherlands.
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17
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van Assen S, Elkayam O, Agmon-Levin N, Cervera R, Doran MF, Dougados M, Emery P, Geborek P, Ioannidis JPA, Jayne DRW, Kallenberg CGM, Müller-Ladner U, Shoenfeld Y, Stojanovich L, Valesini G, Wulffraat NM, Bijl M. Vaccination in adult patients with auto-immune inflammatory rheumatic diseases: a systematic literature review for the European League Against Rheumatism evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases. Autoimmun Rev 2010; 10:341-52. [PMID: 21182987 DOI: 10.1016/j.autrev.2010.12.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 12/11/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To present the systematic literature review (SLR), which formed the basis for the European League Against Rheumatism (EULAR) evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases (AIIRD). METHODS AIIRD, vaccines and immunomodulating drugs, as well as eight key questions were defined by the multidisciplinary expert committee commissioned by EULAR for developing the recommendations. A SLR was performed using MedLine through October 2009 and including data from meta-analyses, systematic reviews, randomized trials, and observational studies, excluding case series with ≤ 5 participants. Articles in English and regarding patients ≥ 16 years of age, were eligible. RESULTS Several vaccine-preventable infections (VPI) occur more often in AIIRD-patients and most vaccines are efficacious in AIIRD-patients, even when treated with immunomodulating agents, except rituximab. There does not appear to be an increase in vaccination-related harms in vaccinated patients with AIIRD in comparison with unvaccinated patients with AIIRD. However, these studies are underpowered and therefore not conclusive. CONCLUSION Based on the current evidence from the literature, recommendations for vaccination in patients with AIIRD were made. However, more research is needed in particular regarding incidence of VPI, harms of vaccination and the influence of (new and established) immunomodulating agents on vaccination efficacy.
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Affiliation(s)
- S van Assen
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands.
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18
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van Assen S, Agmon-Levin N, Elkayam O, Cervera R, Doran MF, Dougados M, Emery P, Geborek P, Ioannidis JPA, Jayne DRW, Kallenberg CGM, Müller-Ladner U, Shoenfeld Y, Stojanovich L, Valesini G, Wulffraat NM, Bijl M. EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2010; 70:414-22. [PMID: 21131643 DOI: 10.1136/ard.2010.137216] [Citation(s) in RCA: 393] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To develop evidence-based European League Against Rheumatism (EULAR) recommendations for vaccination in patients with autoimmune inflammatory rheumatic diseases (AIIRD). METHODS A EULAR task force was composed of experts representing 11 European countries, consisting of eight rheumatologists, four clinical immunologists, one rheumatologist/clinical immunologist, one infectious disease physician, one nephrologist, one paediatrician/rheumatologist and one clinical epidemiologist. Key questions were formulated and the eligible spectrum of AIIRD, immunosuppressive drugs and vaccines were defined in order to perform a systematic literature review. A search was made of Medline from 1966 to October 2009 as well as abstracts from the EULAR meetings of 2008 and 2009 and the American College of Rheumatology (ACR) meetings of 2007 and 2008. Evidence was graded in categories I-IV, the strength of recommendations was graded in categories A-D and Delphi voting was applied to determine the level of agreement between the experts of the task force. RESULTS Eight key questions and 13 recommendations addressing vaccination in patients with AIIRD were formulated. The strength of each recommendation was determined. Delphi voting revealed a very high level of agreement with the recommendations among the experts of the task force. Finally, a research agenda was proposed. CONCLUSION Recommendations for vaccination in patients with AIIRD based on the currently available evidence and expert opinion were formulated. More research is needed, particularly regarding the incidence of vaccine-preventable infectious diseases and the safety of vaccination in patients with AIIRD.
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Affiliation(s)
- S van Assen
- Department of Internal Medicine, Division of Infectious Diseases, University Medical Centre Groningen, AA41 P O Box 30 001, 9700 RB Groningen, The Netherlands.
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19
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Abstract
UNLABELLED Henoch Schönlein Purpura (HSP) is usually mild and self-limiting, but it may be accompanied by severe complications such as bullous lesions. We describe the use of systemic prednisone in two patients with bullous lesions in HSP. The first patient presented with progressive bullous lesions distributed on the limbs that evolved into painful ulcers and necrosis. These were further complicated by a secondary skin infection. He then received 1 mg/kg/day prednisone after 9 days. Patient 2, a 10-year-old boy, presented with HSP and bullous lesions and received intravenous prednisone 1 mg/kg/day within 48 h after appearance of the bullous lesions. He recovered rapidly without any complications. CONCLUSION To reduce the severity of HSP related bullous lesions and their sequelae, we would propose starting prednisone (1 mg/kg/day) as soon as the bullae appear. In addition to prednisone, analgesics and specialist skin care for bullae should be started.
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Affiliation(s)
- S L Den Boer
- Department of Pediatrics, St Antonius Hospital, Nieuwegein, The NetherlandsDepartment of Pediatric Dermatology/Allergology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatric Rheumatology and Immunology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatrics, Meander Medical Centre Amersfoort, Amersfoort, The NetherlandsDepartment of Dermatology, Meander Medical Centre Amersfoort, Amersfoort, The Netherlands
| | - Sgma Pasmans
- Department of Pediatrics, St Antonius Hospital, Nieuwegein, The NetherlandsDepartment of Pediatric Dermatology/Allergology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatric Rheumatology and Immunology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatrics, Meander Medical Centre Amersfoort, Amersfoort, The NetherlandsDepartment of Dermatology, Meander Medical Centre Amersfoort, Amersfoort, The Netherlands
| | - N M Wulffraat
- Department of Pediatrics, St Antonius Hospital, Nieuwegein, The NetherlandsDepartment of Pediatric Dermatology/Allergology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatric Rheumatology and Immunology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatrics, Meander Medical Centre Amersfoort, Amersfoort, The NetherlandsDepartment of Dermatology, Meander Medical Centre Amersfoort, Amersfoort, The Netherlands
| | - N L Ramakers-Van Woerden
- Department of Pediatrics, St Antonius Hospital, Nieuwegein, The NetherlandsDepartment of Pediatric Dermatology/Allergology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatric Rheumatology and Immunology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatrics, Meander Medical Centre Amersfoort, Amersfoort, The NetherlandsDepartment of Dermatology, Meander Medical Centre Amersfoort, Amersfoort, The Netherlands
| | - M T Bousema
- Department of Pediatrics, St Antonius Hospital, Nieuwegein, The NetherlandsDepartment of Pediatric Dermatology/Allergology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatric Rheumatology and Immunology, Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht, The NetherlandsDepartment of Pediatrics, Meander Medical Centre Amersfoort, Amersfoort, The NetherlandsDepartment of Dermatology, Meander Medical Centre Amersfoort, Amersfoort, The Netherlands
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20
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Wulffraat NM, van Rooijen EM, Tewarie R, Brinkman D, Prakken B, Kuis W. Current perspectives of autologous stem cell transplantation for severe Juvenile Idiopathic Arthritis. Autoimmunity 2010; 41:632-8. [PMID: 19117174 DOI: 10.1080/08916930802200224] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The majority of children with Juvenile Idiopathic Arthritis can nowadays be treated adequately. However despite the use of combinations of antirheumatic drugs, corticosteroids and the newer so called biologicals (blocking the TNF, Interleukin 1 or Interleukin 6 pathways) a proportion of children with arthritis remain resistant also to these therapies and suffer from a very severe, debilitating and potentially fatal disease. For such children autologous stem cell transplantation (ASCT) is successfully performed since 1997. Here we describe the long term outcome of the initial cohort of children with resistant Juvenile Idiopathic arthritis, treated with ASCT. The initial cohort of children was treated with a conditioning regimen containing Cyclophosphamide, anti thymocyte globulins and low dose Total Body irradiation. Overall favourable responses were seen, with a drug free remission rate of 50-55 %. In the more recent years late relapses were noted with lower percentages for drug free long term outcome. Special emphasis is given on 2 cases showing very late relapses, occurring after 7 and 9 years. The observed relapses are often less severe compared to the situation before SCT and can be treated successfully with conventional drugs in the majority of cases. More recently, ASCT was performed in 4 JIA children with a fludarabin containing regimen in stead of low dose TBI. With a 4 to 5 year follow up, these 4 patients are all in drug free full remission. Allogeneic transplant with an HLA matched family donor was reported in 2 JIA cases. Follow up of 1 and 3 year is sofar show clinical disease remission and tapering of medition. In conclusion, given the favourable long term outcome, SCT remains a valuable treatment option for children with drug resistant JIA.
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Affiliation(s)
- N M Wulffraat
- Department of Pediatric Immunology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.
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21
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van Pelt PA, Kruize AA, Goren SS, van der Net J, Uiterwaal CSP, Kuis W, Bijlsma JWJ, Wulffraat NM. Transition of rheumatologic care, from teenager to adult: which health assessment questionnaire can be best used? Clin Exp Rheumatol 2010; 28:281-286. [PMID: 20483054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 05/13/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVES Transition of care for adolescents includes a transfer from paediatric to adult health care. This requires a transfer of specific measurements, which evaluate disease profiles such as functional ability. One of the most common measurements is the Health Assessment Questionnaire (HAQ). METHODS Results of the Childhood HAQ (CHAQ) and HAQ were compared among adolescents diagnosed with rheumatic diseases involving the musculoskeletal system. All adolescents had recently dealt with or would in the near future be dealing with transition. RESULTS Overall results of both questionnaires were comparable; intra-class correlation for consistency (ICC) was 0.95 (95% confidence interval 0.93-0.97). For a smooth transfer from CHAQ to HAQ, both correlation and agreement are required. Agreement between both questionnaires was not found. Described by limits of agreement, results of HAQ can differ from CHAQ as much as 0.95. CONCLUSIONS Despite strong correlations for consistency, lack of agreement was found in the results of CHAQ and HAQ. If correlation persists over time, this study suggests evaluating both the childhood and adult version of the HAQ during the transition period. When transfer into adulthood is completed, comparison to earlier tests at younger age is available and reliable.
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Affiliation(s)
- P A van Pelt
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, The Netherlands
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22
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Schimmel RJ, Pasmans SGMA, Xu M, Stadhouders-Keet SAE, Shore EM, Kaplan FS, Wulffraat NM. GNAS-associated disorders of cutaneous ossification: two different clinical presentations. Bone 2010; 46:868-72. [PMID: 19900597 PMCID: PMC3501213 DOI: 10.1016/j.bone.2009.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 11/02/2009] [Accepted: 11/02/2009] [Indexed: 11/23/2022]
Abstract
Progressive osseous heteroplasia (POH) is a rare genetic disorder characterized by dermal ossification during infancy and progressive ossification into deep connective tissue during childhood. POH is at the severe end of a spectrum of GNAS-associated ossification disorders that include osteoma cutis and Albright Hereditary Osteodystrophy (AHO). Here we describe two girls who have different clinical presentations that reflect the variable expression of GNAS-associated disorders of cutaneous ossification. Each girl had a novel heterozygous inactivating mutation in the GNAS gene. One girl had POH limited to the left arm with severe contractures and growth retardation resulting from progressive heterotopic ossification in the deep connective tissues. The other girl had AHO with widespread, superficial heterotopic ossification but with little functional impairment. While there is presently no treatment or prevention for GNAS-associated ossification disorders, early diagnosis is important for genetic counselling and for prevention of iatrogenic harm.
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Affiliation(s)
- R J Schimmel
- Department of Paediatric Dermatology and Allergology, Wilhelmina's Children Hospital, University Medical Center Utrecht, 3508 AB Utrecht, The Netherlands
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23
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Abstract
Lysosomal storage disorders (LSDs), a heterogeneous group of inborn metabolic disorders, are far more common than most doctors presume. Although patients with a severe LSD subtype are often readily diagnosed, the more attenuated subtypes are frequently missed or diagnosis is significantly delayed. The presenting manifestations often involve the bones and/or joints and therefore these patients are frequently under specialist care by (paediatric) rheumatologists, receiving inadequate treatment. Since effective disease-specific treatments, including enzyme replacement therapy and stem cell transplantation, have become available for certain LSDs and timely initiation of these treatments is necessary to prevent the development of severe, disabling and irreversible manifestations, early diagnosis has become essential. The challenge is to raise awareness for better recognition of the presenting signs and symptoms of LSDs by all doctors who may encounter these patients, including rheumatologists.
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Affiliation(s)
- M Aldenhoven
- Department of Paediatric Immunology/Haematology and SCT, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.
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24
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van Gent R, van Tilburg CM, Nibbelke EE, Otto SA, Gaiser JF, Janssens-Korpela PL, Sanders EAM, Borghans JAM, Wulffraat NM, Bierings MB, Bloem AC, Tesselaar K. Refined characterization and reference values of the pediatric T- and B-cell compartments. Clin Immunol 2009; 133:95-107. [PMID: 19586803 DOI: 10.1016/j.clim.2009.05.020] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2008] [Revised: 05/21/2009] [Accepted: 05/27/2009] [Indexed: 11/26/2022]
Abstract
Work in the past years has led to a refined phenotypical description of functionally distinct T- and B-cell subsets. Since both lymphocyte compartments are established and undergo dramatic changes during childhood, redefined pediatric reference values of both compartments are needed. In a cohort of 145 healthy children, aged 0-18 years, the relative and absolute numbers of the various T- and B-cell subsets were determined. In addition, we found that besides thymic output, naive (CD27(+)CD45RO(-)) T-cell proliferation contributed significantly to the establishment of the naive T-cell compartment. At birth, regulatory (CD25(+)CD127(-)CD4(+)) T cells (Tregs) mainly had a naive (CD27(+)CD45RO(-)) phenotype whereas 'memory or effector-like' (CD45RO(+)) Tregs accumulated slowly during childhood. Besides the CD27(+)IgM(+)IgD(+) memory B-cell population, the recently identified CD27(-)IgG(+) and CD27(-)IgA(+) memory B-cell populations were already present at birth. These data provide reference values of the T- and B-cell compartments during childhood for studies of immunological disorders or immune reconstitution in children.
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Affiliation(s)
- R van Gent
- Department of Immunology, University Medical Center Utrecht, Lundlaan 6, PO Box 85090, 3508 AB Utrecht, The Netherlands
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25
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Prince FHM, Twilt M, Simon SCM, van Rossum MAJ, Armbrust W, Hoppenreijs EPAH, Kamphuis S, van Santen-Hoeufft M, Koopman-Keemink Y, Wulffraat NM, ten Cate R, van Suijlekom-Smit LWA. When and how to stop etanercept after successful treatment of patients with juvenile idiopathic arthritis. Ann Rheum Dis 2009; 68:1228-9. [PMID: 19525408 DOI: 10.1136/ard.2008.101030] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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26
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Noordzij JG, Wulffraat NM, Haraldsson A, Meyts I, van't Veer LJ, Hogervorst FBL, Warris A, Weemaes CMR. Ataxia-telangiectasia patients presenting with hyper-IgM syndrome. Arch Dis Child 2009; 94:448-9. [PMID: 19224889 DOI: 10.1136/adc.2008.149351] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Ataxia-telangiectasia (A-T) is characterised by progressive neurological abnormalities, oculocutaneous telangiectasias and immunodeficiency (decreased serum IgG subclass and/or IgA levels and lymphopenia). However, 10% of A-T patients present with decreased serum IgG and IgA with normal or raised IgM levels. As cerebellar ataxia and oculocutaneous telangiectasias are not present at very young age, these patients are often erroneously diagnosed as hyper IgM syndrome (HIGM). Eight patients with A-T, showing serum Ig levels suggestive of HIGM on first presentation, are described. All had decreased numbers of T lymphocytes, unusual in HIGM. The diagnosis A-T was confirmed by raised alpha-fetoprotein levels in all patients. To prevent mistaking A-T patients for HIGM it is proposed to add DNA repair disorders as a possible cause of HIGM.
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Affiliation(s)
- J G Noordzij
- Department of Paediatrics, Reinier de Graaf Gasthuis, Delft, The Netherlands.
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27
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Heijstek MW, Wulffraat NM, Eken Y, Pluijm SMF, Rademaker CMA, de Jonge R. Single-nucleotide polymorphisms in the folate pathway are associated with response to methotrexate treatment in juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2008. [PMCID: PMC3333948 DOI: 10.1186/1546-0096-6-s1-p15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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28
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Vastert SJ, Verweij FJ, de Jager W, Wulffraat NM, van Wijk F, Prakken BJ. Methotrexate does not primarily affect Foxp3+ regulatory T cells in poly-articular juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2008. [PMCID: PMC3334034 DOI: 10.1186/1546-0096-6-s1-p23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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29
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Heijstek MW, Berbers GAM, van Gageldonk PGM, Uiterwaal CSP, Wulffraat NM. Measles, Mumps, Rubella serology in juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2008. [PMCID: PMC3334125 DOI: 10.1186/1546-0096-6-s1-p63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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30
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Aldenhoven M, de Koning TJ, Wulffraat NM, Boelens JJ. [Umbilical cord blood from an unrelated donor as source for stem cell transplantations in inborn errors of metabolism]. Ned Tijdschr Geneeskd 2008; 152:1719-1724. [PMID: 18727602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In certain inborn errors of metabolism, an allogeneic stem cell transplantation is able to prevent disease progression. This is only possible when the stem cell transplantation (SCT) is performed early in life, before cerebral involvement has occurred. In addition to bone marrow and peripheral blood, unrelated umbilical cord blood appears to be an effective stem cell source as well. Important advantages of umbilical blood as stem cell source are: the time between diagnosis and SCT can be considerably reduced; there is a greater chance of finding a suitable donor and the risk of graft-versus-host disease and viral transmission is decreased. By far the most common disease in the group of inborn metabolic errors for which SCTs are performed is Hurler's disease. In these patients, the percentage of successful transplantations is considerably higher after the use ofunrelated cord blood than when bone marrow or peripheral blood is used as a stem cell source. In addition, donor chimerism occurred significantly more often in those patients who had received unrelated umbilical cord blood. There are also potential disadvantages attached to the use of umbilical blood as stem cell source: the possibility of only one donation per donor and less adaptive immunity following umbilical blood SCT with an increased risk of reactivation of a previous viral infection. However, these disadvantages are less applicable to young children with inborn errors of metabolism. The improvement of transplantation techniques and the availability of this new stem cell source could improve the success rate of this procedure and consequently the prognosis of these severely affected patients.
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Affiliation(s)
- M Aldenhoven
- Universitair Medisch Centrum Utrecht, locatie Wilhelmina Kinderziekenhuis, Lundlaan 6, 3584 EA Utrecht
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31
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Prince FHM, Twilt M, ten Cate R, van Rossum MAJ, Armbrust W, Hoppenreijs EPAH, van Santen-Hoeufft M, Koopman-Keemink Y, Wulffraat NM, van Suijlekom-Smit LWA. Long-term follow-up on effectiveness and safety of etanercept in juvenile idiopathic arthritis: the Dutch national register. Ann Rheum Dis 2008; 68:635-41. [PMID: 18413443 DOI: 10.1136/ard.2007.087411] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We undertook an observational study to obtain a complete overview of the long-term effectiveness and safety of etanercept in patients with different juvenile idiopathic arthritis (JIA) subtypes. METHODS At baseline we collected patient and disease characteristics of all Dutch patients with JIA who started treatment with etanercept. Disease activity was evaluated (at start of the study, after 3 months and then yearly) according to the JIA core set of the American College of Rheumatology paediatric definition for 30, 50 and 70% improvement (ACR Pedi 30, 50 and 70). Use of etanercept and concomitant drugs was monitored. Adverse events were recorded. RESULTS We included 146 patients with JIA with a median follow-up of 2.5 years per patient (range 0.3-7.3). JIA subtypes represented: 27% systemic, 8% polyarticular rheumatoid factor positive, 38% polyarticular rheumatoid factor negative, 19% oligoarticular extended, 3% enthesitis-related and 5% psoriatica. Most patients (77%) met the criteria of the ACR Pedi 30 in the first 3 months of treatment. For the majority of patients this improvement was sustained; 53 (36%) of all patients met the remission criteria. No other second-line agents were needed in 43 patients. Although patients with systemic JIA responded initially less to etanercept therapy than patients from other subtypes, those who did respond showed equal effectiveness in the long term. Serious adverse events rate was low (0.029 per patient year). CONCLUSIONS Etanercept is effective and safe in JIA, even for a large proportion of the patients with systemic JIA. The greatest improvement occurred in the first 3 months of treatment, and was sustained for a long time in most patients (up to 75 months).
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Affiliation(s)
- F H M Prince
- Department of Paediatrics/ Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.
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Reininga JK, Los LI, Wulffraat NM, Armbrust W. The evaluation of uveitis in juvenile idiopathic arthritis (JIA) patients: are current ophthalmologic screening guidelines adequate? Clin Exp Rheumatol 2008; 26:367-372. [PMID: 18565265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The aims of this study are to examine in our juvenile idiopathic arthritis (JIA) population: 1) the prevalence and characteristics of uveitis, 2) the complications and outcome of uveitis, 3) prognostic factors, and 4) the adequacy of the current ophthalmologic screening guidelines. METHODS Retrospective analysis of medical records. RESULTS 1) Of the 153 JIA patients included, 27 developed asymptomatic anterior uveitis (17.6%) - 7 unilateral and 20 bilateral. The 27 uveitis patients were significantly younger at JIA presentation than the 126 JIA patients without uveitis. 2) The following uveitis complications were noticed: glaucoma, cataract, posterior synechiae, cystoid macular oedema and papillitis. A visual outcome was acquired in 25 patients - 21 patients had a known visual acuity of > or = 0.1. Four patients had a visual acuity of <0.05 - 3 unilateral and 1 bilateral. 3) Female gender could not be confirmed as an independent risk factor for uveitis, neither was Anti Nuclear Antibody (ANA) positivity. We did not find a significant relationship between the moment of clinical remission of arthritis and of uveitis. 4) When applying current uveitis screening guidelines to our JIA population, we found that the optimum screening regimen would consist of a combination of the higher screening frequency of Southwood (1) and the longer screening period of the American Academy of Pediatrics (2) (AAP) screening guidelines. CONCLUSIONS Uveitis is often encountered in JIA patients. It is a serious cause of morbidity. The use of disease-modifying antirheumatic drugs (DMARDs) probably has a positive effect on the preservation of visual function. We recommend a uveitis screening regimen which combines the AAP and Southwood guidelines and which includes rheumatoid factor positivity (RF+) and systemic onset patients in the quarterly screening.
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Affiliation(s)
- J K Reininga
- Department of Ophthalmology, University Medical Centre Groningen (UMCG), University of Groningen, The Netherlands
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Brinkman DMC, Jol-van der Zijde CM, ten Dam MM, te Boekhorst PAW, ten Cate R, Wulffraat NM, Hintzen RQ, Vossen JM, van Tol MJD. Resetting the adaptive immune system after autologous stem cell transplantation: lessons from responses to vaccines. J Clin Immunol 2007; 27:647-58. [PMID: 17690955 PMCID: PMC2075528 DOI: 10.1007/s10875-007-9120-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 07/06/2007] [Indexed: 12/29/2022]
Abstract
Autologous stem cell transplantation (ASCT) to treat autoimmune diseases (AID) is thought to reset immunological memory directed against autoantigens. This hypothesis can only be studied indirectly because the exact nature of the pathogenetic autoantigens is unknown in most AID. Therefore, 19 children with juvenile idiopathic arthritis (JIA) or systemic lupus erythematodes (SLE) and 10 adults with multiple sclerosis (MS) were vaccinated with the T-cell-dependent neoantigen rabies and the recall antigen tetanus toxoid after, respectively before, bone marrow harvest. Both vaccinations were repeated after ASCT. All except two of the responders mounted a primary antibody response to rabies after revaccination, and 44% of the responders mounted a primary antibody response to tetanus boost after ASCT. These data show that immunological memory to a neoantigen is lost in most patients with AID after immunoablative pretreatment; however, memory to a recall antigen boosted before bone marrow harvest is only lost in part of the patients. Disease progression was arrested in all patients with JIA/SLE except one, but only in a minority of MS patients. Clinical outcome on a per case basis was not associated with the profile of the immune response toward the vaccination antigens after ASCT.
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Affiliation(s)
- D M C Brinkman
- Department of Pediatrics, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands.
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van der Meer A, Wulffraat NM, Prakken BJ, Gijsbers B, Rademaker CMA, Sinnema G. Psychological side effects of MTX treatment in juvenile idiopathic arthritis: a pilot study. Clin Exp Rheumatol 2007; 25:480-5. [PMID: 17631750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To document the psychological side effects of methotrexate (MTX) treatment in children with juvenile idiopathic arthritis (JIA) and to explore the usefulness of psychological therapy to ameliorate these side effects. METHODS The patients included in this study consisted of 29 patients with JIA using MTX. Of these, ten were referred to a pediatric psychologist because of MTX side effects, and had behavioural therapy to cope with these side effects with a strong behavioural component (anticipatory nausea, anxiety). The behavioural therapy was adapted to age and used systemic desensitization (distraction in a positive atmosphere) or cognitive behavioural therapy (relaxation and overruling negative thoughts by positive ones). The parents of the 29 children were interviewed about MTX treatment and the side effects their child had developed. Parents of children referred to the psychologist were also interviewed for their impression of the results of the behavioural therapy. RESULTS Prior to the behavioural therapy, nine out of 10 children reported MTX related nausea. Six of these ten were nauseous even before the administration and developed anticipatory nausea. Nine out of ten patients also showed some sign of distress in anticipation of MTX treatment, either orally of via injections. The behavioural therapy they had fully abolished side effects in five children and decreased the severity of nausea and distress in two children. Of the remaining nineteen children, not referred to the pediatric psychologist, 11 reported nausea after MTX treatment and four of these developed anticipatory nausea. In addition, eight of these 18 developed behavioural distress in anticipation of the treatment. CONCLUSION This study showed that children with JIA who receive MTX treatment frequently develop psychological side effects, such as anticipatory nausea and behavioural distress in anticipation of treatment. This is true for patients selected for reported MTX side effects, as well as for randomly chosen JIA patients using MTX. As MTX is still the first choice in the treatment of severe JIA, more attention should be given to the treatment and prevention of side effects. Psychological intervention can be of help, but further studies are needed on the nature of the side effects, as well as on the prerequisites and efficacy of behavioural therapy.
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Affiliation(s)
- A van der Meer
- Department of Pediatric Immunology, University Medical Center Utrecht, Wilhelmina Children's Hospital, The Netherlands
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Reubsaet LL, Boelens JJ, Rademaker C, Smal J, Wulffraat NM. Successful cord blood transplantation in a premature and dysmature neonate of 1700 g with reticular dysgenesis. Bone Marrow Transplant 2007; 39:307-8. [PMID: 17262063 DOI: 10.1038/sj.bmt.1705577] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Brinkman DMC, de Kleer IM, ten Cate R, van Rossum MAJ, Bekkering WP, Fasth A, van Tol MJD, Kuis W, Wulffraat NM, Vossen JM. Autologous stem cell transplantation in children with severe progressive systemic or polyarticular juvenile idiopathic arthritis: Long-term followup of a prospective clinical trial. ACTA ACUST UNITED AC 2007; 56:2410-21. [PMID: 17599770 DOI: 10.1002/art.22656] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of intensive immunosuppression followed by T cell-depleted autologous hematopoietic stem cell transplantation (ASCT) for induction of disease remission in children with refractory progressive juvenile idiopathic arthritis (JIA). METHODS Twenty-two patients with progressive refractory JIA were followed up over a median period of 80 months after pretreatment with intensive immunosuppression followed by ASCT in a multicenter, prospective, phase II clinical trial. Hematopoietic stem cells were harvested from the patients' bone marrow, depleted of T cells, and kept frozen until used for ASCT. Pretreatment of patients consisted of a combination of antithymocyte globulin, cyclophosphamide, and low-dose total body irradiation. Patients were followed up for ASCT-related complications, recovery of hematologic and immune system parameters, and disease outcomes. RESULTS Reconstitution of hematologic values to normal range was rapid. Recovery of immune system parameters, especially normalization of CD4+, CD45RA+ naive T cells, was delayed, occurring at >/=6 months after ASCT. The prolonged period of immune deficiency resulted in a large number of viral infections and may have contributed to the development of macrophage activation syndrome (MAS), leading to death, in 2 patients. After ASCT, 8 of the 20 evaluable patients reached complete clinical remission of their JIA, 7 were partial responders, and 5 experienced a relapse of their disease (occurring 7 years after ASCT in 1 patient). Later during followup, 2 of the patients whose disease relapsed died from infections that developed after restarting immunosuppressive medication. CONCLUSION Intensive immunosuppression followed by ASCT resulted in sustained complete remission or marked improvement in 15 of 22 patients with progressive refractory JIA. The procedure, however, is associated with significant morbidity and risk of mortality due to prolonged and severe depression of T cell immunity. After fatal complications due to MAS were observed in some patients, the protocol was amended in 1999, to ensure less profound depletion of T cells, better control of systemic disease before transplantation, antiviral prophylaxis after transplantation, and slow tapering of corticosteroids. Following these protocol modifications, no additional ASCT-related deaths were observed among the 11 patients who received the modified treatment.
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Affiliation(s)
- D M C Brinkman
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands.
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Boelens JJ, Lazo G, Gaiser JF, Wulffraat NM. Epstein–Barr virus-associated haemophagocytic lympho-histiocytosis after stem cell transplantation. Bone Marrow Transplant 2006; 38:709-10. [PMID: 17013422 DOI: 10.1038/sj.bmt.1705517] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ferreira RA, Vastert SJ, Abinun M, Foster HE, Modesto C, Olivé T, Kuis W, Wulffraat NM. Hemophagocytosis during fludarabine-based SCT for systemic juvenile idiopathic arthritis. Bone Marrow Transplant 2006; 38:249-51. [PMID: 16770315 DOI: 10.1038/sj.bmt.1705415] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Koffeman EC, Wulffraat NM, Bruin M, Hogeman PHG, Frenkel J. Periodic fever as a presenting sign of childhood acute lymphoblastic leukaemia. Rheumatology (Oxford) 2005; 44:1583-4. [PMID: 16148019 DOI: 10.1093/rheumatology/kei089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Gratwohl A, Passweg J, Bocelli-Tyndall C, Fassas A, van Laar JM, Farge D, Andolina M, Arnold R, Carreras E, Finke J, Kötter I, Kozak T, Lisukov I, Löwenberg B, Marmont A, Moore J, Saccardi R, Snowden JA, van den Hoogen F, Wulffraat NM, Zhao XW, Tyndall A. Autologous hematopoietic stem cell transplantation for autoimmune diseases. Bone Marrow Transplant 2005; 35:869-79. [PMID: 15765114 DOI: 10.1038/sj.bmt.1704892] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Experimental data and early phase I/II studies suggest that high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (HSCT) can arrest progression of severe autoimmune diseases. We have evaluated the toxicity and disease response in 473 patients with severe autoimmune disease treated with autologous HSCT between 1995 and 2003, from 110 centers participating in the European Group for Blood and Marrow Transplantation (EBMT) autoimmune disease working party database. Survival, transplant-related mortality, treatment response and disease progression were assessed. In all, 420 patients (89%; 86+/-4% at 3 years, median follow-up 20 months) were alive, 53 (11%) had died from transplant-related mortality (N=31; 7+/-3% at 3 years) or disease progression (N=22; 9+/-4% at 3 years). Of 370 patients, 299 evaluable for response (81%) showed a treatment response, which was sustained in 213 (71% of responders). Response was associated with disease (P<0.001), was better in patients who received cyclophosphamide during mobilization (relative risk (RR)3.28 (1.57-6.83)) and was worse with increasing age (>40 years, RR0.29 (0.11-0.82)). Disease progression was associated with disease (P<0.001) and conditioning intensity (high intensity, RR1; intermediate intensity, RR1.81 (0.96-3.42)); low intensity, RR2.34 (1.074-5.11)). These data from the collective EBMT experience support the hypothesis that autologous HSCT can alter disease progression in severe autoimmune disease.
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Wulffraat NM, Vastert B, Tyndall A. Treatment of refractory autoimmune diseases with autologous stem cell transplantation: focus on juvenile idiopathic arthritis. Bone Marrow Transplant 2005; 35 Suppl 1:S27-9. [PMID: 15812525 DOI: 10.1038/sj.bmt.1704840] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Autologous stem cell transplantation (ASCT) can be performed in a variety of refractory autoimmune diseases. A retrospective multicenter analysis is presented to evaluate safety and efficacy of ASCT for refractory juvenile idiopathic arthritis. In all, 18 of the 34 patients (53%) with a follow-up of 12 to 60 months achieved a drug-free complete remission. There were three cases (9%) of transplant-related mortality and two cases of disease-related mortality (6%). Infectious complications were seen frequently. We propose adjustments in future protocols to reduce this mortality in this high-risk patient group.
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Affiliation(s)
- N M Wulffraat
- Department of Pediatrics, Section Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Heemskerk MBA, van Walraven SM, Cornelissen JJ, Barge RMY, Bredius RGM, Egeler RM, Tj Lie JLW, Révész T, Sintnicolaas K, Wulffraat NM, Donker AE, Hoogerbrugge PM, van Rood JJ, Claas FHJ, Oudshoorn M. How to improve the search for an unrelated haematopoietic stem cell donor. Faster is better than more! Bone Marrow Transplant 2005; 35:645-52. [PMID: 15723086 DOI: 10.1038/sj.bmt.1704865] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Many patients do not reach haematopoietic stem cell transplantation. Shortage of unrelated donors (UDs) is still seen as the main cause. However, with a worldwide UD pool containing more than 8 million donors, it is possible that other impediments are becoming more important. We analysed 549 UD searches for Dutch patients, performed between 1987 and 2000, in order to find the reasons for failure or success to reach transplantation. Between 1996 and 2000, 59% of the patients of Northwest European origin received a graft from an UD with a median time span of 4.4 months from the start of the search. In all, 11% of the patients lacked a compatible donor, while 30% became medically unfit for transplantation. This is in contrast to the patients of non-Northwest European origin for whom UD shortage is still the most important impediment; only 32% were transplanted while 50% lacked a compatible donor. We conclude that the shortage of donors is no longer the biggest constraint in unrelated stem cell transplantation for patients of Northwest European origin. It may be more effective to optimize the chance on transplantation by making the search process more efficient.
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Abstract
The potential of haemopoietic stem cell transplantation (HSCT) for the treatment of autoimmune and inflammatory diseases was originally supported by almost three decades of animal experiments and by the serendipitous remissions of autoimmune disease observed in patients undergoing transplantation for haematological disorders. Improved safety of both autologous and allogeneic HSCT over the last decade has been followed by increasing acceptance of HSCT as an experimental treatment for severe autoimmune diseases that are resistant to conventional treatment. International databases have collated over 700 procedures performed specifically for a variety of autoimmune diseases. Phase III clinical trials are in progress for some diseases. This review provides a comprehensive update on the efficacy and toxicity of HSCT in severe autoimmune disease. Future directions in the context of other evolving therapies are discussed.
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Affiliation(s)
- R E Hough
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, University of Sheffield, Sheffield, UK
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De Kleer IM, Brinkman DMC, Ferster A, Abinun M, Quartier P, Van Der Net J, Ten Cate R, Wedderburn LR, Horneff G, Oppermann J, Zintl F, Foster HE, Prieur AM, Fasth A, Van Rossum MAJ, Kuis W, Wulffraat NM. Autologous stem cell transplantation for refractory juvenile idiopathic arthritis: analysis of clinical effects, mortality, and transplant related morbidity. Ann Rheum Dis 2004; 63:1318-26. [PMID: 15361393 PMCID: PMC1754760 DOI: 10.1136/ard.2003.017798] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of autologous stem cell transplantation (ASCT) for refractory juvenile idiopathic arthritis (JIA). DESIGN Retrospective analysis of follow up data on 34 children with JIA who were treated with ASCT in nine different European transplant centres. Rheumatological evaluation employed a modified set of core criteria. Immunological reconstitution and infectious complications were monitored at three month intervals after transplantation. RESULTS Clinical follow up ranged from 12 to 60 months. Eighteen of the 34 patients (53%) with a follow up of 12 to 60 months achieved complete drug-free remission. Seven of these patients had previously failed treatment with anti-TNF. Six of the 34 patients (18%) showed a partial response (ranging from 30% to 70% improvement) and seven (21%) were resistant to ASCT. Infectious complications were common. There were three cases of transplant related mortality (9%) and two of disease related mortality (6%). CONCLUSIONS ASCT in severely ill patients with JIA induces a drug-free remission of the disease and a profound increase in general wellbeing in a substantial proportion of patients, but the procedure carries a significant mortality risk. The following adjustments are proposed for future protocols: (1) elimination of total body irradiation from the conditioning regimen; (2) prophylactic administration of antiviral drugs and intravenous immunoglobulins until there is a normal CD4+ T cell count.
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Affiliation(s)
- I M De Kleer
- Paediatric BMT unit, Suite KC 03.063, University Medical Centre Utrecht, PO box 85090, 3508 AB Utrecht, Netherlands
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Armbrust W, Kamphuis SSM, Wolfs TWF, Fiselier TJW, Nikkels PG, Kuis W, Wulffraat NM. Tuberculosis in a nine-year-old girl treated with infliximab for systemic juvenile idiopathic arthritis. Rheumatology (Oxford) 2004; 43:527-9. [PMID: 15024141 DOI: 10.1093/rheumatology/keh074] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Dekker L, Armbrust W, Rademaker CMA, Prakken B, Kuis W, Wulffraat NM. Safety of anti-TNFalpha therapy in children with juvenile idiopathic arthritis. Clin Exp Rheumatol 2004; 22:252-8. [PMID: 15083897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Anti-TNFalpha agents are frequently used in the treatment of severe JIA. Etanercept, a fully human soluble recombinant tumour necrosis factor p75 receptor Fc fusion protein, has been registered for the treatment of polyarticular course JIA patients who fail to respond to or do not tolerate methotrexate (MTX). Infliximab, a chimeric human-mouse monoclonal antibody to TNFalpha, is expected to be registered soon for JIA and Crohn's disease (CD) in children. As in adults, both agents are effective in controlling inflammation and inhibiting the progression of joint destruction. Despite this good clinical efficacy, the physician must remain alert for potential side effects, especially after prolonged use. This review gives an overview of the reported adverse events.
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Affiliation(s)
- L Dekker
- Department of Pediatric Rheumatology and Immunology, University Medical Center Utrecht, Het Wilhelmina Kinder Ziekenhuis, Utrecht, The Netherlands
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Armbrust W, Kamphuis SSM, Wolfs TF, Fiselier TJW, Nikkels PG, Kuis W, Wulffraat NM. Tuberculosis in a nine year old girl treated with Infliximab for systemic juvenile idiopathic arthritis. AKTUEL RHEUMATOL 2003. [DOI: 10.1055/s-2003-45038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Ronaghy A, Huijssoon E, van Rossum MA, Prakken ABJ, Rijkers GT, Vermeer-de Bondt PE, van Tol MJ, Hoes AW, van der Net J, Kuis W, Rademaker CMA, Wulffraat NM. Vaccination does not exacerbate juvenile idiopathic arthritis disease activity in a cohort of Dutch patients. AKTUEL RHEUMATOL 2003. [DOI: 10.1055/s-2003-45073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wulffraat NM. Autologous stem cell transplantation for severe juvenile idiopathic arthritis: A multicenter survey. AKTUEL RHEUMATOL 2003. [DOI: 10.1055/s-2003-45077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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