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.

Microphytobenthos spatio-temporal dynamics across an intertidal gradient using Random Forest classification and Sentinel-2 imagery

Microphytobenthos (MPB) provides important ecosystem functions and services, contributing significantly to the total primary production in shallow coastal ecosystems. However, determining the factors that regulate the seasonal changes of MPB and its distribution patterns at larger scales is hindered by the considerable spatial and temporal variability in these environments. Here, we studied the dynamics of intertidal MPB biomass, cover, and net growth rates in a south European tidal flat (Cadiz Bay, Spain) over a four-year period using the Normalized Difference Vegetation Index (NDVI) calculated from Sentinel-2 satellite images. Pixels dominated by different benthic communities (MPB, Zostera sp., Caulerpa sp. and green macroalgae) were identified at a 10-m resolution using a Random Forest (RF) machine learning classification algorithm. MPB dominated the intertidal zone. MPB cover did not show a clear seasonal pattern and was clearly higher in the middle of the intertidal range of sea level. Despite interannual variability, MPB biomass was always higher during winter, coinciding with observations from other low latitude intertidal flats with temperate climate, and in the upper-middle intertidal. Net rates of MPB biomass change, calculated from the differences in MPB NDVI over time, showed maximal net growth rates from autumn to winter and maximum loss rates during spring and summer, although with high variability. Our study demonstrates that RF algorithms allow mapping MPB and other intertidal communities from Sentinel-2 multispectral satellite imagery accurately obtaining invaluable information from large areas at very high spatio-temporal resolution. The dissimilarities observed in the patterns of MPB variables over time or sea level, indicate differences in their ecological regulation, still largely unknown both here and in other temperate climate intertidal flats. High resolution remote sensing can aid in their detailed and systematic study producing a more integrated view of these systems and contributing to their science-based management and conservation.

Diel patterns of microphytobenthic primary production in intertidal sediments: the role of photoperiod on the vertical migration circadian rhythm

Diel primary production patterns of intertidal microphytobenthos (MPB) have been attributed to short-term physiological changes in the photosynthetic apparatus or to diel changes in the photoautotrophic biomass in the sediment photic layer due to vertical migration. Diel changes in primary production and vertical migration are entrained by external factors like photoperiod and tides. However, the role of photoperiod and tides has not been experimentally separated to date. Here, we performed laboratory experiments with sediment cores kept in immersion, in the absence of tides, with photoperiod or under continuous light. Measurements of net production, made with O₂ microsensors, and of spectral reflectance at the sediment surface showed that, in intertidal sediments, the photoperiod signal was the major driver of the diel patterns of net primary production and sediment oxygen availability through the vertical migration of the MPB photoautotrophic biomass. Vertical migration was controlled by an endogenous circadian rhythm entrained by photoperiod in the absence of tides. The pattern progressively disappeared after 3 days in continuous light but was immediately reset by photoperiod. Even though a potential contribution of a subjective in situ tidal signal cannot be completely discarded, Fourier and cross spectral analysis of temporal patterns indicated that the photosynthetic circadian rhythm was mainly characterized by light/dark migratory cycles.

Radiative Energy Budgets in a Microbial Mat Under Different Irradiance and Tidal Conditions

Irradiance and temperature variations during tidal cycles modulate microphytobenthic primary production potentially by changing the radiative energy balance of photosynthetic mats between immersion and emersion and thus sediment daily net metabolism. To test the effect of tidal stages on the radiative energy budget, we used microsensor measurements of oxygen, temperature, and scalar irradiance to estimate the radiative energy budget in a coastal photosynthetic microbial mat during immersion (constant water column of 2 cm) and emersion under increasing irradiance. Total absorbed light energy was higher in immersion than emersion, due to a lower reflectance of the microbial mat, while most (> 97%) of the absorbed light energy was dissipated as heat irrespective of tidal conditions. During immersion, the upward heat flux was higher than the downward one, whereas the opposite occurred during emersion. At highest photon irradiance (800 μmol photon m^-2 s^-1), the sediment temperature increased ~ 2.5 °C after changing the conditions from immersion to emersion. The radiative energy balance showed that less than 1% of the incident light energy (PAR, 400-700 nm) was conserved by photosynthesis under both tidal conditions. At low to moderate incident irradiances, the light use efficiency was similar during the tidal stages. In contrast, we found an ~ 30% reduction in the light use efficiency during emersion as compared to immersion under the highest irradiance likely due to the rapid warming of the sediment during emersion and increased non-photochemical quenching. These changes in the photosynthetic efficiency and radiative energy budget could affect both primary producers and temperature-dependent bacterial activity and consequently daily net metabolism rates having important ecological consequences.

[Acute leukemia revealed by bone magnetic resonance imaging: Two pediatric case reports]

Bone and joint pain are common causes of pediatric consultation for a variety of etiologies. The causes are mostly traumatic or infectious or have an inflammatory origin. Acute leukemia (AL) can sometimes begin with osteoarticular signs and radiological investigations such as magnetic resonance imaging (MRI) can help guide the diagnosis. We report on two cases of pediatric AL revealed by osteoarticular signs, with MRI helpful in the diagnostic procedure. In these children, the first signs were recurrent joint pain, with no blood count anomalies. There was a delay between the onset of arthralgia and diagnosis due to atypical presentation of the disease. MRI guided the investigations to the diagnosis of AL. The persistence of pain or inflammation must lead to considering a bone MRI and a complete blood count must be repeated in case of persistent inflammatory bone pain to avoid a missed diagnosis of blood disease.