A pediatric case of SAPHO-CNO syndrome with clinical correlation between cutaneous and osteoarticular features

Synovitis acne pustulosis hyperostosis osteitis (SAPHO) and chronic nonbacterial osteomyelitis (CNO) represent overlapping osteoarticular autoinflammatory syndromes, with a minority displaying neutrophilic skin features at the time of diagnosis. The pathophysiological link and chronological timeframe between skin and osteoarticular findings remain ambiguous, which in turn can manifest in diagnostic delay. We present a rare pediatric case of SAPHO-CNO with a clear association between cutaneous and osteoarticular symptoms, treated with nonsteroidal anti-inflammatory medications, corticosteroids, and intravenous pamidronate. By raising physician awareness of these syndromes, we hope that appropriate management will be initiated in a more timely fashion avoiding unnecessary investigations and treatment.

Finding Your Way When You Have Metastatic Breast Cancer: Codesigning Resources With Consumers for Consumers. The Signpost Study

Background: In Australia, women with metastatic breast cancer are not systematically made aware of or helped to access supportive care resources. Finding resources tailored to their needs can be challenging as they spread across several healthcare and advocacy organizations. Furthermore, resources assume varying levels of knowledge about the disease and its treatments, are fragmented and are dispersed across multiple organizations. Aim: The aim of our study was to codesign a signpost resource to direct women to key supportive care organizations that provide relevant, timely and comprehensive support for them; ensure women are made aware of and know how to access support they need, as and when they need it; and ensure that health professionals are aware of the resource, support its use, and distribute it to women. Methods: Using a codesign framework, initial development of the resource was guided by consumer representation on the study Steering Group. The resource was then presented to women living with metastatic breast cancer, and their advice obtained about its relevance and functionality during semistructured interviews. Purposive sampling based on age, time since diagnosis and geographical location (metro/regional), was used to obtain a variety of perspectives. Open-ended questions explored what the resource should contain, look like, and how it could best be introduced and distributed. An iterative descriptive analytical approach was applied. Results: Seven women aged 40-61 years were interviewed. Time since their metastatic breast cancer diagnosis ranged from 5 months to 19 years. Women told us about their preferences for style, content and format for the resource. They also guided discussion about how best to promote the resources in a way that both informed health professionals but also empowered women to find and express a need for support. As a result, 2 videos were produced. In the first 3-minute video for health professionals, consumers powerfully convey messages about the impact of their diagnosis, their need for support and how important it is for health professionals to “value and believe there are emotional, social and material aspects of coping with the disease” (this video will be shared in the presentation). In the second 4-minute video, consumers endorse the need for information and support, and women and consumers watching the video are introduced to the services provided by supportive care organizations profiled on the resource. Conclusion: Resources created and tailored by consumers for consumers are powerful and important. Consumer-led interventions that demonstrate to health professionals the importance of supportive care as a cornerstone of excellent cancer care may have a considerable impact but require empirical testing.

Pregnancy and pregnancy outcome in hepatitis C type 1b

A large cohort of rhesus-negative women in Ireland were inadvertently infected with hepatitis C virus following exposure to contaminated anti-D immunoglobulin in 1977-8. This major iatrogenic episode was discovered in 1994. We studied 36 women who had been infected after their first pregnancy, and compared them to an age- and parity-matched control group of rhesus-positive women. The presence of hepatitis C antibody was confirmed in all 36 by enzyme-linked immunosorbent assay and by recombinant immunoblot assay, while 26 (72%) of the cohort were HCV-RNA-positive (type 1b) on PCR testing. In the 20 years post-infection, all members of the study group had at least one pregnancy, and mean parity was 3.5. They had a total of 100 pregnancies and 85 of these went to term. There were four premature births, one being a twin pregnancy, and 11 spontaneous miscarriages. One miscarriage occurred in the pregnancy following HCV infection. There were two neonatal deaths due to severe congenital abnormalities in the PCR-positive women. Of the children born to HCV-RNA positive mothers, only one (2.3%) tested positive for the virus. Significant portal fibrosis on liver biopsy was confined to HCV-RNA-positive mothers apart from one single exception in the antibody-positive HCV-RNA-negative group. Comparison with the control group showed no increase in spontaneous miscarriage rate, and no significant difference in obstetric complications; birth weights were similar for the two groups.

Social tactics of pigs in a competitive foraging task: the 'informed forager' paradigm

Studies of the social dynamics in foraging groups have focused primarily on birds, rodents and nonhuman primates. We extended the study of animal social tactics to the domestic pig, Sus scrofa, by using an experimental analogue of natural foraging skills, the 'informed forager' paradigm. We investigated the behaviour of 16 pigs foraging in pairs in an arena in which food had been hidden in one of eight monopolizable buckets. Before each pair trial, one of the pigs, the 'informed' pig, was given privileged knowledge about the location of the food during a solitary search trial. The 'noninformed' pig was naïve about the location of the food during pair trials, but heavier than its informed partner and thus able to displace the latter from the baited bucket. By first focusing on the informed pigs' behaviour, we show that pigs are able to remember and relocate the food site. They found the food in relocation trials, using fewer bucket investigations than expected of a random searcher. Second, by focusing on the noninformed pigs, we show that pigs are able to exploit the knowledge of others by following them to a food source. They investigated more buckets immediately after their informed partners significantly more often than expected by chance and required fewer bucket investigations to find the food in pair trials than expected from a random searcher, but not in solitary search trials. We discuss these latter findings with reference to social foraging tactics. Copyright 2000 The Association for the Study of Animal Behaviour.

The effect of total lymphoid irradiation and low-dose steroids on T lymphocyte populations in multiple sclerosis: correlation with clinical and MRI status

We have monitored the cell surface phenotypic changes occurring in T, B and NK cells of chronic progressive multiple sclerosis (MS) patients after total lymphoid irradiation (TLI) plus low-dose prednisone (TLI-LDP) therapy in comparison to sham TLI-LDP. TLI-LDP resulted in a marked reduction in the relative and absolute number of total CD3+ T cells, CD4+ helper T cells, CD4+ CD45RA+ naive T cells and CD19+ B cells for at least 1 year after treatment. No change occurred in the percent CD8+ T cells although the number of these cells declined after radiotherapy. The CD4/CD8 T cell ratio was also decreased. The relative percent of CD16+ NK cells increased steadily after TLI-LDP while the number of NK cells transiently declined but returned to baseline values 1 year later. An increase in the percent of CD2+ CD3- cells and a decrease in their number after therapy was also observed. In contrast, no significant changes in the number of T, B or NK cells were seen in the MS patients receiving sham TLI-LDP. These results provide further evidence that radiotherapy causes a reduction of immunocompetent T and B cells and that a population of possibly NK cells and/or immature T cells appears to be repopulating the circulation after TLI. In addition, a correlation was observed between alterations in lymphocyte populations and the presence or absence of contrast enhancing or new T2 lesions on brain magnetic resonance imaging (MRI) in the TLI-LDP treated MS patients. Patients devoid of contrast enhancing or new T2 lesions had a decreased percentage of CD3+ and CD4+ T cells prior to therapy and at six months following TLI-LDP compared to patients with such lesions. An association was also observed between stability in disease activity as determined on the Expanded Disability Status Scale and relative values of CD3 T cells.

Modified total lymphoid irradiation and low dose corticosteroids in progressive multiple sclerosis

In a double-blind prospective randomized trial, we assessed the efficacy and safety of modified total lymphoid irradiation (TLI) plus low dose prednisone (TLI-LDP) as compared to sham TLI plus identical prednisone therapy (sham TLI-LDP) in 46 patients with progressive forms of multiple sclerosis (MS). No significant difference existed between groups at study entry in patient age, sex, duration of MS, or disability status. However, following treatment, significantly fewer TLI patients showed a sustained one point decline in the Expanded Disability Status Scale, the primary study endpoint, as compared to the sham TLI group using the Kaplan-Meier Product-limit survival analysis, (P<0.005). Risk for relapse requiring treatment with intravenous methylprednisolone was reduced by 54% in the TLI-treated group (P<0.05). Significantly fewer TLI-LDP patients had gadolinium enhancing plus new T2-weighted lesions (P=0.018) when compared to the sham group post-treatment. There was also a substantial and significant decrease in blood lymphocytes in the TLI-LDP group when compared to either pretreatment values or to sham TLI-LDP through at least 12 months post-therapy. Side effects secondary to TLI were generally mild and well-tolerated. These results further support the hypothesis that TLI and systemic immunosuppression have a beneficial effect in progressive forms of MS.

Combination total lymphoid irradiation and low-dose corticosteroid therapy for progressive multiple sclerosis

Total lymphoid irradiation (TLI) has been reported to delay deterioration in patients with progressive multiple sclerosis and other autoimmune disorders. METHODS--In an open trial, the effect of TLI combined with a one year course of low dose prednisone was compared to the effect of sham TLI and TLI only in a prior double-blind study of patients with progressive multiple sclerosis. RESULTS--Twenty-seven patients receiving TLI combined with corticosteroids had significantly greater lymphocytopenia in the year post-therapy than those receiving TLI only or sham TLI and Kaplan Meier product-limit survival analysis showed significantly less progression in the TLI plus steroid group over 4 years of follow-up. No difference in lymphocytopenia or progression was found with TLI plus corticosteroid therapy when the spleen was removed from the field of irradiation. CONCLUSION--These results lend further support to the hypothesis that TLI may be effective in progressive MS, and indicates that adding low-dose prednisone may enhance this effect. The study also suggests that TLI may be equally effective whether or not the spleen is irradiated.

Effect of total lymphoid irradiation on functional status in chronic multiple sclerosis: importance of lymphopenia early after treatment--the pros

To determine whether immunosuppression by total lymphoid irradiation (TLI) slowed deterioration of chronic progressive multiple sclerosis (MS), functional impairment score and blood lymphocyte counts were compared at 6-month intervals through 4 years following treatment of MS patients by either TLI (n = 27) or sham irradiation (n = 21). At each interval, 20 to 30% fewer TLI-treated patients had deteriorated (p less than 0.05 at 6, 12, and 18 months), and the difference in mean functional impairment score between groups became progressively greater (p less than 0.01 at 42 and 48 months). Benefit accrued principally to the 17 TLI-treated patients with absolute blood lymphocyte counts less than 900/mm3 3 months after treatment, whose mean functional impairment score remained within 0.6 units of baseline (p = NS), whereas the ten TLI patients with higher post-treatment lymphocyte counts had progressive deterioration (p less than 0.05 to p less than 0.001 versus TLI-treated patients with lower lymphocyte counts at all intervals except 30 months) and had deteriorated by more than 5 functional scale units by 42 and 48 months. Side effects were minor and complications rare in TLI-treated patients, but one TLI-treated patient developed staphylococcal sepsis. Thus, TLI slows deterioration of chronic progressive MS, with what appears to be enduring benefit through 4 years compartmented to patients with greater induced lymphopenia. Modification of lymphoid irradiation regimens to increase the proportion of MS patients who achieve a favorable degree of lymphopenia and to avert functional hyposplenism may further improve the benefit/risk ratio.

T cell subsets and disease progression after total lymphoid irradiation in chronic progressive multiple sclerosis

T lymphocyte subset percentages were determined in 16 total lymphoid irradiation (TLI) treated and 18 sham treated control patients with chronic progressive multiple sclerosis. During the first year after treatment, the ratio of T helper/inducer to T suppressor/cytotoxic cells (Th/Ts ratio) was significantly higher in sham treated multiple sclerosis patients who worsened clinically compared with TLI treated and sham treated multiple sclerosis patients who remained clinically stable. TLI caused a fall in the percentage of T helper cells in treated patients, while the percentage of T suppressor cells remained stable during the first year after treatment. In contrast, the percentage of T suppressor cells fell in sham treated multiple sclerosis patients who worsened clinically.

Total lymphoid irradiation in multiple sclerosis: blood lymphocytes and clinical course

We have found a significant relationship between blood lymphocyte count and prognosis in 45 patients receiving either total lymphoid irradiation or sham irradiation for chronic progressive multiple sclerosis. Patients with sustained lymphocyte counts less than 900 mm-3 for prolonged periods after treatment showed less rapid progression over the ensuing 3 years than did patients with multiple sclerosis who had lymphocyte counts above this level (p less than 0.01). Our results suggest that a simple laboratory test, the absolute blood lymphocyte count, may serve as a valuable barometer for monitoring the amount of immunosuppressive therapy needed to prevent progression in patients with multiple sclerosis, and possibly other autoimmune diseases.

Effect of total lymphoid irradiation in chronic progressive multiple sclerosis

Total lymphoid irradiation (TLI; 1980 cGy) or sham irradiation was given to 40 patients with chronic progressive multiple sclerosis (MS) in a prospective, randomised, double-blind study. During mean follow-up of 21 months, MS patients treated with TLI had less functional decline than sham-irradiated MS patients (p less than 0.01). A significant relation was noted between absolute blood lymphocyte counts in the first year after TLI and subsequent course, patients with higher lymphocyte counts generally having a worse prognosis (p less than 0.01). TLI was well tolerated and associated with only mild short-term, and to date, long-term side-effects.