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.

A Dual Approach of an Oil-Membrane Composite and Boron-Doped Diamond Electrode to Mitigate Biofluid Interferences

Electrochemical biosensors promise a simple method to measure analytes for both point-of-care diagnostics and continuous, wearable biomarker monitors. In a liquid environment, detecting the analyte of interest must compete with other solutes that impact the background current, such as redox-active molecules, conductivity changes in the biofluid, water electrolysis, and electrode fouling. Multiple methods exist to overcome a few of these challenges, but not a comprehensive solution. Presented here is a combined boron-doped diamond electrode and oil–membrane protection approach that broadly mitigates the impact of biofluid interferents without a biorecognition element. The oil–membrane blocks the majority of interferents in biofluids that are hydrophilic while permitting passage of important hydrophobic analytes such as hormones and drugs. The boron-doped diamond then suppresses water electrolysis current and maintains peak electrochemical performance due to the foulant-mitigation benefits of the oil–membrane protection. Results show up to a 365-fold reduction in detection limits using the boron-doped diamond electrode material alone compared with traditional gold in the buffer. Combining the boron-doped diamond material with the oil–membrane protection scheme maintained these detection limits while exposed to human serum for 18 h.

Oil-Membrane Protection of Electrochemical Sensors for Fouling- and pH-Insensitive Detection of Lipophilic Analytes

To take full advantage of the reagent- and label-free sensing capabilities of electrochemical sensors, a frequent and remaining challenge is interference and degradation of the sensors due to uncontrolled pH or salinity in the sample solution or foulants from the sample solution. Here, we present an oil-membrane sensor protection technique that allows for the permeation of hydrophobic (lipophilic) analytes into a sealed sensor compartment containing ideal salinity and pH conditions while simultaneously blocking common hydrophilic interferents (proteins, acids, bases, etc.) In this paper, we validate the oil-membrane sensor protection technique by demonstrating continuous cortisol detection via electrochemical aptamer-based (EAB) sensors. The encapsulated EAB cortisol sensor exhibits a 5 min concentration-on rise time and maintains a measurement signal of at least 7 h even in the extreme condition of an acidic solution of pH 3.

Analysis of pressure-driven membrane preconcentration for point-of-care assays

Point-of-care diagnostic devices for both physicians and patients themselves are now ubiquitous, but often not sensitive enough for highly dilute analytes (e.g., pre-symptomatic viral detection). Two primary methods to address this challenge include (1) increasing the sensitivity of molecular recognition elements with greater binding affinity to the analyte or (2) increasing the concentration of the analyte being detected in the sample itself (preconcentration). The latter approach, preconcentration, is arguably more attractive if it can be made universally applicable to a wide range of analytes. In this study, pressure-driven membrane preconcentration devices were developed, and their performance was analyzed for detecting target analytes in biofluids in the form of point-of-care lateral-flow assays (LFAs). The demonstrated prototypes utilize negative or positive pressure gradients to move both water and small interferents (salt, pH) through a membrane filter, thereby concentrating the analyte of interest in the remaining sample fluid. Preconcentration up to 33× is demonstrated for influenza A nucleoprotein with a 5 kDa pore polyethersulfone membrane filter. LFA results are obtained within as short as several minutes and device operation is simple (very few user steps), suggesting that membrane preconcentration can be preferable to more complex and slow conventional preconcentration techniques used in laboratory practice.

Continuous, quantifiable, and simple osmotic preconcentration and sensing within microfluidic devices

Insurmountable detection challenges will impede the development of many of the next-generation of lab-on-a-chip devices (e.g., point-of-care and real-time health monitors). Here we present the first membrane-based, microfluidic sample preconcentration method that is continuous, quantifiable, simple, and capable of working with any analyte. Forward osmosis rapidly concentrates analytes by removing water from a stream of sample fluid. 10-100X preconcentration is possible in mere minutes. This requires careful selection of the semi-permeable membrane and draw molecule; therefore, the osmosis performance of several classes of membranes and draw molecules were systematically optimized. Proof-of-concept preconcentration devices were characterized based on their concentration ability and fouling resistance. In-silico theoretical modeling predicts the experimental findings and provides an engineering toolkit for future designs. With this toolkit, inexpensive ready-for-manufacturing prototypes were also developed. These devices provide broad-spectrum detection improvements across many analytes and sensing modalities, enabling next-generation lab-on-a-chip devices.

Complete validation of a continuous and blood-correlated sweat biosensing device with integrated sweat stimulation

A wearable sweat biosensing device is demonstrated that stimulates sweat and continuously measures sweat ethanol concentrations at 25 s intervals, which is then correlated with blood ethanol during a >3 hour testing phase. The testing involves a baseline condition (no ethanol) followed by a rapid blood and sweat rise of ethanol (oral bolus), and finally, the physiological response of the body as ethanol concentrations return to baseline (metabolized). Data sets include multiple in vivo validation trials and careful in vitro characterization of the electrochemical enzymatic ethanol sensor against likely interferents. Furthermore, the data is analyzed through known pharmacokinetic models with a strong linear Pearson correlation of 0.9474-0.9996. The continuous nature of the data also allows analysis of blood-to-sweat lag times that range between 2.3 to 11.41 min for ethanol signal onset and 19.32 to 34.44 min for the overall pharmacokinetic curve lag time. This work represents a significant advance that builds upon a continuum of previous work. However, unresolved questions include operation for 24 hours or greater and with analytes beyond those commonly explored for sweat (electrolytes and metabolites). Regardless, this work validates that sweat biosensing can provide continuous and blood-correlated data in an integrated wearable device.

Enhancing glucose flux into sweat by increasing paracellular permeability of the sweat gland

Non-invasive wearable biosensors provide real-time, continuous, and actionable health information. However, difficulties detecting diluted biomarkers in excreted biofluids limit practical applications. Most biomarkers of interest are transported paracellularly into excreted biofluids from biomarker-rich blood and interstitial fluid during normal modulation of cellular tight junctions. Calcium chelators are reversible tight junction modulators that have been shown to increase absorption across the intestinal epithelium. However, calcium chelators have not yet been shown to improve the extraction of biomarkers. Here we show that for glucose, a paracellularly transported biomarker, the flux into sweat can be increased by >10x using citrate, a calcium chelator, in combination with electroosmosis. Our results demonstrate a method of increasing glucose flux through the sweat gland epithelium, thereby increasing the concentration in sweat. Future work should examine if this method enhances flux for other paracellularly transported biomarkers to make it possible to detect more biomarkers with currently available biosensors.

Chemically Enhanced Polymer-Coated Carbon Nanotube Electronic Gas Sensor for Isopropyl Alcohol Detection

Breathing-air quality within commercial airline cabins has come under increased scrutiny because of the identification of volatile organic compounds (VOCs) from the engine bleed air used to provide oxygen to cabins. Ideally, a sensor would be placed within the bleed air pipe itself, enabling detection before it permeated through and contaminated the entire cabin. Current gas-phase sensors suffer from issues with selectivity, do not have the appropriate form factor, or are too complex for commercial deployment. Here, we chose isopropyl alcohol (IPA), a main component of de-icer spray used in the aerospace community, as a target analyte: IPA exposure has been hypothesized to be a key component of aerotoxic syndrome in pre, during, and postflight. IPAs proposed mechanism of action is that of an anesthetic and central nervous system depressant. In this work, we describe IPA sensor development by showing (1) the integration of a polymer as an IPA capture matrix, (2) the adoption of a redox chemical additives as an IPA oxidizer, and (3) the application of carbon nanotubes as an electronic sensing conduit. We demonstrate the ability to not only detect IPA at 100-10 000 ppm in unfiltered, laboratory air but also discriminate among IPA, isoprene, and acetone, especially in comparison to a typical photoionization detector. Overall, we show an electronic device that operates at room temperature and responds preferentially to IPA, where the increase in the resistance corresponds directly to the concentration of IPA. Ultimately, this study opens up the pathway to selective electronic sensors that can enable real-time monitoring in a variety of environments for the force health prevention and protection, and the potential through future work to enable low parts-per-million and possibly high parts-per-billion selective detection of gas-phase VOCs of interest.

Advancing Peptide-Based Biorecognition Elements for Biosensors Using in-Silico Evolution

Sensors for human health and performance monitoring require biological recognition elements (BREs) at device interfaces for the detection of key molecular biomarkers that are measurable biological state indicators. BREs, including peptides, antibodies, and nucleic acids, bind to biomarkers in the vicinity of the sensor surface to create a signal proportional to the biomarker concentration. The discovery of BREs with the required sensitivity and selectivity to bind biomarkers at low concentrations remains a fundamental challenge. In this study, we describe an in-silico approach to evolve higher sensitivity peptide-based BREs for the detection of cardiac event marker protein troponin I (cTnI) from a previously identified BRE as the parental affinity peptide. The P2 affinity peptide, evolved using our in-silico method, was found to have ∼16-fold higher affinity compared to the parent BRE and ∼10 fM (0.23 pg/mL) limit of detection. The approach described here can be applied towards designing BREs for other biomarkers for human health monitoring.

Oxide-Free Actuation of Gallium Liquid Metal Alloys Enabled by Novel Acidified Siloxane Oils

Electrowetting and electrocapillarity of liquid metals have a long history, and a recent explosion of renewed interest. Liquid metals have electromagnetic properties and surface tensions (>500 mN/m) that enable new forms of reconfigurable devices. However, the only nontoxic option, gallium alloys, suffer from immediate formation of a semirigid surface oxide. Although acids or electrochemical reduction can remove this oxide, these approaches surround the gallium alloy in a fluid that is also electrically conducting, diminishing electromagnetic effectiveness and precluding electrowetting actuation. Reported here are acidified siloxanes that remove and prevent oxide formation. Importantly, the siloxane oil associatively incorporates hydrochloric or hydrobromic acids, is electrically insulating, is chemically stable, removes etching byproducts (including water), and allows robust electrowetting. This work opens up new opportunities for liquid metal reconfiguration, and is of fundamental interest due to the unexpected chemical stability of the acidified siloxanes and their application to other materials and surfaces.

Iron deficiency in women and its potential impact on military effectiveness

Iron deficiency is recognized as a significant health concern for women of childbearing age in the civilian population. In the military, most women are of childbearing age. Not only do they carry the normal risks for developing iron deficiency, but they also have the added threats of possible decreased choices of food high in iron content, increased physical activity, and weight loss. This can put these women at risk for decreased energy efficiency and impaired cognitive performance. This article describes the pathophysiology of iron deficiency and iron deficiency anemia, the consequences of each, and the need to routinely screen military women for iron depletion.

Evaluating glioma therapies: modeling treatments and predicting outcomes

BACKGROUND

Intra-arterial chemotherapy with carmustine (BCNU) and interstitial radiation therapy with the use of stereotactically placed 125I sources are aggressive local therapies for malignant glioma. These therapies emerged in the 1980s and both appeared promising in phase II studies but yielded disappointing results in subsequent randomized controlled trials by the Brain Tumor Cooperative Group (BTCG). Florell and colleagues had prepared us for the possibility that brachytherapy would have less impact on survival than anticipated from the phase II experience by demonstrating that patients who were judged eligible for interstitial radiation, but treated conventionally, lived significantly longer than those who were ineligible and had better than average outcomes.

PURPOSE

To further examine the impact of patient selection on outcome, we used the database of Florell et al. to assess the survival of patients with malignant glioma who were eligible or ineligible for chemotherapy by three intra-arterial methods, one of which was similar to that employed by the BTCG in its randomized, controlled trial evaluating intra-arterial BCNU.

METHODS

The medical records and computed tomography (CT) scans of 102 consecutive patients with malignant glioma receiving standard treatment (i.e., maximum feasible surgical resection, external-beam radiotherapy, and often adjuvant systemic chemotherapy) at a single cancer center in Canada during the calendar years 1988 and 1989 were used for this analysis. Based on CT imaging and blind to outcome, an interventional neuroradiologist decided which patients were eligible or ineligible for intra-arterial chemotherapy via injection of two major arteries, via injection of one major artery, or via selective middle-cerebral artery injection. A Karnofsky performance score of greater than or equal to 60 was required. The percent of eligible patients, the median survival time, and the distribution of prognostic factors were analyzed for each group of eligible and ineligible patients. Median survival times were compared with the use of the generalized Wilcoxon (Breslow) test. All P values were based on two-tailed tests.

RESULTS

For two-vessel treatment, 72.5% of the patients (74 of 102) were eligible; the eligible patients on average lived longer than the ineligible patients (14.8 versus 3.5 months; P < .00001). For one-vessel treatment, 48% of the patients (49 of 102) were eligible; again, the eligible patients lived longer than the ineligible patients (18.4 versus 5.1 months; P < .00001). For middle-cerebral artery treatment, 30% of the patients (31 of 102) were eligible, and these eligible patients did live somewhat longer than the ineligible patients, but this result did not reach statistical significance (13.6 versus 9.9 months; P = .1304). Trends were similar for patients with glioblastoma multiforme and anaplastic glioma. The median duration of survival was 11.4 months for all patients.

CONCLUSIONS

Patients who were eligible for intra-arterial chemotherapy lived significantly longer or somewhat longer (depending on the selection criteria used) than patients who were ineligible and had better than expected outcomes. Patients who were judged eligible for intra-arterial chemotherapy by the two-vessel method and the control group in the BTCG phase III trial of intra-arterial chemotherapy had similar median survival times (14.8 versus 14.0 months).

IMPLICATIONS

Modeling treatments with the use of a comprehensive clinical and imaging database of unselected, conventionally treated patients may help investigators decide if new therapies warrant definitive evaluation in randomized trials by measuring the degree to which patient selection may have enhanced phase II study outcomes.

Preradiation intracarotid cisplatin treatment of newly diagnosed anaplastic gliomas. The CNS Cancer Consortium

PURPOSE

This phase II study was performed to assess the response of patients with newly diagnosed, untreated malignant gliomas (anaplastic astrocytoma [AA] and glioblastoma multiforme [GBM]) to intracarotid (IC) cisplatin.

PATIENTS AND METHODS

Eligibility criteria included surgical intervention limited to biopsy only, measurable contrast-enhancing tumor, and unilateral tumor location within the vascular territory of one internal carotid artery. Patients were scheduled to receive four infusions of IC cisplatin (75 mg/m2 every 4 weeks) before beginning standard radiotherapy. Twenty-six patients were treated, and 22 were assessable for response.

RESULTS

Ten patients (45%) showed a greater than 25% decrease in the enhancing tumor area before radiotherapy with stabilization or improvement of neurologic deficits, and three patients (14%) had a greater than 70% decrease in tumor area. The likelihood of response to IC cisplatin was not clearly linked to patient age, tumor histology, or pretreatment tumor size. Myelosuppression, nephrotoxicity, and ototoxicity were mild. Optic neuropathy occurred in one patient, seizures in two, and fatal postinfusion cerebral edema in one.

CONCLUSION

This study design, which permits assessment of the drug sensitivity of the untreated glioma, has shown definite antitumor activity of IC cisplatin in newly diagnosed malignant glioma patients.

Employability: the challenge ahead

The author outlines the problems faced by visually impaired people in finding appropriate employ ment, and discusses the attempts being made to improve the situation in the UK, USA and Europe. The article proposes further steps that should be taken in the near future.

Randomized, controlled trial of diabetic patient education: improved knowledge without improved metabolic status

We randomized 749 insulin-treated patients on the rolls of the Mount Sinai Medical Center Diabetes Clinic in a controlled trial of diabetic patient education; 345 agreed to participate, of whom 165 were assigned to the education group and 180 to the control group. Cognitive scores increased from 5.3 +/- 1.6 to 5.8 +/- 1.6 in the education group, but there was no change in the control group, whose score was 5.3 +/- 1.7 before and after the intervention (P = .0073). HbA1c fell from 6.8 +/- 2.1 to 6.1 +/- 2.0% in the education group and from 6.6 +/- 2.0 to 6.3 +/- 2.0% in the control group, an insignificant difference (P = .1995). The fasting blood glucose decreased from 223 +/- 94 to 179 +/- 73 mg/dl in the education group and from 199 +/- 81 to 185 +/- 76 mg/dl in the controls (P = .1983). Triglycerides, high- and low-density lipoprotein cholesterol, and insulin dosage also failed to show significant variation among groups. The foot-lesion score showed similar progression in the education and control groups. Neither diastolic nor systolic blood pressure showed significantly greater change in the education or the control group, with falls noted, particularly in diastolic pressures, in both patient groups. Differences between the groups were not significant for sick days, hospitalizations, emergency room visits, or outpatient visits. The sample sizes of the study and control populations were sufficiently large to detect a difference in means between the education and control groups in the HbA1c, the primary outcome variable, of greater than 1.0%, with alpha = .05 and a power of .95. Thus, our study suggests that patient education may not be an efficacious therapeutic intervention in most adults with insulin-treated diabetes mellitus.

Pituitary apoplexy associated with a triple bolus test. Case report

The authors report a case of pituitary apoplexy resulting in bilateral internal carotid artery occlusion, with marked depression of consciousness and hemiplegia. After transsphenoidal tumor decompression, restoration of flow in both carotid arteries was documented angiographically and the patient made an excellent clinical recovery. The unique aspect of this case is that the pituitary apoplexy was apparently precipitated by neuroendocrine manipulation, performed as a preoperative test of pituitary function.