Biologics with or without methotrexate in treatment of polyarticular juvenile idiopathic arthritis: effectiveness, safety and drug survival.

OBJECTIVE: To investigate the impact of additionally given MTX on biologic treatment of polyarticular JIA in terms of effectiveness, safety and drug survival. METHODS: Patients suffering from polyarticular JIA and treated with either monotherapy with a first biologic or a combination of a biologic and MTX were selected from the BIKER registry. The TNF-α inhibitors (TNFi) adalimumab, etanercept and golimumab and the IL-6 inhibitor tocilizumab were considered. Upon a non-randomized study design, we adjusted the different cohorts using propensity score matching to improve comparability. RESULTS: A total of 2148 patients entered the analysis, who were treated by either combination therapy (n = 1464) or monotherapy (n = 684). Disease activity declined significantly more in patients upon combination therapy than upon biologic monotherapy. Comparison of adjusted cohorts revealed that patients who received TNFi gained more benefit from additionally given MTX than patients treated with tocilizumab. Median survival time of therapy with biologics was significantly longer upon combination therapy (3.1 years) than with monotherapy (2.7 years), as demonstrated by a Kaplan-Meier analysis (log rank test: P = 0.002). The safety profile was moderately affected by additional MTX due to increased incidence of gastrointestinal and hepatic adverse events. Serious adverse events occurred at an equal rate of 3.6 events per 100 patient-years in both cohorts. CONCLUSION: Additionally given MTX improves the effectiveness of biologic treatment in polyarticular JIA without seriously compromising treatment safety. Especially TNFi benefit from combination, while no improvement in outcome has been observed by combining tocilizumab with MTX.

Update of evidence- and consensus-based guidelines for the treatment of juvenile idiopathic arthritis (JIA) by the German Society of Pediatric and Juvenile Rheumatic Diseases (GKJR): New perspectives on interdisciplinary care.

BACKGROUND: New therapeutic strategies for juvenile idiopathic arthritis (JIA) have evolved within the past ten years, and as a result, an update of the 2011 recommendations of the German management guidelines was initiated. METHODS: A systemic literature review was performed, overarching principles were proposed and pre-selected via an online survey followed by two multidisciplinary consensus conferences. Pharmacological and non-pharmacological treatments were discussed, statements were proposed and ultimately agreed upon by nominal group technique (NGT). RESULTS: 12 overarching therapeutic principles, as well as 9 recommendations on pharmacological and 5 on non-pharmacological treatments for JIA were agreed upon. CONCLUSION: This report summarizes the recent update of the interdisciplinary, consensus-based German guidelines on the management of JIA. The multi- and interdisciplinary participation of all caregivers was central for this patient-focused update. With these guidelines, physicians can choose an evidence-based approach, which allows better tailored treatment in this vulnerable cohort of children and adolescents.

Efficacy and Safety of Etanercept Biosimilars Compared With the Originator for Treatment of Juvenile Arthritis: A Prospective Observational Study.

OBJECTIVE: Analysis of etanercept biosimilars in pediatric patients with juvenile idiopathic arthritis (JIA) in comparison with the etanercept originator in terms of efficacy and safety. METHODS: Patients diagnosed with JIA who started treatment with either the etanercept originator or a biosimilar after January 1, 2017, were selected from the German BIKER registry (Biologics in Paediatric Rheumatology Registry). Furthermore, patients who started therapy with the originator and switched to a biosimilar during the course of therapy were identified. For both patient groups, disease activity and safety were examined and compared separately. RESULTS: After January 1, 2017, 348 patients started treatment with the etanercept originator (n = 293) or a biosimilar (n = 55). Another 57 patients switched to a biosimilar during the course of therapy. A significant decrease or a stable remission of disease activity was observed in both patient groups. The safety profiles were comparable, and frequencies and types of adverse events (AEs) and serious AEs were similar in patients starting therapy with the originator or a biosimilar. Only injection site reactions occurred slightly more frequently under biosimilar therapy, without having an impact on therapy adherence. In patients who switched therapy, the AE rate per 100 patient-years was comparable before (26.4) and after (32.1) the switch. CONCLUSION: In patients with JIA who require treatment with etanercept, the originator is still used much more frequently. However, our study highlights the equivalence of etanercept biosimilars for therapy for JIA. Increased use of these biosimilars in pediatric patients can therefore be recommended without hesitation.

The diagnostic challenge of progressive pseudorheumatoid dysplasia (PPRD): a review of clinical features, radiographic features, and WISP3 mutations in 63 affected individuals.

Progressive pseudorheumatoid dysplasia (PPRD) is a genetic, non-inflammatory arthropathy caused by recessive loss of function mutations in WISP3 (Wnt1-inducible signaling pathway protein 3; MIM 603400), encoding for a signaling protein. The disease is clinically silent at birth and in infancy. It manifests between the age of 3 and 6 years with joint pain and progressive joint stiffness. Affected children are referred to pediatric rheumatologists and orthopedic surgeons; however, signs of inflammation are absent and anti-inflammatory treatment is of little help. Bony enlargement at the interphalangeal joints progresses leading to camptodactyly. Spine involvement develops in late childhood and adolescence leading to short trunk with thoracolumbar kyphosis. Adult height is usually below the 3rd percentile. Radiographic signs are relatively mild. Platyspondyly develops in late childhood and can be the first clue to the diagnosis. Enlargement of the phalangeal metaphyses develops subtly and is usually recognizable by 10 years. The femoral heads are large and the acetabulum forms a distinct "lip" overriding the femoral head. There is a progressive narrowing of all articular spaces as articular cartilage is lost. Medical management of PPRD remains symptomatic and relies on pain medication. Hip joint replacement surgery in early adulthood is effective in reducing pain and maintaining mobility and can be recommended. Subsequent knee joint replacement is a further option. Mutation analysis of WISP3 allowed the confirmation of the diagnosis in 63 out of 64 typical cases in our series. Intronic mutations in WISP3 leading to splicing aberrations can be detected only in cDNA from fibroblasts and therefore a skin biopsy is indicated when genomic analysis fails to reveal mutations in individuals with otherwise typical signs and symptoms. In spite of the first symptoms appearing in early childhood, the diagnosis of PPRD is most often made only in the second decade and affected children often receive unnecessary anti-inflammatory and immunosuppressive treatments. Increasing awareness of PPRD appears to be essential to allow for a timely diagnosis.

Influence of a single viral epitope on T cell response and disease after infection of mice with respiratory syncytial virus.

CTL are important for virus clearance but also contribute to immunopathology after the infection of BALB/c mice with respiratory syncytial virus (RSV). The pulmonary immune response to RSV is dominated by a CTL population directed against the CTL epitope M2-1 82-90. Infection with a virus carrying an M2-1 N89A mutation introduced by reverse genetics failed to activate this immunodominant CTL population, leading to a significant decrease in the overall antiviral CTL response. There was no compensatory increase in responses to the mutated epitope, to the subdominant epitope F 85-93, or to yet undefined minor epitopes in the N or the P protein. However, there was some increase in the response to the subdominant epitope M2-1 127-135, which is located in the same protein and presented by the same H-2Kd MHC molecule. Infection with the mutant virus reversed the oligoclonality of the T cell response elicited by the wild-type virus. These changes in the pattern and composition of the antiviral CTL response only slightly impaired virus clearance but significantly reduced RSV-induced weight loss. These data illustrate how T cell epitope mutations can influence the virus-host relationship and determine disease after an acute respiratory virus infection.

Computational analysis of CFSE proliferation assay.

CFSE based tracking of the lymphocyte proliferation using flow cytometry is a powerful experimental technique in immunology allowing for the tracing of labelled cell populations over time in terms of the number of divisions cells undergone. Interpretation and understanding of such population data can be greatly improved through the use of mathematical modelling. We apply a heterogenous linear compartmental model, described by a system of ordinary differential equations similar to those proposed by Kendall. This model allows division number-dependent rates of cell proliferation and death and describes the rate of changes in the numbers of cells having undergone j divisions. The experimental data set that we specifically analyze specifies the following characteristics of the kinetics of PHA-induced human T lymphocyte proliferation assay in vitro: (1) the total number of live cells, (2) the total number of dead but not disintegrated cells and (3) the number of cells divided j times. Following the maximum likelihood approach for data fitting, we estimate the model parameters which, in particular, present the CTL birth- and death rate "functions". It is the first study of CFSE labelling data which convincingly shows that the lymphocyte proliferation and death both in vitro and in vivo are division number dependent. For the first time, the confidence in the estimated parameter values is analyzed by comparing three major methods: the technique based on the variance-covariance matrix, the profile-likelihood-based approach and the bootstrap technique. We compare results and performance of these methods with respect to their robustness and computational cost. We show that for evaluating mathematical models of differing complexity the information-theoretic approach, based upon indicators measuring the information loss for a particular model (Kullback-Leibler information), provides a consistent basis. We specifically discuss methodological and computational difficulties in parameter identification with CFSE data, e.g. the loss of confidence in the parameter estimates starting around the sixth division. Overall, our study suggests that the heterogeneity inherent in cell kinetics should be explicitly incorporated into the structure of mathematical models.

The impact of splenectomy on antiviral T cell memory in mice.

The contribution of the spleen to protective antiviral T cell memory was studied using the mouse model of infection with respiratory syncytial virus (RSV). Virus-specific CD8+ memory T cells were induced by local (intranasal or intracutaneous) or systemic (intravenous) immunization using RSV or vaccinia virus-recombinants expressing an RSV protein. After all three routes of immunization, the spleen was clearly identified as the main anatomic compartment harbouring virus-specific memory T cells. Surprisingly, however, splenectomy performed 30 days after immunization did not impair the efficacy of the memory T cell response to a subsequent RSV challenge infection. Irrespective of the route of priming, splenectomy did not influence the number or the functional activity of virus-specific memory T cells recruited to the lung following RSV challenge. More importantly, splenectomy did not impair pulmonary virus control by antiviral memory T cells in vivo. These findings were confirmed under experimental conditions where no neutralizing antibodies were induced by the priming infection. Thus, although most memory CD8+ T cells localize to the spleen after viral infections, this important lymphoid organ is dispensable for efficient recall responses. These findings have implications for the immunocompetence of splenectomized patients.

TV-image analysis based quantification of the proliferative activity and the apoptotic rate in thyroid tumors and thyroiditis.

To analyze the impact of cellular proliferative activity and apoptosis, MIB-1 immunopositivity and the apoptotic rate of normal tissue (n = 20), follicular adenoma (n = 30), follicular carcinoma (n = 32), papillary carcinoma (n = 40), Hashimoto thyroiditis (n = 17) and de Quervain thyroiditis (n = 12) was investigated by means of TV-image analysis. Three-micron sections from paraffin-embedded surgical specimens were investigated. Immunohistochemical reactions were performed using an indirect peroxidase method. For determination of apoptosis the in situ DNA nick-end labeling method (TUNEL) was used. The rate of positive cells was determined using the CM-2 TV-image analysis system (Hund, Wetzlar, Federal Republic of Germany). Forty viewing fields (1.94 mm2) were measured with 20:1 objective mangnification. An average of > 4,400 cells were assessed in each case. The mean MIB-1 immunopositivity was higher in follicular carcinoma (average, 2.30%) than in de Quervain thyroiditis (1.48%), papillary carcinoma (1.26%), Hashimoto thyroiditis (0.97%), follicular adenoma (0.58%) and normal thyroid tissue (0.14%). The apoptotic rates were higher in Hashimoto thyroiditis (4.54%) and de Quervain thyroiditis (3.55%) than in thyroid tumors (0.31%-0.49%) and normal thyroid tissue (0.10%). Calculating the ratio of MIB-1 expression and apoptotic rate, thyroid tumors (12.1-14.6) revealed higher values than normal thyroid tissue (3.6), indicating cell gain. In Hashimoto thyroiditis (1.7) and de Quervain thyroiditis (0.7) the ratio was lower than in normal tissue indicating cell loss. MIB-1 immunohistometry and apoptotic rate quantification present new insights into the proliferative and apoptotic potential of thyroid lesions based on a high number of cells investigated per case. The impact of both methods could be used for the interpretation of diagnostically difficult and inconclusive fine-needle aspirates. However, as there was an overlap of the single values, the results have to be interpreted carefully for diagnostic purposes.