Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America.

BACKGROUND: The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA). METHODS: The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting. RESULTS: One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups. CONCLUSIONS: Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.

Estado actual de la tuberculosis en el Servicio de Salud Metropolitano Occidente / Current status of tuberculosis in the Servicio de Salud Metropolitano Occidente

La tuberculosis persiste como un problema clínico, diagnóstico, terapéutico y epidemiológico pese a observarse una lenta pero mantenida tendencia a la disminución, tanto de la morbilidad como de la mortalidad atribuídas a ella en el curso de la última década. Lo anterior obliga a mantener una actitud de permanente alerta y a intensificar la pesquisa de los casos bacilíferos diseminados en la comunidad a través de la baciloscopía de expectoración de los casos sintomáticos y de los integrantes de los grupos de alto riesgo (inmunodeprimidos). Es necesario propender al diagnóstico y tratamiento lo mas precozmente posible de los casos detectados, aplicar cabalmente las normas establecidas y rescatar los pacientes que abandonan. Por último es de la mayor importancia el estudio de los contactos de los casos pesquisados y la educación sanitaria individual, familiar y colectiva

[Elaboration and evaluation of infant food based on Andean crops]. / Elaboración y evaluación de alimentos infantiles con base en cultivos andinos.

The Andes mountain range of South America is one of the most important centres for crop domestication, potato, corn, and lesser known grains such as quinua, cañihua, kiwicha and tarwi are indigenous of these highlands. These Andean grains have adapted perfectly to the climatic and geographical conditions present, whereas other grains have not been able to survive. In addition to their hardiness, they also have a high nutritional value. Bearing in mind on one hand, the high nutritional value of these indegenous products, and on the other hand the high rate of child malnutrition prevalent in the population, it was considered important to look for new variations in their processing which would facilitate their consumption by the poor working classes, especially the children. Accordingly three different flour mixtures were developed based on these Andean grains, the mixtures were then subjected to bromatological and biological analysis. The three new flour mixtures were: Quinua-Cañihua-Broad Bean (Q-C-B), Quinua-Kiwicha-Bean (Q-K-B) and Kiwicha-Rice (K-R). The protein content of these mixtures varied between 11.35-15.46 g/100g, the mixture K-R having the lowest protein level and the Q-C-B having the highest. The Q-K-B mixture had the highest chemical score, PER and NPU value. This PER value of 2.59 was higher than the value of casein which was 2.50. In addition this mixture had a chemical score of 0.94 and a NPU value of 59.38. The Q-C-B mixture had a chemical score of 0.88 and its PER, NPU and Digestibility values were 2.36, 47.24 and 79.2 respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical epidemiological findings in infants who were dead on arrival to hospital]. / Muertes infantiles extrahospitalarias en un servicio de salud metropolitano.

Some clinical and social aspects of 262 infants who were considered to be dead on arrival to the emergency care room of a suburban hospital at south east metropolitan Santiago, Chile, in the last five years were analysed. This figure amounts for 24% of infant mortality rate of that area. Males under age 6 month were more frequently affected (61.2%) than any other group; low birth weight was present in 25.4% of the cases and previous hospital admission in 41.7% incidence of death before hospital admittance was more frequent in spring and summer than in autumn and winter (22.9 vs. 77.1%); monthly family income was under U$50 in 58% of cases, 30% of mothers were under age twenty year, and 43% of patients had been reared by maritally unstable couples. Previous denial of care was reported in only four cases. Body temperature was recorded at hospital arrival in 72.5% of dead on arrival infants and it was above 40 degrees C in 20% of them. Preventive measures to control family based infant mortality should probably include education of mothers at the well baby clinic on risk factors, early consultation, appropriate initial management of fever and other emergencies at home, together with measures to provide easy access for everybody to timely an efficient medical care.

Estado actual de la tuberculosis: servicio de salud metropolitano occidente / Current situation of tuberculosis in the west metropolitan health service

Se analiza el estado actual de la tuberculosis en el Servicio de Salud Metropolitano Occidente, así como del Programa de control de la afección en sus diversos aspectos de prevención (vacunación BCG); detección y localización de casos en la comunidad; notificación, tratamiento y control de ellos; capacitación del personal médico y paramédico involucrado en las acciones y supervisión técnica y evaluación periódica de las acciones programadas

The hormonal ring. A new contraceptive gains acceptance.

PIP: The vaginal contraceptive ring under development by the Population Council's International Committee on Contraceptive Research (ICCR) is 58 mm in diameter and consists of a core of Salastic covered by a thin layer of levonorgestrel and estradiol with an overcoat of silicone rubber. The ring is inserted on the 5th day of the menstrual cycle and withdrawn 3 weeks later for 1 week. The steroids are released from the Silastic and readily absorbed through the vagina. The blood levels of contraceptive hormones are sufficient to prevent ovulation but do not display the great daily variation commonly observed in women on oral contraceptive (OCs). The ring contains sufficient hormones for 6 months of contraception. Preliminary research in developed countries indicates that the ring is as effective as and safer than the pill. In order to determine whether a method requiring twice monthly handling of the genitals and carrying a foreign body in the vagina for 3 weeks at a time would prove acceptable to poorer periurban and rural women in developing countries, the International Development Research Centre supported a study of the ring's acceptability in actual practice in Santo Domingo, Dominican Republic, and Campinas, Brazil. The ring was offered, with other methods, in several clinics in each country where prescription, instructions, and follow-up were provided by paramedical personnel. 150-200 ring acceptors in each country were to be compared with pill users, who were chosen for comparative purposes because both methods are hormonal, require the same sequence of use and rest, and tend to induce regular menses. Ring users were slightly older than pill users and tended to be better educated. 10% of ring users complained of difficulty with insertion, 20% of difficulty with removal, 43% worried about correct placement despite being told that the ring would work however inserted, 33% reported vaginal pain, and 10% reported having expelled it at some time. About half the women said the ring had changed color and about 1/3 of them did not like the change. Twice as many ring as pill users reported menstrual problems but 26% of pill users compared to 17% of ring users reported other problems such as headaches. 42% of ring users and 62% of pill users reported gaining weight. 17% of ring users and 7% of pill users considered their experiences "very good" but the general level of satisfaction with both methods was similar. An earlier study indicated that women liked having control over use of the method, inserting and removing the ring at will for intercourse or washing. The decreased amount and duration of menstrual bleeding was welcomed by most users, as was weight gain by some users.^ieng

User's perception of the contraceptive vaginal ring: a field study in Brazil and the Dominican Republic.

PIP: The basis for this report is home interviews of users of the contraceptive vaginal ring and the pill from urban and rural clinics in 2 provinces in the Dominican Republic and clinics from 2 towns and a large city in Brazil. Dominican ring users were significantly more likely to be older than pill users, to have more schooling, and have partners with more education. 6% were illiterate and 75% had only elementary education. 1/10 of the ring users reported having had problems with insertion of the ring and 1/5 had problems removing it. It may be worthwhile to try a narrower, more flexible model that may be easier to insert and remove. 1 out of every 6 users reported vaginal odor, 1 out of 8 reported having felt the ring move in their vagina, and 1/3 were aware of the ring at some time. About 1/2 the women in each country said the ring had changed color during use, and about 1/2 of those who reported the change did not like it. It became light gray and looked dirty. Correction may improve acceptance. 10% reported having expelled the ring. Twice as many ring users reported having menstrual problems. Ring and pill users both reported headaches, vaginal discharge, menstrual pain, and increased libido. A large proportion of ring and pill users experienced decreased duration and amount of menstrual bleeding, which was seen more as a beneficial than a negative effect. The same can be said for weight gain, which was "linked" by 89% of the women in the Dominican Republic. 64% of ring users and 67% of pill users described thier respective method as good or very good. Detailed instructions should accompany the final model. They should say that it is alright for the ring to be any place within tha vagina for it to be effective.^ieng

Acceptability of the contraceptive vaginal ring by rural and urban population in two Latin American countries.

A study of the field acceptability of the Contraceptive Vaginal Ring (CVR) was carried out in rural, small town and urban slum clinics in four locations, two in Brazil and two in the Dominican Republic (D.R.) The CVR was offered as a new method in the clinics and described as similar to the pill but placed in the vagina for three weeks each month with a one-week rest interval. Follow-up surveys were carried out in the four locations at the end of the experimental period. Three, eight, nine and 12.5% of the total acceptors in each of the 4 locations chose the CVR. The acceptance rate fell after the first five months but recovered during the second year. The acceptance rate was much higher in three rual clinics where the nurses themselves used the ring. The follow-up surveys showed that the fact that the ring is placed and kept in the vagina without removal for a prolonged period was the most important attribute of the method and played a large role in women's reactions to it. Anticipated use-related problems were the most prominent reason given by pill users for not choosing the ring, however ease of use was named as the "most killed" characteristic by 55% of ring users. Women tended to remove the ring for intercours and washed it frequently, often with detergents, thus illustrating their concern with "cleanliness" of an object kept within a body cavity for long periods of time.