Open-label phase 3 study of intravenous golimumab in patients with polyarticular juvenile idiopathic arthritis.

OBJECTIVES: To assess efficacy, pharmacokinetics (PK) and safety of intravenous (i.v.) golimumab in patients with polyarticular-course JIA (pc-JIA). METHODS: Children aged 2 to <18 years with active pc-JIA despite MTX therapy for ≥2 months received 80 mg/m2 golimumab at weeks 0, 4, then every 8 weeks through week 52 plus MTX weekly through week 28. The primary and major secondary endpoints were PK exposure and model-predicted steady-state area under the curve (AUCss) over an 8-week dosing interval at weeks 28 and 52, respectively. JIA ACR response and safety were also assessed. RESULTS: In total, 127 children were treated with i.v. golimumab. JIA ACR 30, 50, 70, and 90 response rates were 84%, 80%, 70% and 47%, respectively, at week 28 and were maintained through week 52. Golimumab serum concentrations and AUCss were 0.40 µg/ml and 399 µg ⋅ day/ml at week 28. PK exposure was maintained at week 52. Steady-state trough golimumab concentrations and AUCss were consistent across age categories and comparable to i.v. golimumab dosed 2 mg/kg in adults with rheumatoid arthritis. Golimumab antibodies and neutralizing antibodies were detected via a highly sensitive drug-tolerant assay in 31% (39/125) and 19% (24/125) of patients, respectively. Median trough golimumab concentration was lower in antibody-positive vs antibody-negative patients. Serious infections were reported in 6% of patients, including one death due to septic shock. CONCLUSION: Body surface area-based dosing of i.v. golimumab was well tolerated and provided adequate PK exposure for clinical efficacy in paediatric patients with active pc-JIA.ClinicalTrials.gov number NCT02277444.

Exploration of knowledge and understanding in patients with primary adrenal insufficiency: a mixed methods study.

BACKGROUND: Primary adrenal insufficiency (PAI) is a rare and severe condition requiring lifelong steroid replacement. During acute illness or stressful events, it is important to appropriately adjust glucocorticoid dose; failure to do so may lead to an adrenal crisis. The aim of the study was to explore patients PAI knowledge and understanding of the condition, steroid replacement adjustment during acute illness or stress and provided education. METHODS: Ten adult patients with PAI were purposefully recruited from two hospitals in a tertiary NHS Trust in England, UK. Data was collected using a mixed method approach utilising semi-structured audio-recorded interviews and hospital case note review. Interviews were transcribed verbatim and analysed using Burnard's content analysis framework. Information from the hospital case note review was captured using a matrix table based on pre-defined criteria. RESULTS: Four key themes emerged: 'Addison's disease and hydrocortisone replacement'; 'stress and corticosteroids'; 'patient compliance/adherence' and 'transition'. Patients reported feelings of 'going through a transition from uncertainty to adaption' following diagnosis. All participants had a good level of knowledge and understanding of required medication however application in times of need was poor. Medication adherence and prevention of a crisis relied not only on patient knowledge and application but also the support of family and health professionals. Health care professional knowledge required improvement to aid diagnosis and management of PAI. CONCLUSION: Patients with PAI did not apply existing knowledge to adjust steroid dose during acute illness or stress. Although a sample of limited size, our study identified there is a need to further explore why patients with Addison's disease do not apply existing knowledge during times of increased need. Future research should consider appropriate behaviour change interventions to promote medication adherence to reduce risk of an adrenal crisis.

Diagnosis and Management of Suspected Pediatric Autoimmune Encephalitis: A Comprehensive, Multidisciplinary Approach and Review of Literature.

Autoimmune encephalitis is an increasingly recognized entity in children. When treated promptly, favorable outcomes are seen in a majority of pediatric patients. However, recognition of autoimmune encephalitis in young patients is challenging. Once autoimmune encephalitis is suspected, additional difficulties exist regarding timing of treatment initiation and duration of treatment, as evidence to guide management of these patients is emerging. Here, we review available literature regarding pediatric autoimmune encephalitis and present our institution's comprehensive approach to the evaluation and management of the disease. These guidelines were developed through an iterative process involving both pediatric neurologists and rheumatologists.

Rearing environment affects development of the immune system in neonates.

Early-life exposure to appropriate microbial flora drives expansion and development of an efficient immune system. Aberrant development results in increased likelihood of allergic disease or increased susceptibility to infection. Thus, factors affecting microbial colonization may also affect the direction of immune responses in later life. There is a need for a manipulable animal model of environmental influences on the development of microbiota and the immune system during early life. We assessed the effects of rearing under low- (farm, sow) and high-hygiene (isolator, milk formula) conditions on intestinal microbiota and immune development in neonatal piglets, because they can be removed from the mother in the first 24 h for rearing under controlled conditions and, due to placental structure, neither antibody nor antigen is transferred in utero. Microbiota in both groups was similar between 2 and 5 days. However, by 12-28 days, piglets reared on the mother had more diverse flora than siblings reared in isolators. Dendritic cells accumulated in the intestinal mucosa in both groups, but more rapidly in isolator piglets. Importantly, the minority of 2-5-day-old farm piglets whose microbiota resembled that of an older (12-28-day-old) pig also accumulated dendritic cells earlier than the other farm-reared piglets. Consistent with dendritic cell control of T cell function, the effects on T cells occurred at later time-points, and mucosal T cells from high-hygiene, isolator pigs made less interleukin (IL)-4 while systemic T cells made more IL-2. Neonatal piglets may be a valuable model for studies of the effects of interaction between microbiota and immune development on allergy.

Medial temporal lobe functional connectivity predicts stimulation-induced theta power.

Focal electrical stimulation of the brain incites a cascade of neural activity that propagates from the stimulated region to both nearby and remote areas, offering the potential to control the activity of brain networks. Understanding how exogenous electrical signals perturb such networks in humans is key to its clinical translation. To investigate this, we applied electrical stimulation to subregions of the medial temporal lobe in 26 neurosurgical patients fitted with indwelling electrodes. Networks of low-frequency (5-13 Hz) spectral coherence predicted stimulation-evoked increases in theta (5-8 Hz) power, particularly when stimulation was applied in or adjacent to white matter. Stimulation tended to decrease power in the high-frequency broadband (HFB; 50-200 Hz) range, and these modulations were correlated with HFB-based networks in a subset of subjects. Our results demonstrate that functional connectivity is predictive of causal changes in the brain, capturing evoked activity across brain regions and frequency bands.

Widespread theta synchrony and high-frequency desynchronization underlies enhanced cognition.

The idea that synchronous neural activity underlies cognition has driven an extensive body of research in human and animal neuroscience. Yet, insufficient data on intracranial electrical connectivity has precluded a direct test of this hypothesis in a whole-brain setting. Through the lens of memory encoding and retrieval processes, we construct whole-brain connectivity maps of fast gamma (30-100 Hz) and slow theta (3-8 Hz) spectral neural activity, based on data from 294 neurosurgical patients fitted with indwelling electrodes. Here we report that gamma networks desynchronize and theta networks synchronize during encoding and retrieval. Furthermore, for nearly all brain regions we studied, gamma power rises as that region desynchronizes with gamma activity elsewhere in the brain, establishing gamma as a largely asynchronous phenomenon. The abundant phenomenon of theta synchrony is positively correlated with a brain region's gamma power, suggesting a predominant low-frequency mechanism for inter-regional communication.

Validation of computer-assisted, pixel-based analysis of multiple-colour immunofluorescence histology.

Developments in immunohistology allow the routine simultaneous use on tissue sections of three monoclonal antibodies, tagged with different fluorochromes. Such staining can identify seven different cell populations and the limiting factor is rapid, reliable and reproducible analysis. Future reliance on computer-assisted analysis of digitised images depends on validation against manual counting, often viewed as the 'gold standard'. In this study images were digitised from sections of normal porcine skin, inflamed skin and tonsil, simultaneously stained with three monoclonal antibodies. Combinations of staining were quantified by four manual counts and by pixel-based area measurement. On individual images, the correlation between automated and manual measurements was poor. Despite this, the concordance between manual and automated measurements in the means and variances of tissues was good, and both techniques identified the same changes in inflamed versus normal tissues. In addition, pixel-based counting permitted statistical analysis of co-localisation of cell types in tissue sections. We conclude that automated counting is acceptable for the assessment of tissues, is faster and provides less opportunity for observer variation than manual counting. We also demonstrate that the technique is applicable where more than three fluorochromes are used such that manual counting becomes essentially impossible.

The influence of environment on development of the mucosal immune system.

The mucosal immune system expresses active responses against pathogens and also tolerance against harmless food and commensal bacterial antigens. The mechanisms that determine which of these outcomes occur after recognition of antigens by T-cells are not clear. One possibility is that it is determined by the initial interaction between a dendritic and a naïve T-cell in organised lymphoid tissue. However, such organised structures are, evolutionarily, quite recent and the original immune system must have made appropriate responses in more diffuse immunological architecture; a second possibility is that the critical interaction is between primed T-cells and their environment, in the lamina propria of the intestine. The mucosal immune system of neonates is poorly developed and inefficient at expressing appropriate immune responses. Development is influenced by a range of environmental factors including maternally derived antigen or antibody and commensal flora and pathogens. The intestine is a complex immunological structure in which the immune system and the macro- and microenvironment interact.

Epidermal growth factor induced tyrosine phosphorylation of nuclear proteins associated with translocation of epidermal growth factor receptor into the nucleus.

Treatment of human squamous carcinoma cells (HN5 cells) with epidermal growth factor (EGF) caused a time-dependent increase in tyrosine phosphorylation of six nuclear proteins of molecular mass 166, 140, 117, 95, 86 and 79 kDa. The major tyrosine phosphorylated protein was indistinguishable from the plasma membrane form of the epidermal growth factor receptor and was shown by enzyme linked immunosorbent assay (ELISA) to be translocated into the nucleus from extra-nuclear sites upon ligand stimulation. Using immunoelectron microscopy of both isolated nuclei and whole cells, epidermal growth factor receptor (EGF-R) was found to be associated with the chromatin and, to a lesser extent, with the inner surface of the nuclear membrane. Tyrosine phosphorylation of proteins other than EGF-R was particularly notable in the nucleoli. These observations suggest that EGF-R may exert some of its physiological functions by directly inducing tyrosine phosphorylation of specific nuclear proteins. Translocation of EGF-R to the nucleus may provide a vital link between plasma membrane signalling and gene activation.

Mechanical loading attenuates bone loss due to immobilization and calcium deficiency.

Our purpose was to determine the effects of a mechanical loading intervention on mass, geometry, and strength of rat cortical bone during a period of disuse concurrent with calcium deficiency (CD). Adult female rats were assigned to unilateral hindlimb immobilization, immobilized-loaded, or control (standard chow, 1.85% calcium) treatments. Both immobilized groups were fed a CD rat chow (0.01% calcium) to induce high bone turnover. Three times weekly, immobilized-loaded rats were subjected to 36 cycles of 4-point bending of the immobilized lower leg. After 6 wk, the immobilized rats exhibited decreased tibial shaft bone mineral density (-12%), ultimate load (-19%), and stiffness (-20%; tested in 3-point bending to failure) vs. control rats. Loading prevented this decline in bone density and attenuated decreases in ultimate load and stiffness. Elastic modulus was unaffected by disuse or loading. Bone cross-sectional area in the immobilized-loaded rats was equivalent to that of control animals, even though endocortical resorption continued unabated. On the medial periosteum, percent mineralizing surface doubled vs. that in immobilized rats. This loading regimen stimulated periosteal mineralization and maintained bone mineral density, thereby attenuating the loss in bone strength incurred with disuse and concurrent calcium deficiency.

Estradiol effect on anterior crural muscles-tibial bone relationship and susceptibility to injury.

The study's objective was to determine whether estradiol (E2) deficiency alters the functional relationship of muscle to bone and causes a differential increase in injury susceptibility. Ovariectomized 6-wk-old mice were administered E2 (40 micrograms. day-1. kg-1; n = 8) or the oil vehicle (n = 8) for 21 days. The anterior crural muscles of the left hindlimb were then stimulated to produce 150 maximal in vivo eccentric contractions. In vitro functional measurements were then made on the extensor digitorum longus (EDL) muscle and tibia from both the exercised and unexercised legs. The maximal isometric torque produced by the anterior crural muscles before the eccentric contraction protocol and the unexercised EDL maximal isometric tetanic force (P(0)) were higher in E2-treated mice by 18 and 14%, respectively (P < or = 0.03). Both ultimate load and stiffness for the unexercised tibia were higher by 16% in E2-treated mice (P < or = 0.03). The muscle-to-bone relationship of these measurements was unaffected by E2 status (P > or = 0.59). No evidence for increased injury susceptibility was found in either tissue from E2-deficient mice. In fact, the decrement in P(0) was only 36.9 +/- 3.8% in exercised EDL muscles from E2-deficient mice compared with 50.6 +/- 4.2% in exercised muscles from E2-treated mice (P = 0.03). Tibia stiffness was 3.9% higher in bones from exercised legs than in bones from unexercised legs (72.64 +/- 2.77 vs. 69.95 +/- 2.66 N/mm; P = 0.05) with ultimate load showing a similar trend (P = 0.07); no effect of E2 status was observed on these differences (P > or = 0.53). In conclusion, the functional relationship of bone to muscle and the susceptibility to injury in bone are not altered by the presence of E2 in ovariectomized mice; however, E2 does increase injury susceptibility in the EDL muscle.

Ionic permeability of the opossum sciatic nerve perineurium, examined using electrophysiological and electron microscopic techniques.

A parallel electrophysiological and electron microscopic study was used to assess the ionic permeability of the sciatic nerve perineurium of the opossum Monodelphis domestica. The electrophysiological method was used to monitor permeability to K(+), followed by combined electron microscopy and X-ray probe analysis to monitor permeability to the electron-dense tracer lanthanum. Isolated but intact nerves were mounted in a 'grease gap' chamber for extracellular measurement of DC potential and compound action potential (CAP). Challenge with 100 mM [K(+)] Ringer was used to assess the K(+) permeability of the perineurium, since a change in DC potential (DeltaDC) under these conditions reflected changes in the axonal resting membrane potential. There was no detectable change in DC potential or CAP to the first K(+) challenge (n=71 nerves) indicating negligible K(+) permeability under control conditions. The inflammatory mediators histamine 0.1-40 mg/ml (1. 3-130 mM), bradykinin (0.1-4.7 mM) and 5HT (serotonin) 0.1-5.0 mg/ml (0.5-23.5 mM) caused no measurable DeltaDC on subsequent challenge with 100 mM [K(+)] Ringer, indicating no effect on perineurial K(+) permeability. In nerves exposed to the bile salt sodium deoxycholate (DOC, 6 min, 4 mM), challenge with elevated K(+) Ringer caused a dose-dependent DeltaDC in the range 10-100 mM [K(+)] (1.67+/-0.17 mV in 100 mM [K(+)], n=20), indicating increased perineurial permeability caused by DOC, but the response was smaller than that previously reported for the frog perineurium. Lanthanum was observed in the outer layers of the perineurium, but was not seen to penetrate the endoneurium in any of the nerves examined (n=51), even after DOC application. This study shows that the combined electrophysiological and electron microscopic technique for monitoring ionic permeability can be applied to mammalian nerve, and suggests that the opossum perineurium is more resistant to tight junction opening by chemical modulators than is the frog perineurium.

Effect of ozone on metabolic activities of rat hepatocytes and mouse peritoneal macrophage.

Peritoneal macrophage from mice and isolated hepatocytes from rats were exposed to ozone. Ozone dosages were expressed as 0-5 nmol/10(6) cells. Measurements were made of viability, glucose transport, glutathione, glyceraldehyde-3-phosphate dehydrogenase, Mg-ATPase, Na/K-ATPase, and lipid synthesis. The most sensitive parameter was glyceraldehyde-3-phosphate dehydrogenase in the peritoneal macrophage. In hepatocytes both lipid synthesis and glyceraldehyde-3-phosphate dehydrogenase were sensitive to ozone. Effects on viability, glucose transport, Mg-ATPase, and Na/K-ATPase were small to negligible in both cell types.

Microtubule systems associated with the septate junctions of the gill cells of four gammarid amphipods.

The microtubular systems associated with the septate junctions of the gill epithelial cells of four species of gammarid amphipod are described. The four species examined included two relatively stenohaline marine forms, Chaetogammarus marinus and Gammarus locusta; a highly euryhaline species, Gammarus duebeni, and a stenohaline freshwater species, Gammarus pulex. Of these amphipods, G. locusta and C. marinus maintain only a limited osmotic gradient between their haemolymph and the medium and have a poorly developed junctional microtubular system; G. pulex has haemolymph which is some 300 mOsmol hypertonic to freshwater and has a well ordered system of microtubules on both sides of fairly long septate junctions; G. duebeni from brackish water tend to have a somewhat shorter length of septate junctions lined by one or occasionally by a double row of microtubules. The most complex junctional microtubular systems are shown by specimens of the freshwater race of G. duebeni celticus which have been acclimated to seawater. These can take the form of multiple arrays in which some microtubules are linked to the plasma membrane by dense strands. It is suggested that these findings are consistent with the hypothesis that one role of these microtubules is to provide mechanical stability to enable the integrity of the septate junctions to be maintained during osmotic stress.

Structural changes in the gill cells of Gammarus duebeni (Crustacea, Amphipoda) under osmotic stress; with notes on microtubules in association with the septate junctions.

The amphipod crustacean Gammarus duebeni (Lilljeborg) tolerates salinities in the range freshwater to seawater. Such tolerance requires the ability to respond to the varying degrees of osmotic stress imposed on the single layer of epithelial cells separating the outside medium from the haemolymph space in the gills. Following transfer of individuals from low salinities to seawater, changes occur in the fine structure of the epithelial cells. These changes involve the configuration of the apical border of the cells, the mitochondria and cytoplasmic lacunae. Despite such variation in cell organisation, the association between neighbouring epithelial cells appears unaffected. Attention is drawn to a well developed system of microtubules in association with the septate junctions. The possible mechanical role of these microtubules in protecting the integrity of the septate junctions from the effects of osmotically induced changes in cell volume is discussed.

Pressure sore prevalence in the community.

As increasing numbers of patients are now being nursed in the community it is important that strategies for the prevention of pressures sores are in place. A prevalence survey in one trust helped staff to assess their resource needs and plan care.

The development of the mucosal immune system pre- and post-weaning: balancing regulatory and effector function.

The mucosal immune system fulfils the primary function of defence against potential pathogens that may enter across vulnerable surface epithelia. However, a secondary function of the intestinal immune system is to discriminate between pathogen-associated and 'harmless' antigens, expressing active responses against the former and tolerance to the latter. Control of immune responses appears to be an active process, involving local generation of IgA and of regulatory and/or regulated T lymphocytes. Two important periods of maximum exposure to novel antigens occur in the young animal, immediately after birth and at weaning. In both cases the antigenic composition of the intestinal contents can shift suddenly, as a result of a novel diet and of colonisation by novel strains and species of bacteria. Changes in lifestyles of man, and husbandry of animals, have resulted in weaning becoming much more abrupt than previously in evolution, increasing the number of antigens that must be simultaneously evaluated by neonates. Thus, birth and weaning are likely to represent hazard and critical control points in the development of appropriate responses to pathogens and harmless dietary and commensal antigens. Neonates are born with relatively undeveloped mucosal immune systems. At birth this factor may prevent both expression of active immune responses and development of tolerance. However, colonisation by intestinal flora expands the mucosal immune system in antigen-specific and non-specific ways. At weaning antibody to fed proteins can be detected, indicating active immune responses to fed proteins. It is proposed that under normal conditions the ability of the mucosal immune system to mount active responses to foreign antigens develops simultaneously with the ability to control and regulate such responses. Problems arise when one or other arm of the immune system develops inappropriately, resulting in inappropriate effector responses to harmless food proteins (allergy) or inadequate responses to pathogens (disease susceptibility).

Effectiveness of spinal cord injury rehabilitation.

As in other areas of rehabilitation, relatively small numbers and diversity--both of condition and of patients' goals--hinder the assimilation of robust evidence for the effectiveness of rehabilitation. Patients with spinal cord injury (SCI) tend to be gathered together in a small number of regional services, each with their own philosophy and each with different attitudes to outcome measurement, and thus collection of the existing trials for meta-analysis is problematic. The marked improvement in outcome from SCI that has occurred with the development of specialist rehabilitation programmes argues strongly for the effectiveness of rehabilitation, and we have progressed beyond the point where randomized controlled trials that deny a group such intervention could be considered ethical. Current research is aimed at teasing apart the aspects of different care models that are most effective, or the evidence for the usefulness of interventions for control of symptoms such as spasticity and pain. This evidence is reviewed and discussed.