Screening for juvenile idiopathic arthritis associated uveitis with laser flare photometry in the pediatric rheumatology office: a prospective observational study.

BACKGROUND: Juvenile Idiopathic Arthritis (JIA) Associated Uveitis (JIA-U) remains one of the most serious complications of JIA in children. Historically, pediatric JIA is diagnosed by an Optometrist or Ophthalmologist; however, barriers to scheduling increase wait times that may delay diagnosis and treatment. The purpose of this study was to evaluate laser flare photometry (LFP) use to diagnose JIA-U in the Pediatric Rheumatology clinic for patients with JIA. METHODS: This prospective, observational study assessed pediatric patients diagnosed with JIA without a previous history of uveitis between January 2020 and September 2022. All patients underwent at least one evaluation of both eyes using a Kowa FM-600 laser flare photometer during a routine Rheumatology appointment, as well as a standard slit lamp examination (SLE) by optometry or ophthalmology during routine clinical care. Data collected at patient visits included demographics, JIA characteristics, treatment, LFP readings, and anterior chamber (AC) cell grade score utilizing the SUN grading system. Data were summarized using descriptive analyses and the uveitis false positive rate was calculated. RESULTS: The study cohort included 58 pediatric patients diagnosed with JIA. The mean age was 8.4 years (1.2-16.3 years) at diagnosis and 11.9 (4.8-16.5 years) at enrollment. The mean duration of disease at time of enrollment was 42 months (range; 0-157 months). Participants were predominantly female (n = 43, 74.1%) and white/Caucasian race (n = 37, 63.8%). The most common JIA subtypes included persistent oligoarticular JIA (n = 19, 32.8%), and RF negative polyarticular JIA (n = 12, 20.7%). There were 12 ANA positive patients (20.7%). At enrollment, 16 patients (27.6%) were not on medications, with 20 (34.5%) on methotrexate, 20 (34.5%) on adalimumab, 6 (10.3%) on tocilizumab, and 5 (8.6%) on etanercept. During the study period, no eye exams detected active uveitis based on SLE with a SUN grade over 0. However, of the 135 LFP readings, 131 (97.0%) were normal, yielding a false positive rate of 3% (95% CI: 0.8%, 7.4%). CONCLUSIONS: LFP is a non-invasive tool that can be utilized in the pediatric rheumatology clinic to evaluate for JIA-U. There is a low false positive rate of LFP when compared with standard slit lamp exam.

Community Pharmacy Personnel Understanding of Antibiotic Dispensing in Eastern Nepal.

BACKGROUND: Community pharmacies are easily accessible outlets providing medicines to the general public in Nepal, but it is known that irrational dispensing of antibiotics from such outlets contributes to antimicrobial resistance. OBJECTIVE: To assess the understanding of community pharmacy personnel around antibiotic-dispensing in Eastern Nepal and the relationship between this understanding and their personal characteristics. METHODS: A cross-sectional survey was conducted on 312 pharmacy personnel working in community pharmacies of three districts within Eastern Nepal using a self-administered questionnaire. Descriptive statistics were used to analyze participants' characteristics and their understanding of antibiotic dispensing. The relationships between their understanding of antibiotic dispensing and their characteristics were determined using Chi-square tests. RESULTS: Most of the pharmacy personnel considered that dispensing antibiotics without a valid prescription is a problem (76.9%), and that it would not be legal to do so (86.9%). In the survey, 34.9% of participants agreed that they had dispensed antibiotics without prescription, and 26.9% disagreed with the assertion that inappropriate dispensing of antibiotics could promote antimicrobial resistance. Most (94.5%) reported that they would advise patients to follow their antibiotic dosage regimen, but 34.3% reported that they believed antibiotics to reduce pain and inflammation. Bivariate analysis showed that the level of understanding about antibiotic indication was significantly associated with age (p<0.001), work experience (p<0.001) and qualifications (p=0.017) of the pharmacy personnel. Work experience and qualifications also had significant but independent relationships with the level of understanding that irrational dispensing of antibiotics promotes antimicrobial resistance (p=0.018 and p=0.004) and is on the need for patient follow-up after dispensing antibiotics (p<0.001 and p=0.042). CONCLUSION: The understanding of community pharmacy personnel about antibiotic dispensing in Eastern Nepal requires significant improvement. Degree of understanding of some aspects of antibiotic dispensing was influenced by age, work experience and qualifications.

Unraveling the role of the transcriptional regulator VirS in low pH-induced responses of Mycobacterium tuberculosis and identification of VirS inhibitors.

The ability of Mycobacterium tuberculosis to respond and adapt to various stresses such as oxygen/nitrogen radicals and low pH inside macrophages is critical for the persistence of this human pathogen inside its host. We have previously shown that an AraC/XylS-type transcriptional regulator, VirS, which is induced in low pH, is involved in remodeling the architecture of the bacterial cell envelope. However, how VirS influences gene expression to coordinate these pH responses remains unclear. Here, using a genetic biosensor of cytoplasmic pH, we demonstrate that VirS is required for the intracellular pH maintenance in response to acidic stress and inside acidified macrophages. Furthermore, we observed that VirS plays an important role in blocking phagosomal-lysosomal fusions. Transcriptomics experiments revealed that VirS affects the expression of genes encoding metabolic enzymes, cell-wall envelope proteins, efflux pumps, ion transporters, detoxification enzymes, and transcriptional regulators expressed under low-pH stress. Employing electrophoretic mobility-shift assays, DNA footprinting, and in silico analysis, we identified a DNA sequence to which VirS binds and key residues in VirS required for its interaction with DNA. A significant role of VirS in M. tuberculosis survival in adverse conditions suggested it as a potential anti-mycobacterial drug target. To that end, we identified VirS inhibitors in a virtual screen; the top hit compounds inhibited its DNA-binding activity and also M. tuberculosis growth in vitro and inside macrophages. Our findings establish that VirS mediates M. tuberculosis responses to acidic stress and identify VirS-inhibiting compounds that may form the basis for developing more effective anti-mycobacterial agents.

Recurrent Kawasaki Disease: A Case Report of Three Separate Episodes at >4-Year Intervals.

Kawasaki disease (KD) is a self-limited systemic vasculitis, most often occurring in children 1⁻5 years old. It has a 2% recurrence rate and is associated with coronary aneurysms (CA), which can develop within two weeks of onset. A 25% increased risk is noted in patients who are recalcitrant to treatment. We describe a patient with recurrence of KD three times, approximately four years apart. A 10-year-old female with two previous episodes of KD, at 11 months and five years of age), in which she met five out of five criteria for KD and had no coronary involvement, presented with 15 days of fever, conjunctivitis and mucocutaneous changes. Infectious work-up was negative, and she was diagnosed with incomplete KD meeting three out of five criteria. An echocardiogram (ECHO) on day 12 revealed dilation of the right coronary artery (RCA) and left coronary artery (LCA). Treatment with intravenous immunoglobulin (IVIG) and high-dose aspirin was started at an outside hospital. After transfer, serial ECHOs showed evolving coronary aneurysms, left anterior descending (LAD) z-score + 8.2 and RCA z-score + 4.0. She received 10 mg/kg infliximab (day 18) and began clopidogrel. A cardiac MRI (day 20) demonstrated progression of the LAD aneurysm, with a z-score + 13, and warfarin was started. To our knowledge, this is the first report of recurrent KD occurring three times at ~5 year intervals.