Majority of new patient referrals to a large pediatric rheumatology center result in non-rheumatic diagnosis.

OBJECTIVE: Pediatric rheumatology faces a looming supply-demand crisis. While strategies have been proposed to address the supply shortfall, investigation into the increased demand for pediatric rheumatic care has been limited. Herein, we analyze new patient visits to a large tertiary care pediatric rheumatology center to identify emerging trends in referrals and areas for potential intervention to meet this increased demand. METHODS: All patients referred to and seen by the University of Alabama at Birmingham Pediatric Rheumatology Division between January 2019 and December 2021 for a new patient evaluation were identified. Patient data was retrospectively abstracted, de-identified, and analyzed to develop trends in referrals and frequency of rheumatic disease, non-rheumatic disease, and specific diagnoses. RESULTS: During the study period, 2638 patients were referred to and seen in by the pediatric rheumatology division. Six hundred and ten patients (23.1%) were diagnosed with rheumatic disease. The most common rheumatic disease was juvenile idiopathic arthritis (JIA) at 45.6%, followed by primary Raynaud phenomenon (7.4%), recurrent fever syndromes (6.9%), vasculitides (6.7%), and inflammatory eye disease (6.2%). Of the 2028 patients (76.9%) diagnosed with a non-rheumatic condition, benign musculoskeletal pain was the most common (61.8%), followed by a combination of somatic conditions (11.6%), and non-inflammatory rash (7.7%). CONCLUSION: In this analysis of new patient referrals to a large pediatric rheumatology center, the majority of patients were diagnosed with a non-rheumatic condition. As a worsening supply-demand gap threatens the field of pediatric rheumatology, increased emphasis should be placed on reducing non-rheumatic disease referrals.

Viewing both sides of the coin for infectious disease diagnosis.

Optimal management of lower respiratory tract infection relies on distinguishing infectious from noninfectious etiologies and identifying the microbiologic cause if applicable. This process is complicated by overlapping clinical symptoms and the colonizing lung microbiota. In a recent issue of the JCI, Mick, Tsitsiklis, and colleagues apply RNA-Seq to tracheal aspirates from critically ill children and demonstrate how integration of the host response with microbial identification results in a harmonious and accurate diagnostic classifier. Though promising, there are numerous barriers to realizing a combined host and pathogen diagnostic.

Modified 30-Second Sit-to-Stand Test: Reliability and Validity in Older Adults Unable to Complete Traditional Sit-to-Stand Testing.

BACKGROUND AND PURPOSE: Sit-to-stand tests measure a clinically relevant function and are widely used in older adult populations. The modified 30-second sit-to-stand test (m30STS) overcomes the floor effect of other sit-to-stand tests observed in physically challenged older adults. The purpose of this study was to examine interrater and test-retest intrarater reliability for the m30STS for older adults. In addition, convergent validity of the m30STS, as well as responsiveness to change, was examined in older adults undergoing rehabilitation. METHODS: In phase I, 7 older adult participants were filmed performing the m30STS. The m30STS was standardized to allow hand support during the rise to and descent from standing but required participants to let go of the armrests with each stand. Ten physical therapists and physical therapist assistants independently scored the filmed m30STS twice, with 21 days separating the scoring sessions. In phase II, 33 older adults with comorbidities admitted to physical therapy services at a skilled nursing facility were administered the m30STS, Berg Balance Scale, handheld dynamometry of knee extensors, and the modified Barthel Index at initial examination and discharge. RESULTS: In phase I, the m30STS was found to be reliable. Interrater reliability using absolute agreement was calculated as intraclass correlation coefficient (ICC)2,1 = 0.737 (P ≤ .001). Test-retest intrarater reliability using absolute agreement was calculated as ICC2,k = 0.987 (P ≤ .001). In phase II, concurrent validity was established for the m30STS for the initial (Spearman ρ = 0.737, P = .01) and discharge (Spearman ρ = 0.727, P = .01) Berg Balance Scale as well as total scores of the modified Barthel Index (initial total score Spearman ρ = 0.711, P = .01; discharge total score Spearman ρ = 0.824, P = .01). The initial m30STS predicted 31.5% of the variability in the discharge Berg Balance Scale. The m30STS did not demonstrate significant correlation with body weight-adjusted strength measures of knee extensors measured by handheld dynamometry. The minimal detectable change (MDC90) was calculated to be 0.70, meaning that an increase of 1 additional repetition in the m30STS is a change beyond error. CONCLUSION: The m30STS is a reliable, feasible tool for use in a general geriatric population with a lower level of function. The m30STS demonstrated concurrent validity with the Berg Balance Scale and modified Barthel Index but not with knee extensor strength to body weight ratio. One repetition of the m30STS was established as the MDC90 as change beyond error.

Needle-free jet injection for administration of influenza vaccine: a randomised non-inferiority trial.

BACKGROUND: Administration of vaccines by needle-free technology such as jet injection might offer an alternative to needles and syringes that avoids the issue of needle phobia and the risk of needle-stick injury. We aimed to assess the immunogenicity and safety of trivalent influenza vaccine given by needle-free jet injector compared with needle and syringe. METHODS: For this randomised, comparator-controlled trial, we randomly assigned (1:1) healthy adults (aged 18-64 years) who attended one of four employee health clinics in the University of Colorado health system, with stratification by site, to receive one dose of the trivalent inactivated influenza vaccine Afluria given either intramuscularly with a needle-free jet injector (Stratis; PharmaJet, Golden, CO, USA) or with needle and syringe. Randomisation was done with a computer-generated randomisation schedule with a block size of 100. Because of the nature of the study, masking of participants was not possible. Immunogenicity was assessed by measurement of the hemagglutination inhibition antibody titres in serum for the three viral strains included in the vaccine. We included six coprimary endpoints: three strain-specific geometric mean titre ratios and the absolute differences in three strain-specific seroconversion rates. The immune response of the jet injector group was regarded as non-inferior to that of the needle and syringe group if both the upper bound of each of the three 95% CIs for the strain-specific geometric mean titre ratios was 1.5 or less, and the upper bound of the three 95% CIs for the strain-specific seroconversion rate differences was less than 10 percentage points. We used t test for group comparison. This study is registered with ClinicalTrials.gov, number NCT01688921. FINDINGS: During the 2012-13 influenza season of the northern hemisphere, we allocated 1250 participants to receive vaccination by needle-free jet injector (n=627) or needle and syringe (n=623). In the intention-to-treat immunogenicity population, all participants with two serum samples were included (575 in the jet injector group and 574 in the needle and syringe group). The immune response to Afluria when given by needle-free jet injector met the criteria for non-inferiority for all six coprimary endpoints. The jet injector group met the geometric mean titre criterion for non-inferiority for the A/H1N1, A/H3N2, and B strains (upper bound of the 95% CI for the geometric mean titre ratios were 1·10 for A/H1N1, 1·17 for A/H3N2, and 1·04 for B strains). The jet injector group met the seroconversion rate criterion for non-inferiority for the A/H1N1, A/H3N2, and B strains (upper bound of the 95% CI of the seroconversion rate differences were 6·0% for A/H1N1, 7·0% for A/H3N2, and 5·7% for B strains). We recorded serious adverse events in three participants, none of which were study related. INTERPRETATION: The immune response to influenza vaccine given with the jet injector device was non-inferior to the immune response to influenza vaccine given with needle and syringe. The device had a clinically acceptable safety profile, but was associated with a higher frequency of local injection site reactions than was the use of needle and syringe. The Stratis needle-free jet injector device could be used as an alternative method of administration of Afluria trivalent influenza vaccine. FUNDING: Biomedical Advanced Research and Development Authority (BARDA), PATH, bioCSL, and PharmaJet.

Halogen- and hydrogen-bonded salts and co-crystals formed from 4-halo-2,3,5,6-tetrafluorophenol and cyclic secondary and tertiary amines: orthogonal and non-orthogonal halogen and hydrogen bonding, and synthetic analogues of halogen-bonded biological systems.

Co-crystallisation of, in particular, 4-iodotetrafluorophenol with a series of secondary and tertiary cyclic amines results in deprotonation of the phenol and formation of the corresponding ammonium phenate. Careful examination of the X-ray single-crystal structures shows that the phenate anion develops a C=O double bond and that the C-C bond lengths in the ring suggest a Meissenheimer-like delocalisation. This delocalisation is supported by the geometry of the phenate anion optimised at the MP2(Full) level of theory within the aug-cc-pVDZ basis (aug-cc-pVDZ-PP on I) and by natural bond orbital (NBO) analyses. With sp(2) hybridisation at the phenate oxygen atom, there is strong preference for the formation of two non-covalent interactions with the oxygen sp(2) lone pairs and, in the case of secondary amines, this occurs through hydrogen bonding to the ammonium hydrogen atoms. However, where tertiary amines are concerned, there are insufficient hydrogen atoms available and so an electrophilic iodine atom from a neighbouring 4-iodotetrafluorophenate group forms an I⋅⋅⋅O halogen bond to give the second interaction. However, in some co-crystals with secondary amines, it is also found that in addition to the two hydrogen bonds forming with the phenate oxygen sp(2) lone pairs, there is an additional intermolecular I⋅⋅⋅O halogen bond in which the electrophilic iodine atom interacts with the C=O π-system. All attempts to reproduce this behaviour with 4-bromotetrafluorophenol were unsuccessful. These structural motifs are significant as they reproduce extremely well, in low-molar-mass synthetic systems, motifs found by Ho and co-workers when examining halogen-bonding interactions in biological systems. The analogy is cemented through the structures of co-crystals of 1,4-diiodotetrafluorobenzene with acetamide and with N-methylbenzamide, which, as designed models, demonstrate the orthogonality of hydrogen and halogen bonding proposed in Ho's biological study.

Electrophilic bromination of substituted stilbenes and stilbazoles: a quantum-chemical investigation.

In order to study the effect of substituents on the electrophilic bromination of stilbenes and stilbazoles, the geometries of the reaction intermediates were optimised at the MP2/6-31G(d,p) and M06-2X/6-31G(d,p) levels of theory. Stilbenes with two electron-withdrawing substituents are shown to favour bromonium ion intermediates, whereas the presence of an electron-donating substituent leads to a carbocation intermediate. These observations are rationalised by means of Hammett and Taft parameters. Localised molecular orbitals indicate that the bonding between the bromine atom and the carbon atoms in the stilbene varies from a σ-bond in a carbocation intermediate to a 3-centre-2-electron bond in a bromonium ion intermediate. Natural bond orbital (NBO) analyses reveal that carbocation intermediates are stabilised by resonance. The optimised geometries of charge-transfer complexes, the pre-reactive intermediates formed between molecular bromine and the stilbene, show that these species can be considered as halogen-bonded complexes with binding energies ranging from 14.5 to 20.1 kJ mol(-1).

Halogen-bonded liquid crystals of 4-alkoxystilbazoles with molecular iodine: a very short halogen bond and unusual mesophase stability.

Complexes of molecular iodine with alkoxystilbazoles are liquid crystals with unusually high mesophase stability, predicated on an intermolecular I···I contact. Attempts to prepare analogous complexes with bromine led to an unexpected electrophilic substitution product.

Quantum chemical investigation of attractive non-covalent interactions between halomethanes and rare gases.

The interaction between rare gas atoms and trifluoromethylhalides and iodomethane is investigated using ab initio and density functional theory (DFT) methods: MP2, CCSD, B3LYP, M06, M06-L, M06-2X, M06-HF, X3LYP, PBE, B97-D, B3LYP-D3, and M06-L-D3, in combination with the aug-cc-pVTZ and aug-cc-pVTZ-PP basis sets. A weakly attractive interaction is observed for all complexes, whose strength increases as the rare gas and halogen bond donor become more polarizable, and as the group bound to the halogen bond donor becomes more electron-withdrawing. The separation between iodine and krypton in the complex CF(3)I···Kr, calculated at the MP2 and B3LYP-D3 levels of theory, agrees very well with recent experimental results (Stephens, S. L.; Walker, N. R.; Legon, A. C. J. Chem. Phys. 2011, 135, 224309). Analysis of the ability of theoretical methods to account for the dispersion interaction present in these complexes leads to the conclusion that MP2 and B3LYP-D3, which produce very similar results, are the better performing methods, followed by B97-D and the M06 suite of functionals; the popular B3LYP as well as X3LYP perform poorly and significantly underestimate the interaction strength. The orbitals responsible for the interaction are identified through Edmiston-Ruedenberg localization; it is shown that, by combining the key orbitals, it is possible to observe a molecular orbital picture of a σ-hole interaction.

Halogen bonding interaction between fluorohalides and isocyanides.

The optimized geometries and corresponding binding energies of complexes between fluorohalides, FX (X = Cl, Br, and I), and isocyanides, CNY (Y = CN, NC, NO(2), F, CF(3), Cl, Br, H, CCF, CCH, CH(3), SiH(3), Li, and Na), were calculated at the MP2(Full)/aug-cc-pVTZ (aug-cc-pVTZ-PP on I) level of theory, without and with basis set superposition error (BSSE) corrections through the counterpoise (CP) method. The optimized complex geometries were analyzed through the Steiner-Limbach relationship, which can be used to establish correlations between the F-X and X-C bond lengths. For all complexes, the correlations were shown to improve considerably when using optimized geometries including BSSE corrections. It was shown that further improvements can be achieved through the introduction of an extended four-parameter form of the Steiner-Limbach relationship which accounts for all differences between the valences associated with the two bonds involving the halogen in an A-X···B complex. The results indicate that chlorine as a halogen bond donor is affected by the basicity of the isocyanides and forms different types of halogen bonds as the F-Cl bond lengthens in parallel with the shortening of the distance between Cl and the isocyanide carbon. This is not observed for iodine and bromine as halogen-bond donors, which is illustrated by the low levels of correlation obtained when applying the standard and extended Steiner-Limbach relationships to the corresponding complexes.

Association of elevated E6 oncoprotein with grade of cervical neoplasia using PDZ interaction-mediated precipitation of E6.

OBJECTIVE: To determine the expression of human papillomavirus (HPV) type 16 E6 oncoprotein in cervical specimens of women with and without cervical intraepithelial neoplasia (CIN). MATERIALS AND METHODS: Cervical specimens from 2,530 unscreened women aged 30 to 54 years from Shanxi, China, were obtained. All women were assessed by liquid-based cytology, high-risk HPV DNA tests, and colposcopy with directed biopsy and endocervical curettage as necessary. Women with abnormal cytologic results or positive HPV DNA results were recalled for colposcopy, 4-quadrant cervical biopsies, and endocervical curettage. Women with biopsy-proven CIN and cancer and a convenience sample of HC2-positive, disease-negative women were tested for the presence of HPV-16 infection via HPV-16 E6 DNA-specific polymerase chain reaction. A PDZ interaction-mediated E6 oncoprotein precipitation method followed by E6-specific Western blot was performed on specimens from women with HPV-16 infections. Associations between elevated expression of E6 oncoprotein and CIN 2 and 3 were determined using logistic regression and a reference category of CIN 1 and disease-negative. RESULTS: A significant trend for the detection of HPV-16 E6 oncoprotein in specimen of women with proven HPV-16 infection was determined: 0% (0/12), 12.5% (1/8), 36.4% (4/11), and 42.9% (3/7) of those with negative findings, CIN 1, 2, and 3, respectively (p = .01). Compared with the category combining negative findings and CIN 1, detection of E6 oncoprotein was associated with CIN 2 (odds ratio = 10.9, p = .05) and CIN 3 (odds ratio = 14.3, p = .04). CONCLUSIONS: There is a significant association between elevated expression of E6 oncoprotein and grade of CIN. This finding seems consistent with the role played by E6 oncoprotein in carcinogenesis.

A large-scale genetic association study confirms IL12B and leads to the identification of IL23R as psoriasis-risk genes.

We performed a multitiered, case-control association study of psoriasis in three independent sample sets of white North American individuals (1,446 cases and 1,432 controls) with 25,215 genecentric single-nucleotide polymorphisms (SNPs) and found a highly significant association with an IL12B 3'-untranslated-region SNP (rs3212227), confirming the results of a small Japanese study. This SNP was significant in all three sample sets (odds ratio [OR](common) 0.64, combined P [Pcomb]=7.85x10(-10)). A Monte Carlo simulation to address multiple testing suggests that this association is not a type I error. The coding regions of IL12B were resequenced in 96 individuals with psoriasis, and 30 additional IL12B-region SNPs were genotyped. Haplotypes were estimated, and genotype-conditioned analyses identified a second risk allele (rs6887695) located approximately 60 kb upstream of the IL12B coding region that exhibited association with psoriasis after adjustment for rs3212227. Together, these two SNPs mark a common IL12B risk haplotype (OR(common) 1.40, Pcomb=8.11x10(-9)) and a less frequent protective haplotype (OR(common) 0.58, Pcomb=5.65x10(-12)), which were statistically significant in all three studies. Since IL12B encodes the common IL-12p40 subunit of IL-12 and IL-23, we individually genotyped 17 SNPs in the genes encoding the other chains of these cytokines (IL12A and IL23A) and their receptors (IL12RB1, IL12RB2, and IL23R). Haplotype analyses identified two IL23R missense SNPs that together mark a common psoriasis-associated haplotype in all three studies (OR(common) 1.44, Pcomb=3.13x10(-6)). Individuals homozygous for both the IL12B and the IL23R predisposing haplotypes have an increased risk of disease (OR(common) 1.66, Pcomb=1.33x10(-8)). These data, and the previous observation that administration of an antibody specific for the IL-12p40 subunit to patients with psoriasis is highly efficacious, suggest that these genes play a fundamental role in psoriasis pathogenesis.

Identification of two gene variants associated with risk of advanced fibrosis in patients with chronic hepatitis C.

BACKGROUND & AIMS: Previously identified clinical risk factors such as sex, alcohol consumption, and age at infection do not accurately predict which patients with chronic hepatitis C (CHC) will develop advanced fibrosis (bridging fibrosis and cirrhosis). The aim of this study was to identify genetic polymorphisms that can predict the risk of advanced fibrosis in patients with CHC. METHODS: A total of 916 subjects with CHC was enrolled from 2 centers. A gene-centric disease association study of 24,832 putative functional, single nucleotide polymorphisms (SNPs) was performed. Of the 1609 SNPs that were significantly associated (P

A missense single-nucleotide polymorphism in a gene encoding a protein tyrosine phosphatase (PTPN22) is associated with rheumatoid arthritis.

Rheumatoid arthritis (RA) is the most common systemic autoimmune disease, affecting approximately 1% of the adult population worldwide, with an estimated heritability of 60%. To identify genes involved in RA susceptibility, we investigated the association between putative functional single-nucleotide polymorphisms (SNPs) and RA among white individuals by use of a case-control study design; a second sample was tested for replication. Here we report the association of RA susceptibility with the minor allele of a missense SNP in PTPN22 (discovery-study allelic P=6.6 x 10(-4); replication-study allelic P=5.6 x 10(-8)), which encodes a hematopoietic-specific protein tyrosine phosphatase also known as "Lyp." We show that the risk allele, which is present in approximately 17% of white individuals from the general population and in approximately 28% of white individuals with RA, disrupts the P1 proline-rich motif that is important for interaction with Csk, potentially altering these proteins' normal function as negative regulators of T-cell activation. The minor allele of this SNP recently was implicated in type 1 diabetes, suggesting that the variant phosphatase may increase overall reactivity of the immune system and may heighten an individual carrier's risk for autoimmune disease.