Outcomes of Children Treated for Lyme Arthritis

Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
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Martian
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Outcomes of Children Treated for Lyme Arthritis

Post by Martian » Sun 4 Apr 2010 18:53

J Rheumatol. 2010 Apr 1. [Epub ahead of print]

Outcomes of Children Treated for Lyme Arthritis: Results of a Large Pediatric Cohort.

Tory HO, Zurakowski D, Sundel RP.

From the Department of Pediatrics, Yale-New Haven Children's Hospital, New Haven, Connecticut; Department of Orthopedic Surgery, Children's Hospital Boston; and Rheumatology Program, Division of Immunology, Children's Hospital Boston, Boston, Massachusetts, USA.

OBJECTIVE: Children often develop arthritis secondary to Lyme disease; however, optimal treatment of Lyme arthritis in pediatric patients remains ill-defined. We sought to characterize the outcomes of a large cohort of children with Lyme arthritis treated using the approach recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America.

METHODS: Medical records of patients with Lyme arthritis seen by rheumatologists at a tertiary care children's hospital from 1997 to 2007 were reviewed. Patients were classified with antibiotic responsive or refractory arthritis based on absence or presence of persisting joint involvement 3 months after antibiotic initiation. Treatment regimens and outcomes in patients with refractory arthritis were analyzed.

RESULTS: Of 99 children with Lyme arthritis, 76 had arthritis that responded fully to antibiotics, while 23 developed refractory arthritis. Most patients with refractory arthritis were successfully treated with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid injections (4), or disease-modifying antirheumatic drugs (DMARD) (2). Five were lost to followup. Six patients with refractory arthritis were initially treated elsewhere and received additional antibiotic therapy, with no apparent benefit. Three subsequently required DMARD, while 3 had gradual resolution of arthritis without further therapy. Antibiotic responsiveness could not be predicted from our clinical or laboratory data.

CONCLUSION: Lyme arthritis in children has an excellent prognosis. More than 75% of referred cases resolved with antibiotic therapy. Of patients with antibiotic refractory arthritis, none in whom followup data were available developed chronic arthritis, joint deformities, or recurrence of infection, supporting current treatment guidelines.

PMID: 20360182 [PubMed - as supplied by publisher]

Fin24
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Re: Outcomes of Children Treated for Lyme Arthritis

Post by Fin24 » Mon 5 Apr 2010 0:58

Not even addressing the fact that they have never examined my own child's records refuting their assertions,I wish to comment that their basing that wide spread generalized conclusion that
More than 75% of referred cases resolved with antibiotic therapy. Of patients with antibiotic refractory arthritis, none in whom followup data were available developed chronic arthritis, joint deformities, or recurrence of infection, supporting current treatment guidelines.

on these facts, has me a bit disconcerted:

"Of 99 children with Lyme arthritis"--making that 75% exaggerated IMO--75% of that TINY cohort sample but of course thats not mentioned here

"We sought to characterize the outcomes of a large cohort of children with Lyme arthritis"
frankly I do NOT call 99 kids a "large" cohort by any stretch of anyone's imagination--heck if I'd have used just 99 chick pituitaries for GH studies in any ONE of my trials Id have been dismissed

"Most patients with refractory arthritis were successfully treated with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid injections (4), or disease-modifying antirheumatic drugs (DMARD) (2)."

MOST??? really??? I count of the 23 refractory, 12 just 12 ( 6+4+2) or a bit under half--as in "less than half" which per MY science training is not = to "most", ever.AND those DMARD drugs are quite risky--Id take 10 abx over one of them any day of the week!!! Funny how its not mentioned that taking those drugs pose their own hazards.Losing those 2 on DMARD leaves 10 of the 23--and thats not "most" either.

"Six patients with refractory arthritis were initially treated elsewhere and received additional antibiotic therapy, with no apparent benefit"--with which abx and how much and for how long??? y'see "we" KNOW that matters--if all they got was 2 more weeks of low dose amoxil then of course there wasnt "apparent benefit"

"Three subsequently required DMARD, while 3 had gradual resolution of arthritis without further therapy"

REQUIRED DMARD??? per whom?? was anything else tried--what and for how long. JUST 3 of the original 23 refractory APPARENTLY has resolution--but for how long?? a week, a month a year?? Ive seen "remissions" or resolution of arthritis only to return after as many as 3 years!! ( this time NOT my kid, but in someone with other disabilities that absolutely precluded another tick bite) so their conclusions that 3 of the 23 ) and of the 6 getting "more abx", required NO further therapy--thats not positive in MY mind. I wouldnt want to take the chance that MY kid would be in that 3. would YOU???

the ONLY intelligent piece in here??
"Antibiotic responsiveness could not be predicted from our clinical or laboratory data."

so abx responsiveness cannot be predicted and yet they feel comfortable DECLARING that this study SUPPORTS current IDSA guidelines????

this insults the intelligence of the reader with what I assume is the hopes that most reading it wont notice these glaring problems and inconsistencies

Wanna bet US insurance companies are adding this to their list of supporting studies, whilst ignoring the inconsistencies??

LymeH
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Re: Outcomes of Children Treated for Lyme Arthritis

Post by LymeH » Mon 5 Apr 2010 1:44

Specifically which DMARD's are they using?

Some Lyme doctors use minocycline under the guise of DMARD's to treat Lyme. They can claim they are treating a rheumatic illness that way, without directly admitting to long-term use of antibiotics for Lyme disease. Other LLMD's use minocycline as a matter of habit. Minocycline is a DMARD.

This is another reason why more detailed information about how these studies are conducted is needed.

migs
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Re: Outcomes of Children Treated for Lyme Arthritis

Post by migs » Mon 5 Apr 2010 2:59

"...based on absence or presence of persisting joint involvement 3 months after antibiotic initiation."

I'd be more interested in when the treatment ended. If treatment was 6 weeks, then 3 months is indicating 6 weeks off antibiotics. Were the antibiotics followed with anything in the following 6 weeks? Exactly how much pain and/or swelling had to be present to be put in the unsuccessful column and how long were these patients symptom free and treatment free?

"Most patients with refractory arthritis were successfully treated with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid injections (4), or disease-modifying antirheumatic drugs (DMARD) (2)."

"Most" were, and successfully treated for how long. Did they do a three month follow up on these patients as well? And how long were these patients OFF ALL TREATMENT and symptom free to be called successful.

Amazing the time spent to propogate incomplete and/or false information.

I will believe thorough studies with transparency. Why can they list all meds and dosages and size of patient, level of illness with symptoms, times spent treating, and details on patient reports of symptoms upon cessation of any medication, one month later, 3 months later, 6 months later.

Is successful better than prior to treatment or symptom free, as prior to illness? I hate all these incomplete, BS Lyme studies.

Fin24
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Joined: Sat 8 Mar 2008 20:14

Re: Outcomes of Children Treated for Lyme Arthritis

Post by Fin24 » Mon 5 Apr 2010 4:16

I was curious about authors since there has been a spate of ghosting--that is using data from the Shapiro/Aurwater/Sigals and having others write the study--seems many "famous" are willing to forego a publication citation to avoid the study being labeled as "IDSA"

despite this new interesting tactic, I looked at the authors:

Dr. David Zurakowski, PhD- statistician- directs statistical work in the Sports Medicine Research Laboratory, including power analysis for experiment planning and design, and multivariate analysis.
Dr. Zurakowski is the Director of Biostatistics in the Department of Orthopedic Surgery at Children's Hospital Boston, where he also supports the Departments of Anesthesiology, Radiology and Cardiac Surgery. Dr. Zurakowski holds an appointment as Assistant Professor of Orthopedic Surgery at Harvard Medical School. He earned his Ph.D. at the University of Chicago with postdoctoral training at Stanford University. His research interests include survival analysis, DNA microarray analysis, proteomics, evaluation of biomarkers and clinical trials.
http://www.childrenshospital.org/cfapps ... vel17.html

Robert Sundel--MD- pediatric rheumatologist at Boston Children's Hospital
5 times co-publsihed with Zurakowski
main areas of research-Kowasaki, dermatomyositis, SLE,peds autoimmune and inflammatory disorders

the ONLY pub or info for HO Tory is
Collaer ML, Tory HO, Valkenburgh MC. Do steroid hormones
contribute to sexual differentiation of the human brain? In:
Legato M, editor. Principles of gender-specific medicine.
San Diego (CA): Elsevier Science; 2003.

Dr Heather Olleia Tory, MD- pediatrics
she is NOT listed at the Yale-New Haven hospital system under Peds as she claims
maybe she is simply a pediatrician that has privileges to admit there

what I get from this is LIMITED if any experience in tick borne illnesses and so where did their data come from?? Im guessing one or a few of the IDSA heavy hitters

So far, all we have is this prelim study report since it was posted "pre publication"

Hystorian
I doubt highly that this study used minocycline as a DMARD, since its most likely theyd have to include that as an 'antibiotic' as well; plus the well known avoidance of any/all abx past 2 weeks in that neck of the woods.

WEBMD, Mayo et al lists these as usually referred to as DMARDs ( all of them pretty scary IMO)
DMARDs include:

Hydroxychloroquine (Plaquenil )
Leflunomide (Arava)
Cyclosporine (Neoral)
Sulfasalzine (Azulfidine)
Gold (Ridaura, Solganal, Myochrysine)
Methotrexate (Rheumatrex, Trexall)
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
Biologics (Cimzia, Enbrel, Humira, Kineret, Orencia, Remicade, Rituxan, Simponi)

MIGS

it DID say they followed std IDSA so that means 14 days tops of abx except for the few (6) who were treated elsewhere with "additional abx"; so its safe to guess that they mean 3 mo after abx started or 2.5 months ( 10 weeks??) from diagnosis??

not that I dont agree with you that this looks like one of them useless studies , quite biased; BUT to be fair this is a pre-publication summary--abstract---and if and when the complete study is actually in print they may (hopefully) have some answers to your very pertinent questions!!

meanwhile even you repeated their conjecture that "most" did fine--yet again I ask you--do you define 12/23 as "most"??? I dont ( and I erred--12/23 is a tiny bit over half actually--apologies but still not = "most", espceially when you remove the non qualifiers. drop the 2 on DMARD leaves just 10/23 and THAT is absolutely not "most")

plus now I wonder how many were on "plaquenil" since its showing some anti babesia ( and antimalarial) benefits--if they did use that and some sx were in fact due to Babs that would also explain the resolution of sx and Im gonna guess that wont be admitted neither

Martian
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Re: Outcomes of Children Treated for Lyme Arthritis

Post by Martian » Mon 5 Apr 2010 18:31

RR posted the full text: http://relative-risk.blogspot.com/2010/ ... ritis.html
Outcomes of Children Treated for Lyme Arthritis: Results of a Large Pediatric Cohort

HEATHER O. TORY, DAVID ZURAKOWSKI, and ROBERT P. SUNDEL

J Rheumatol. 2010 Apr 1.

The outcomes of adult patients treated for Lyme disease with antibiotics are fairly well established. Most cases of Lyme arthritis resolve without sequelae following a single course of doxycycline, amoxicillin, or cefuroxime for 28 days. In approximately 10% of cases, however, arthritis persists despite this treatment, requiring either an additional 28 days of oral antibiotics or intravenous ceftriaxone for 14–28 days, or both6. Of the patients in whom arthritis is persistent, 1%–3% will develop refractory arthritis and continue to have active synovitis despite the additional antibiotic therapy. These patients are often treated with intraarticular steroid injections, surgical synovectomy, or immunomodulating agents, but there remains no well developed treatment protocol to guide the management of this antibiotic-refractory, postinfectious arthritis.

The Kids

Overall, the prognosis of children with Lyme arthritis appears to be good, with most series reporting that 10%–20% of patients recover each year even without specific therapy. Most do not develop chronic or disabling arthritis, regardless of treatment status, although at least one group argued that almost 25% of patients continued to have joint symptoms more than 1 year after treatment. Complicating interpretation of these studies is that patients in these case series were treated with a variety of interventions, including prolonged courses of antibiotics, disease modifying antirheumatic agents (DMARD), and surgical synovectomy. Initial antibiotic treatment in pediatric patients with Lyme arthritis is standardized, but published treatment guidelines for the management of children with persistent Lyme arthritis reflect a broad array of approaches, based on minimal clinical data. Indeed, the optimal treatment strategy and follow up of children with Lyme arthritis remain unclear. Accordingly, we sought to characterize the outcomes of a large cohort of children who were treated for Lyme arthritis using a hierarchical treatment approach.

We characterized treatment regimens and outcomes achieved in our cohort of pediatric patients with Lyme arthritis. The efficacy of antibiotic therapy for treatment of Lyme disease, specifically tetracyclines and ceftriaxone, has been well established. In a comparison study of adults with Lyme arthritis, 90% of patients treated with doxycycline and 89% treated with amoxicillin plus probenecid had complete resolution of arthritis within 3 months. Of the remaining 4 patients, 2 were treated with an additional month of oral antibiotic therapy and had resolution of arthritis within 1 year. Two others received intraarticular steroids followed by a course of intravenous ceftriaxone. One of these patients also underwent arthroscopic synovectomy, but full resolution did not occur for up to 4 years after treatment.

Rheumatology

This study included only patients that were seen and treated by rheumatologists, and the percentage of refractory cases was therefore likely skewed by referral bias. Our patients were similarly less likely to respond fully to antibiotics. Only 71% of children in our series had resolution of arthritis following the initial course of antibiotics, and further antibiotic therapy achieved full resolution in another 6%. A total of 23% of our patients qualified as having antibiotic-refractory Lyme arthritis. This relatively high antibiotic failure rate likely reflects a bias for referral of refractory cases, since nearly two-thirds of the patients with refractory arthritis had already failed one course of antibiotic therapy prior to presentation at our clinic. While some of the study subjects were children who had readily responded to antibiotics and were referred simply for confirmation of the diagnosis, many such cases likely were not referred to our tertiary care sub- specialty clinic. Therefore, we cannot make any conclusions about the overall prevalence of antibiotic-refractory arthritis in this population.

Guidelines

Our study supports adherence to AAP and IDSA guidelines in the treatment of pediatric patients with Lyme arthritis. Of our 23 patients with ongoing synovitis after antibiotic therapy, 11 were treated only with NSAID. Those patients not lost to followup experienced full relief of symptoms, as reported in other reviews. Six patients received intraarticular steroid injections following antibiotic therapy, which appeared to be well tolerated and generally effective. While concern has been raised over administering steroid injections to patients prior to antibiotic therapy, the effectiveness of such treatment in cases of persistent effusions has also been demonstrated. In our study, two-thirds of the patients who received steroid injections experienced rapid and persisting improvement with no additional therapy. It may be reasonable to consider this treatment more consistently in patients with antibiotic-refractory arthritis.

Most importantly, our findings support previous data that prolonged antibiotic courses do not have a role in the treatment of persistent synovitis following infection with B. burgdorferi, as antibiotic-refractory arthritis is not thought to be due to continuing or persistent infection. B. burgdorferi DNA is demonstrable in synovial aspirates prior to antibiotic therapy, but is absent upon repeat testing of patients with persistent arthritis after therapy, indicating eradication of infection. Rather, the etiology of antibiotic refractory arthritis likely involves infection-induced autoimmunityinciting persistent synovial inflammation.

Conclusions

Our results lend support to the management of Lyme arthritis in children in accord with AAP (Red Book) and IDSA guidelines. Our patients were treated with 1 to 2 months of oral antibiotics, with or without an additional month of intravenous therapy. In those patients with persisting arthritis, prolonged antibiotic therapy was not of clear benefit. Instead, our findings support results from others recommending treatment of patients with antibiotic-refractory Lyme arthritis with NSAID, intraarticular steroid injections, or DMARD. These treatments were safe and effective in managing persistent arthritis in our patients. All the children in this study who were treated following this regimen and for whom we have follow up data had excellent outcomes, with no evidence of chronic arthritis, permanent joint changes, or breakthrough cases of persistent infection.

Fin24
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Re: Outcomes of Children Treated for Lyme Arthritis

Post by Fin24 » Mon 5 Apr 2010 18:59

thank you Martian!!!

playing with the stats for a minute to point out possible bias:
In a comparison study of adults with Lyme arthritis, 90% of patients treated with doxycycline and 89% treated with amoxicillin plus probenecid had complete resolution of arthritis within 3 months. Of the remaining 4 patients, 2 were treated with an additional month of oral antibiotic therapy and had resolution of arthritis within 1 year.
if 90% had resolution, "the REMAINING 4 pts" = the 10 percent who did not.
that means the total number was 40 pts--THAT again is NOT a "large cohort" or numbers upon which to base such conclusions IMO
This study included only patients that were seen and treated by rheumatologists
other biases are in fact mentioned---all but this one. again IMO this is important. Did they include Rheumotologists like Dr Fine who is also ILADS???
Therefore, we cannot make any conclusions about the overall prevalence of antibiotic-refractory arthritis in this population.
a conclusions thats valid!!BUT then they add this:
Our study supports adherence to AAP and IDSA guidelines in the treatment of pediatric patients with Lyme arthritis.
ummm HOW can they support guidelines that presume that there arent many cases of refractory symptoms?
IF they cant make conclusions about the rare vs common prevalence then how on earth can they state that the current guidelines are therefore supported???

HOW does one get from here to there??

" we dont really know how many kids have sx, let alone treatable sx, after the initial or even second round of abx tx, but we are still going to say that not treating them further is the right way to go"

based upon WHAT??
Of our 23 patients with ongoing synovitis after antibiotic therapy
oh I see--JUST 23 pts hand selected by them!!! and again thats not the "large" cohort as reported

Now, here is a disturbing bit of poop:
Most importantly, our findings support previous data that prolonged antibiotic courses do not have a role in the treatment of persistent synovitis following infection with B. burgdorferi, as antibiotic-refractory arthritis is not thought to be due to continuing or persistent infection
first using 23 pts do not support or refute anything IMO.
secondly,they didnt really examine long term abx
thridly, the "as antibiotic-refractory arthritis is not thought to be due to continuing or persistent infection" is pretty inflammatory IMO -'NOT THOUGHT' vs studies showing persistence of infection?? and THATS the reason they give for the conclusion that more abx dont have a role??? that some THINK there isnt persistence despite contrary proof??

whats unknown is whether those remaining spirochetes can cause the sx, and/or whether continued tx can eradicate them. There are enough studies now out there showing PERSISTENCE of "infection" or presence of organisms post abx, and IN synovial fluids for Pete's sake, so for this statement to not have been questioned by the journal's editors and yet--it was published anyway is a bit wonky IMO

I have to ask WHY if not politically biased.

Then their conclusions give a mess of what they examined and compared:
Our patients were treated with 1 to 2 months of oral antibiotics, with or without an additional month of intravenous therapy.
1-2 months, with OR WITHOUT additional month of IV abx---which got what?? and which had faster or more complete resolution?? and why wasnt the data more critically examined??
In those patients with persisting arthritis, prolonged antibiotic therapy was not of clear benefit
again Id have to ask--which additional abx and for how long using what dose

and how was that presumed--the lack of benefit?? perhaps it was not long enough, the wrong abx, the wrong dose?? as a scientist it bothers me to see such generalizations based upon such a lack of solid data.
All the children in this study who were treated following this regimen and for whom we have follow up data had excellent outcomes, with no evidence of chronic arthritis, permanent joint changes, or breakthrough cases of persistent infection.
I dont doubt this at all--since there were ONLY 23 HAND PICKED cases.
IMO this study is as bad as the ILADS' biased ones and should be classified as USELESS. if IDSA wont or cant address its deficiencies and use it de facto, to support their guidelines for tx,then perhaps the many clamoring for better accountability among IDSA have a point.

Fin24
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Joined: Sat 8 Mar 2008 20:14

Re: Outcomes of Children Treated for Lyme Arthritis

Post by Fin24 » Mon 5 Apr 2010 19:06

Martian
does anyone have their "methods" and "data"??? is this simply their word in a summarized "report"?
IOW how they gathered these 23 and from whom--limited Drs vs randomly. and what exactly were the kids treated with. perhaps THEIR opinions wouldnt be shared by others looking at same data.

After all when a team states "large cohort" after using a mere 23 ( and also hides the fact that they compared with 40 adults total) Im a bit concerned about their reliability for the rest of it.

thnx
F

Martian
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Joined: Thu 26 Jul 2007 18:29
Location: Friesland, the Netherlands

Re: Outcomes of Children Treated for Lyme Arthritis

Post by Martian » Mon 5 Apr 2010 20:22

Fin24 wrote:Martian
does anyone have their "methods" and "data"??? is this simply their word in a summarized "report"?
I don't know for sure if it's the complete full text. Maybe RR omitted pieces, but I don't see [snip]s.

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