Two Ro (SS-A) autoantibody responses in systemic lupus erythematosus. Correlation of HLA-DR/DQ specificities with quantitative expression of Ro (SS-A) autoantibody

Autoantibodies to Ro (SS-A), La (SS-B), and Sm/nuclear RNP were quantitated by enzyme-linked immunosorbent assay in 106 white patients with systemic lupus erythematosus. Two Ro autoantibody subgroups were identified that differed quantitatively, genetically, and clinically. The subgroup having anti-Ro only demonstrated significantly lower mean anti-Ro levels than did the subgroup with concomitant anti-La and showed a strong association with the linked HLA alleles DR2 and DQw1. The anti-Ro with anti-La subgroup was associated with the linked HLA alleles B8, DR3, DRw52, and DQw2 (DR3 was primary), and this subgroup consisted of patients with older ages at disease onset, sicca complex, and less renal involvement. Overall, the relative risk (RR) for having anti-Ro was highest in HLA-DR2/DR3 heterozygotes compared with non-DR2/DR3 heterozygotes (RR 15) and all other DR combinations (RR 7), suggesting a compound effect of 2 immune responses. Heterozygotes for HLA-DQw1/DQw2 demonstrated significantly higher mean levels of anti-Ro, which may be indicative of trans gene interaction at HLA-DQ. These data suggest the hypothesis that HLA genes exert their major effects on Ro/La autoantibody subsets of systemic lupus erythematosus.

In vitro suppression of anti-DNA antibody and immunoglobulin synthesis in systemic lupus erythematosus patients by human gamma interferon

The immunoregulator human gamma interferon (IFN-gamma) suppressed the spontaneous in vitro synthesis and secretion of anti-DNA antibodies by peripheral blood mononuclear cells of patients with systemic lupus erythematosus (SLE-PBMC). Comparable level of suppression were observed with both natural human IFN-gamma and recombinant derived human IFN-gamma. In addition, the inhibitory effects of human IFN-gamma were completely neutralized by a monoclonal antibody directed against it. Human IFN-gamma also inhibited the antigen induced production of anti-DNA synthesis by SLE-PBMC. Based on the kinetics of inhibition, human IFN-gamma appeared to be acting directly on the B cell. Lastly, human IFN-gamma also suppressed the spontaneous production of IgG and IgM by SLE-PBMC. Our findings support the conclusion that SLE Ig production can be regulated and that human IFN-gamma may be clinically useful in the treatment of SLE as well as other immune complex diseases.

Mortality from systemic lupus erythematosus in England and Wales, 1974-1983

Mortality rates from systemic lupus erythematosus (SLE) in England and Wales were estimated from Office of Population Censuses and Surveys data from 1974 to 1983, by age and sex. Age-specific average annual mortality rates showed unimodal distributions for both sexes with maximal death rates in the 65-74-year age groups. The overall age-adjusted mortality rate for females was about four times that in males, 3.94 versus 1.02 per million person-years, respectively. Examination of individual age-specific rates showed an early sharp rise in females producing female-to-male ratios which exceeded 10 in the 25-34-year age group. Age-adjusted annual mortality rates in females significantly declined during the 10-year interval studied from 4.47 to 2.99 per million person-years (p = 0.0083). These patterns of mortality from SLE observed in England and Wales are comparable to those reported among Caucasians in the United States during a similar time period.

Prevalence of systemic lupus erythematosus in England and Wales, 1981-2

The prevalence of systemic lupus erythematosus (SLE) was estimated from a secondary analysis of data collected during the Third National Study of Morbidity Statistics from General Practice, 1981-2. A total of 20 cases, all female, were seen by general practitioners during the study period. The period prevalence of SLE was 12.5/100,000 among women of all ages and 17.7/100,000 among women aged 15 to 64. These rates are lower than those reported from other developed Western countries; this is probably due to misclassification in diagnosis or prior referral of cases to consultants for chronic care, or both.

Systemic sclerosis (scleroderma): clinical, genetic, and serologic subsets

Immunogenetic markers, autoantibodies, and clinical features were studied in 47 patients, 35 Caucasian and 12 black, with systemic sclerosis. Twenty-two had generalized scleroderma, while 25 had limited skin involvement. HLA-DR1 (RR = 2.1, p = 0.08) and DR5 (RR = 2.1, p = 0.08) were increased in Caucasian patients vs controls as was the supertypic specificity HLA-DRw52 (RR = 2.8, p = 0.02, pc = 0.04). HLA-DR6.1 was increased in black patients vs controls (RR = 15.4, p = 0.008, pc = 0.088). There were no significant increases in any of the complement allotypes in either racial group. Anticentromere antibody was noted in 10 patients, all Caucasian; 7 had limited disease. Anti-Scl-70 was noted in 4 patients; all had generalized disease (p = 0.036). HLA-DR2 was present in all anti-Scl-70 positive patients (RR = 22.5, p = 0.006). Our results suggest that clinical subsets of systemic sclerosis can be defined by genetic and serological markers.

Development of clinical criteria for osteoarthritis

Clinical criteria for the classification of osteoarthritis (OA) in the knee have been developed and the use of algorithms has been proposed. Criteria for the classification of OA in the hand and hip are still being developed.

HLA-DR4 and pulmonary dysfunction in rheumatoid arthritis

Rheumatoid arthritis is associated with an increased frequency of the B cell alloantigen HLA-DR4, and preliminary work has suggested an association between HLA-DR4 and obstructive lung disease in subjects with rheumatoid arthritis. To prospectively evaluate the influence of HLA-DR4 on pulmonary involvement in patients with rheumatoid arthritis, pulmonary function was measured in four groups of subjects with rheumatoid arthritis in whom HLA-DR4 and smoking status was known: 16 DR4-positive smokers (six current and 10 exsmokers), 16 DR4-negative smokers (six current and 10 exsmokers), eight DR4-positive nonsmokers, and eight DR4-negative nonsmokers. Significant reductions in one-second forced expiratory volume and forced vital capacity were observed in DR4-positive subjects compared with DR4-negative subjects irrespective of cigarette smoking status. In addition, patients with keratoconjunctivitis sicca (secondary Sjögren's syndrome) demonstrated significant reductions in one-second forced expiratory volume, forced vital capacity, and ratio of one-second forced expiratory volume to forced vital capacity compared with those patients without evidence of secondary Sjögren's syndrome. It is concluded that the presence of the HLA-DR4 antigen and secondary Sjögren's syndrome are associated with abnormal pulmonary function in patients with rheumatoid arthritis.

Fetal viral myocarditis and congenital complete heart block in a pregnancy complicated by systemic lupus erythematosus. A case report

Congenital complete heart block has been associated with collagen vascular disorders. Many etiologies have been proposed for the myocarditis that develops and results in the complete heart block. Transplacental antibody transfer--specifically, antibodies to tissue-soluble ribonuclear protein antigen-A--has been implicated as the etiology of the myocarditis. This case supports the association of this antibody while suggesting that viral infection may serve as an initiator of the autoimmune destruction. Also, fetal viral infection alone must be considered a possible cause of congenital complete heart block.

Auranofin or D-penicillamine in the treatment of rheumatoid arthritis

Ninety patients were entered into a randomized, controlled, double-blind trial lasting 12 months to compare auranofin (6 mg/d), and D-penicillamine (250 mg/d for 4 weeks, 500 mg/d for 4 weeks, then 750 mg/d thereafter) in the treatment of rheumatoid arthritis. Most patients in both groups completed the trial with significant improvement in all quantitative measures of efficacy. Patients treated with D-penicillamine were more likely to have "important improvement" in physician global assessment, swollen joint count, and score and grip strength. The overall frequency of side effects was similar between the two groups; however, more patients were withdrawn for adverse effects from the D-penicillamine group, and proteinuria (greater than or equal to 2+) and thrombocytopenia (less than 100 000 mm3) occurred significantly more frequently with D-penicillamine than auranofin (p = 0.028). These results suggest that in the dosage regimen used, auranofin is safer than D-penicillamine but that D-penicillamine tends to show greater clinical effectiveness in patients with rheumatoid arthritis.

Relationship between C4 null genes, HLA-D region antigens, and genetic susceptibility to systemic lupus erythematosus in Caucasian and black Americans

The complement components C4A, C4B, and factor B, and the HLA-A, B, C, DR, DQ, and DRw antigens were analyzed in 103 patients (66 Caucasian, 37 black) with systemic lupus erythematosus (SLE) and 98 control subjects (63 Caucasian, 35 black). Only the C4A null (silent) allele was significantly increased in SLE (0.254 versus 0.095 in Caucasians, p = 0.033; 0.200 versus 0.071 in blacks, p = 0.046). The absence of any detectable C4A gene products (homozygous C4A null or C4A*Q0,Q0) was found in 11.1 percent of Caucasian patients but in no control subjects (p = 0.006 with relative risk of 16.86). HLA-DR2 was significantly associated with Caucasian SLE (R2 = 0.63, p less than 0.0012). Multivariate analysis demonstrated that the HLA-DR2 antigen and C4A null allele contributed independently to the risk of SLE (relative risk 3.0 and 3.2, respectively); when HLA-DR2 and the homozygous C4A null phenotype were present together, the relative risk of SLE was 24.9. Both HLA-B8 and HLA-DR3 were increased in SLE, but these antigens are in linkage disequilibrium with the C4A null allele; the presence of HLA-B8 or DR3 did not contribute further to the risk of SLE. It is concluded that the HLA-DR2 antigen and the C4A null allele are independent and additive risk factors for development of SLE.

Severe retinal vaso-occlusive disease in systemic lupus erythematous

Retinopathy in systemic lupus erythematosus generally consists of cotton-wool spots with or without intraretinal hemorrhages. Although rare, a more severe retinal vaso-occlusive disease, termed retinal vasculitis, has been described. We report data from 11 patients with SLE and severe retinal vaso-occlusive disease. Visual outcome was often poor, with 55% of the involved eyes suffering visual loss, frequently to an acuity of worse than 20/200. The systemic feature significantly associated with severe retinal vascular disease was central nervous system involvement (CNS lupus), present in eight (73%) of the 11 patients vs an overall prevalence of 37%. The association of CNS lupus with severe retinal vaso-occlusive disease probably reflects a similar pathogenetic mechanism and microangiopathy.

Fetal wastage in women with anti-Ro(SSA) antibody

Retrospective obstetric histories were obtained in 50 anti-Ro(SSA) antibody positive women (aged 15-50 years) and 47 anti-nRNP antibody positive women of similar age range. Twenty (40%) anti-Ro(SSA) positive women and 33 (70%) anti-nRNP positive women fulfilled the revised ARA criteria for systemic lupus erythematosus (SLE). Thirty-four anti-Ro(SSA) positive women had a total of 84 pregnancies with a fetal loss of 28%; 29 anti-nRNP positive women had a total of 63 pregnancies with a fetal loss of 19%. Although the overall frequency of fetal wastage between the 2 groups was not significantly different, analysis of the subgroup of SLE patients demonstrated a significantly greater fetal wastage in black anti-Ro(SSA) positive women (15 of 21, 71%) compared with black anti-nRNP positive women (5 of 28, 18% p less than .001). No significant difference in fetal wastage was noted between either the white SLE or the non-SLE women in either antibody group. These data suggest that black SLE patients with anti-Ro(SSA) antibody may be at increased risk of fetal wastage.

Systemic lupus erythematosus: a review of clinico-laboratory features and immunogenetic markers in 150 patients with emphasis on demographic subsets

Clinical and laboratory features as well as immunogenetic markers were analyzed in 150 patients with SLE to determine if demographic factors--age at diagnosis, sex and race--influenced the expression of disease. The overall series included 103 white females, 35 black females, 10 white males and 2 black males; the mean age at diagnosis was 32.5 years. Males had a significantly older mean age at diagnosis than females (40.4 versus 31.8 years) and a significantly higher frequency of peripheral neuropathy (50% versus 18.8%). No other differences in clinical or laboratory features or HLA-DR or DQ phenotype frequencies were noted. Blacks had a significant younger mean age at diagnosis than whites (26.9 versus 33.4 years) as well as significantly higher frequencies of nephritis, hypertension, acute lupus pneumonitis, discoid rash, hyperglobulinemia and hypocomplementemia. There were no differences in autoantibody frequencies between race-specific subgroups. HLA-DR2, DRw52 and DQ1 were significantly associated with SLE in whites compared to controls; no HLA-DR or DQ associations were found with SLE in blacks. In whites, HLA-DR2 was associated with the presence of anti-Ro(SS-A) antibody while HLA-DR3 was associated with the presence of both anti-Ro(SS-A) and anti-La(SS-B) antibody. In blacks, HLA-DR2 was associated with the presence of anti-nDNA antibody. In whites, patients with late-onset SLE (age at diagnosis greater than or equal to 50 years) had significantly lower frequencies of nephritis and mesenteric vasculitis but, on the other hand, a higher frequency of secondary Sjögren syndrome than patients with age at diagnosis less than or equal to 22 years. Similar findings were noted when blacks aged 35 and above were compared to those aged 17 and below at diagnosis. In whites, the frequency of both anti-Ro(SS-A) and La(SS-B) antibodies increased with increasing age as did that of HLA-DR3; HLA-DR2, however, was more frequent in those with younger age at diagnosis. These data suggest the existence of two serologic-genetic subsets of SLE with different age at diagnosis.

The incidence of systemic lupus erythematosus in Baltimore, Maryland, 1970-1977

The incidence of systemic lupus erythematosus, based on first hospital discharge diagnosis, in Baltimore, Maryland for the years 1970 through 1977 was determined for individual sex-race groups and the total population. Age-specific incidence rates were consistently highest among black females and lowest among white males: rates for white females exceeded those for black males through age 54, but then declined for ages greater than or equal to 55. Mean age at diagnosis was significantly lower for black females versus white females (35.5 versus 41.7 years, P = 0.005) and for all females versus all males (37.2 versus 44.2 years, P = 0.012). There were no temporal trends noted in yearly age-adjusted incidence rates during the 8-year study period. The overall population incidence of systemic lupus erythematosus was 4.6 per 100,000 per year, representing a twofold increase over a comparable study done in New York City 15 years ago.

Carbon monoxide diffusing capacity as predictor of outcome in systemic sclerosis

In order to determine the predictive value of lung function studies for subsequent prognosis in systemic sclerosis, 71 patients with systemic sclerosis were followed up for a mean of five years after pulmonary function testing. A carbon monoxide diffusing capacity less than or equal to 40 percent of the predicted reference value was associated with only a 9 percent five-year cumulative survival rate compared with a 75 percent cumulative five-year survival in patients with a carbon monoxide diffusing capacity greater than 40 percent of predicted. An obstructive ventilatory defect was also associated with increased mortality, and all six patients with obstruction and a diffusing capacity less than 70 percent of the predicted died during the study period. Male gender, independent of abnormalities of pulmonary function, was also associated with a poor prognosis. Although it is not clear whether a severely impaired diffusing capacity is indicative of interstitial pulmonary fibrosis or pulmonary vasculopathy or is a marker of generalized vascular disease, a severely depressed carbon monoxide diffusing capacity is an important predictor of mortality in patients with systemic sclerosis.

Sjögren's syndrome. Influence of multiple HLA-D region alloantigens on clinical and serologic expression

The relationships of HLA-DR and the newer DS (second D locus) B cell alloantigens (MB and MT) to the clinical and serologic expression of primary and secondary forms of Sjögren's syndrome (SS) were examined in 102 patients (86 whites and 16 blacks). Although HLA-DR3 was significantly increased in whites (25 of 50, 50%) and blacks (4 of 5, 80%) with primary SS compared with race-matched normal controls, it was not appreciably elevated in those with systemic lupus erythematosus (SLE)-SS, rheumatoid arthritis (RA)-SS, or connective tissue disease-SS. The MT2 specificity, however, was more strongly associated with primary SS (86% of whites and 100% of blacks) and also with SLE-SS and RA-SS compared with race-matched normal controls. Furthermore, MT2 was significantly increased in SLE-SS and RA-SS when compared with non-sicca SLE and RA controls. Although primary and secondary SS were most strongly associated with this DS specificity (MT2), the anti-Ro (SS-A) and anti-La (SS-B) antibody responses were more closely allied to DR antigens. HLA-DR3 was increased in anti-Ro positive patients, both whites and blacks, with primary SS (74%) and in total anti-Ro positive subjects (54%) compared with their anti-Ro negative counterparts (38% and 31%, respectively). Among DR3 negative patients, HLA-DR2 correlated with anti-Ro in both primary SS (83%) and in the total SS group (58%). Thus, 96% of Ro antibody positive patients with primary SS had DR3 and/or DR2, as did 80% of anti-Ro positive subjects in all categories.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibody to Jo-1 in polymyositis/dermatomyositis: association with interstitial pulmonary disease

Forty-four patients with polymyositis/dermatomyositis (PM/DM) were studied for precipitating antibody to Jo-1. Ten (23%) had anti-Jo-1 antibodies including 8 (47%) of 17 PM patients and 2 (15%) of 13 PM-overlap patients. None of the 11 DM nor 3 PM/DM-cancer patients had anti-Jo-1 antibody. Interstitial pulmonary disease was present in 5 (50%) of the 10 anti-Jo-1 positive compared to 5 (13%) of the 34 anti-Jo-1 negative patients (odds ratio = 5.8, p = 0.05). No differences in other demographic or clinical features or survivorship were noted between these groups. These data confirm the association of anti-Jo-1 antibody with an increased frequency of interstitial pulmonary disease in PM/DM patients.

Mortality from polymyositis and dermatomyositis in the United States, 1968-1978

Mortality from polymyositis and dermatomyositis was estimated between 1968 and 1978. Age-specific average annual mortality rates showed unimodal distributions for all sex-race groups. Synergistic interaction was demonstrated between female sex and nonwhite race, greatest mortality being in nonwhite females through age 74. Increases in annual death rates occurred among both white males and white females during the interval. Finally, the increase in mean age at death among all sex groups correlated with improved prognosis as well as decreased mortality among younger persons over time.

Degenerative joint disease

We have focused on several features somewhat unique to OA which require special attention relative to clinical trials. These include disease classification, for which the schema in Table 1 was developed, patient selection and admission criteria, and the choice of appropriate clinical outcome parameters. We suggest the following: That future trials be limited to patients with idiopathic OA with specified joint groups involved. That pain, assessed with a visual analogue scale, and both the patient's and investigator's global assessment be the primary clinical outcome variables to be analysed. That concomitant analgesic agents not be used during anti-inflammatory drug trials to prevent confounding pain relief as an outcome variable. That future, long-term studies use validated health status measures to assess functional outcomes.

Case-control studies

This paper will provide an overview of the case-control study including the definition, types of study design, advantages and disadvantages, potential types and sources of bias, selection of controls, statistical measures of association, and criteria for suggesting inferences about causation. Measures of association for HLA-B27 and ankylosing spondylitis (AS) and HLA-DR4 and rheumatoid arthritis (RA) are calculated from previously published data. Case-control studies are useful for identifying etiologic associations in uncommon diseases.