The systemic lupus erythematosus Tri-nation Study: absence of a link between health resource use and health outcome

OBJECTIVE

Health consumption and health status in SLE in three countries with different health funding structures were compared.

METHODS

Seven hundred and fifteen SLE patients (Canada 231, USA 269, UK 215) were surveyed semi-annually over 4 yr for health resource utilization and health status. Cross-country comparisons of (i) cumulative health expenditure (calculated by applying 2002 Canadian prices to resources in all countries) and (ii) disease damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, SLICC/ACR DI) at study conclusion were performed after adjustment. Missing expenditure and damage data were managed through multiple imputation using best predictive regressions with all available data from all patients as potential covariates.

RESULTS

Four hundred and eighty-five patients provided data at study entry and conclusion and at least four resource questionnaires (Canada 162, USA 157, UK 166); 41 died (Canada 13, USA 18, UK 10); 189 withdrew, were lost to follow-up or provided data at entry and conclusion but fewer than four resource questionnaires (Canada 56, USA 94, UK 39). At conclusion, after imputation, in Canada, the USA and the UK respectively, mean cumulative costs per patient over 4 yr [95% confidence interval (CI)] were $15,845 (13,509, 18,182), $20,244 (17,764, 22,724) and $17,647 (15,557, 19,737) and mean changes in SLICC/ACR DI were 0.49 (0.39, 0.60), 0.63 (0.52, 0.74) and 0.48 (0.39, 0.57). After adjustment for baseline differences, on average (95% CI), Canadian and British patients utilized 20% (8%, 32%) and 13% (1%, 24%) less resources than patients in the USA respectively, but experienced similar health outcomes.

CONCLUSION

Despite patients in the USA incurring higher health expenditures, they did not experience superior health outcomes.

Incidence and prevalence of adult systemic lupus erythematosus in a large US managed-care population

Objective

The objective of this paper is to determine the incidence and prevalence of adult systemic lupus erythematosus (SLE) in a large US managed-care population.

Methods

Subject inclusion in the incidence cohort required a medical claim with an SLE diagnosis and a service date from 2003 to 2008 that satisfied the following criteria: 1) ≥18 years on service date; 2) continuously enrolled for 24 months before and 12 months after service date; 3) in the 12 months after service date, ≥ one inpatient claim or ≥ two office or ER visits with an SLE diagnosis; 4) no SLE diagnosis 24 months prior to service date; and 5) no SLE medications 12 months prior to service date. Prevalence cohort subjects were identified using a similar algorithm and were not required to satisfy criteria 4) and 5).

Results

A total of 1,557 subjects were included in the incidence cohort, and 15,396 were included in the prevalence cohort. The overall age- and gender-adjusted SLE incidence rate (2003–2008) was 7.22 cases per 100,000 person-years. The annual prevalence of SLE (per 100,000 individuals) varied from 81.07 in 2003 to 102.94 in 2008.

Conclusion

The SLE incidence in this large managed-care plan with geographic diversity was slightly higher than previous estimates, and the prevalence was within the range of previous estimates.

The 1.55 A resolution structure of Nicotiana alata S(F11)-RNase associated with gametophytic self-incompatibility

The crystal structure of Nicotiana alata (ornamental tobacco) S(F11)-RNase, an S-allelic glycoprotein associated with gametophytic self-incompatibility, was determined by X-ray diffraction at 1.55 A resolution. The protein has a tertiary structure typical of members of the RNase T(2) family as it consists of a variant of the (alpha+beta) fold and has eight helices and seven strands. A heptasaccharide moiety is also present, and amino acid residues that serve as the catalytic acid and base can be assigned to His32 and His91, respectively. Two "hypervariable" regions, known as HVa and HVb, are the proposed sites of S-allele discrimination during the self-incompatibility reaction, and in the S(F11)-RNase these are well separated from the active site. HVa and HVb are composed of a long, positively charged loop followed by a part of an alpha-helix and short, negatively charged alpha-helix, respectively. The S(F11)-RNase structure shows both regions are readily accessible to the solvent and hence could participate in the process of self/non-self discrimination between the S-RNase and an unknown pollen S-gene product(s) upon pollination.

The relationship between health status, social support and satisfaction with medical care among patients with systemic lupus erythematosus

OBJECTIVE

To examine the effect of physical and mental health status and social support on patient satisfaction with health care in patients with systemic lupus erythematosus (SLE).

STUDY DESIGN

Using a cross-sectional design, 220 SLE patients were recruited from rheumatology departments in two hospitals in the Montreal (Canada) area. Data comprised physician-rated indices of health status and patient-completed questionnaires.

MEASURES

Independent variables included demographics, disease duration, physician-rated indices of disease activity (SLAM-R) and disease damage (SLICC/ACR), patient self-reported health status (SF-36), and perceived social support (ISEL). Patient satisfaction with medical care (PSQ-IV) was the dependent variable.

ANALYSES

Univariate analyses were performed to describe the sample and examine univariate associations between the independent variables and patient satisfaction with medical care. A hierarchical multiple linear regression analysis was computed to determine the relative importance of physician-rated indices of health status, self-reported physical and mental health status and social support on patient satisfaction after controlling for demographic variables.

RESULTS

A multivariate hierarchical regression computed to predict patient satisfaction included the following variables in the equation: age, education, income (step 1), disease duration, SLAM-R, SLICC/ACR (step 2), mental and physical health status (step 3), and perceived social support (step 4). Less education (P< 0.01), better self-reported mental (P< 0.05) and physical health status (P< 0.005) and higher perceived social support (P< 0.005) were significant predictors of patient satisfaction (R2 = 0.15, P< 0.0001).

CONCLUSION

The findings suggest that self-reported physical and mental health status and social support are more important than clinical status variables in understanding patient satisfaction with medical care.

Neuropsychiatric events in systemic lupus erythematosus: a longitudinal analysis of outcomes in an international inception cohort using a multistate model approach

OBJECTIVES

Using a reversible multistate model, we prospectively examined neuropsychiatric (NP) events for attribution, outcome and association with health-related quality of life (HRQoL), in an international, inception cohort of systemic lupus erythematosus (SLE) patients.

METHODS

Annual assessments for 19 NP events attributed to SLE and non-SLE causes, physician determination of outcome and patient HRQoL (short-form (SF)-36 scores) were measured. Time-to-event analysis and multistate modelling examined the onset, recurrence and transition between NP states.

RESULTS

NP events occurred in 955/1827 (52.3%) patients and 592/1910 (31.0%) unique events were attributed to SLE. In the first 2 years of follow-up the relative risk (95% CI) for SLE NP events was 6.16 (4.96, 7.66) and non-SLE events was 4.66 (4.01, 5.43) compared with thereafter. Patients without SLE NP events at initial assessment had a 74% probability of being event free at 10 years. For non-SLE NP events the estimate was 48%. The majority of NP events resolved over 10 years but mortality was higher in patients with NP events attributed to SLE (16%) versus patients with no NPSLE events (6%) while the rate was comparable in patients with non-SLE NP events (7%) compared with patients with no non-SLE events (6%). Patients with NP events had lower SF-36 summary scores compared with those without NP events and resolved NP states (p<0.001).

CONCLUSIONS

NP events occur most frequently around the diagnosis of SLE. Although the majority of events resolve they are associated with reduced HRQoL and excess mortality. Multistate modelling is well suited for the assessment of NP events in SLE.

The systemic lupus erythematosus Tri-Nation study: cumulative indirect costs

OBJECTIVE

We previously reported that patients with systemic lupus erythematosus (SLE) in the US incurred approximately 19% and 12% higher direct medical costs than patients in Canada and the UK, respectively, without experiencing superior outcomes expressed as disease damage or quality of life. In the present study, we compared cumulative indirect costs over 4 years in these patients.

METHODS

A total of 715 patients with SLE (269 US, 231 Canada, 215 UK) were surveyed semiannually for 4 years on employment status and time lost from labor and nonlabor market activities. Cross-country comparisons of indirect costs were performed.

RESULTS

In the US, Canada, and the UK, mean 4-year cumulative indirect costs (95% confidence interval [95% CI]) due to diminished labor market activity were $56,745 ($49,919, $63,571), $38,642 ($32,785, $44,500), and $42,213 ($35,859, $48,567), respectively, and cumulative indirect costs due to diminished nonlabor market activity were $5,249 ($2,766, $7,732), $5,455 ($3,290, $7,620), and $8,572 ($5,626, $11,518), respectively. Regression results showed that cumulative indirect costs (95% CI) due to diminished labor market activity in the US were $6,750 ($580, $12,910) greater than in Canada and $10,430 ($4,050, $16,800) greater than in the UK. Indirect costs due to diminished nonlabor market activity in the US were $280 (-$2,950, $3,520) less than in Canada and $2,010 (-$1,490, $5,510) less than in the UK, both results insignificant due to wide CIs.

CONCLUSION

Despite American patients incurring greater direct medical costs than Canadian and British patients, they do not experience superior health outcomes in terms of less productivity loss in either labor market or nonlabor market activities.

Use of complementary and alternative therapies by patients with self-reported chronic back pain: a nationwide survey in Canada

OBJECTIVE

Complementary and alternative medicine (CAM) is gaining popularity among patients with chronic back pain. We looked for factors associated with CAM use.

METHODS

The data came from the cross-sectional household component of the 1996-1997 National Population Health Survey on the health status and behaviors of Canadians. The sample comprising 66.999 individuals aged 20 years or older represented 21 million adults. Cross tabulations were used to estimate the percentage of CAM use among adults with chronic back pain. Factors independently associated with CAM use during the year before the surveys were identified using multiple logistic regression.

RESULTS

CAM use was highest in the subgroup of Canadian adults reporting chronic back pain (39.07%). CAM use was associated with younger age, being married, having a higher level of education, and earning a higher income. Overall, the CAM users reported less pain, greater analgesic use, more depression, and more co-morbidities. In addition to CAM, these patients used conventional medical services.

CONCLUSION

Our results show that patients with chronic back pain who use CAM are more active, more involved in social life, and healthier, suggesting better management of their condition. They use CAM in addition to, rather than instead of, conventional care. CAM use in these patients may be ascribable to dissatisfaction with mainstream physicians.

Economic impact of juvenile idiopathic arthritis

OBJECTIVE

Juvenile idiopathic arthritis (JIA) is a potentially devastating chronic pediatric disease. Although high costs have been well described in adult arthritis, little is known about the economic impact of JIA. Our objective was to describe direct medical costs for children with JIA compared with controls.

METHODS

Consecutive clinic attendees (n = 155) with JIA were enrolled from 2 tertiary referral pediatric centers. Outpatient clinic controls without JIA (n = 181) were recruited at the respective centers. Data on direct medical costs were obtained at 3-month intervals. Average annualized direct medical costs were calculated, expressed in 2005 Canadian dollars.

RESULTS

The total difference in annualized average direct medical costs for children with JIA versus controls was $1,686 (95% confidence interval $875, $2,500). JIA subjects had substantially higher costs concerning medication use, visits to specialists and allied health care professionals, and diagnostic tests. Multiple linear regression models for the JIA sample revealed that higher active joint count was independently associated with greater total direct medical costs. Also, JIA type was a predictor of greater direct costs, with higher costs for patients with polyarthritis (rheumatoid factor positive or negative) or systemic JIA.

CONCLUSION

The economic impact of JIA is substantial, and higher active joint count is independently associated with greater costs. This may be of particular significance given the emergence of new, costly medications for use in JIA. Insights into the relationship between disease activity and cost in JIA should assist policy makers regarding resource allocation in the setting of competing demands. Ultimately, decisions regarding access to therapies should be considered in terms of overall cost-benefit ratios.

Molecular aspects of self-incompatibility in flowering plants

It is seven years since the first reports of cDNAs encoding pistil glycoproteins that segregated with particular S-alleles. During this time, the S-glycoproteins of the Solanaceae have been identified as RNases. This enzymatic activity relies on the presence of histidine residues at the putative active site of the RNase, and these are conserved in all S-glycoproteins so far characterized. The proteins also contain "hypervariable" regions that may have some role in allelic specificity. It is particularly interesting that putative S-glycoproteins from Japanese pear, which is from a different family, the Rosaceae, are also RNases. To counter the temptation to extrapolate to other families with gametophytic self-incompatibility, there is evidence that in another family, the Papaveraceae, poppy S-glycoproteins are not RNases. The current evidence is consistent with a process in which the S-RNase moves into the incompatible pollen tube and degrades RNA, including rRNA. As rRNA genes are not transcribed in pollen, the resulting degradation would lead to the death of the cell. But still we are left with some important gaps in our knowledge. How does the S-RNase move across the wall and membrane and into the pollen tube? How is the specificity of the interaction controlled? What is the mechanism of signal transduction? A major bottleneck in unraveling the story is understanding the nature of the S-locus product in pollen. Is it related to the stylar S-locus product or is it the product of a different gene in the same locus? Each question underlines the sketchiness of our knowledge of many plant processes that are not specific to pollination, but that we need to understand if we are to work out the details of self-incompatibility. For example, we have a very incomplete understanding of cell wall synthesis generally and pollen wall synthesis in particular. How do macronutrients move through cell walls to the cytoplasm of cells generally and pollen tubes in particular? What is the nature of the receptor-ligand interaction in plant cells generally and pollen tubes in particular? A similar range of questions and gaps in our knowledge exist in the sporophytic system, exemplified by studies in Brassica spp. In this case, we have no known enzymatic or other function for the stigmatic S-glycoproteins. We do, however, know that the S-locus in Brassica includes at least two genes, one encoding a S-glycoprotein and the other encoding a protein kinase.(ABSTRACT TRUNCATED AT 400 WORDS)

Structural studies on the major component of Gladiolus style mucilage, an arabinogalactan-protein

The major component of the Gladiolus style mucilage was shown to be an arabinogalactan-protein. The arabinogalactan-protein was isolated from the style extract by affinity chromatography with tridacnin (the galactose-binding lectin from the clam Tridacna maxima) coupled to Sepharose 4B. The isolated arabinogalactan-protein represents 40% of the soluble style extract; it contains 90% (w/w) carbohydrate and 3% protein. The major monosaccharides of the carbohydrate component are galactose and arabinose, in the proportions 6:1. A component with a similar composition was also isolated from the crude extract by precipitation with the beta-glucosyl artifical carbohydrate antigen. The protein moiety of the arabinogalactan-protein remained associated with the carbohydrate after chromatography in urea, and has high contents of serine, glutamic acid, aspartic acid, glycine and alanine. The arabinogalactan-protein is apparently chemically homogeneous; it eluted as a single symmetrical peak from Sepharose 4B, and three fractions collected across the peak were structurally similar. Ultracentrifugal studies showed it to be polydisperse in the mol.wt. range 150 000--400 000. The information obtained from methylation analyses, oxalic acid and enzymic hydrolyses is consistent with a model having a beta 1 leads to 3 galactan backbone, branched through C(O)6 to beta 1 leads to 6 galactan side chains. The arabinose is exclusively present as terminal alpha-L-arabinofuranosyl residues. Enzymic removal of the arabinose residues resulted in a marked decrease in solubility of the molecule. The localization of the arabinogalactan-protein in the mucilage of the style canal was demonstrated cytochemically. The possible roles of the arabinogalactan-protein in relation to recognition of compatible pollen and pollen-tube growth are discussed.

Isolation of the protein backbone of an arabinogalactan-protein from the styles of Nicotiana alata and characterization of a corresponding cDNA

Arabinogalactan-proteins (AGPs) from the styles of Nicotiana alata were isolated by ion exchange and gel filtration chromatography. After deglycosylation by anhydrous hydrogen fluoride, the protein backbones were fractionated by reversed-phase HPLC. One of the protein backbones, containing mainly hydroxyproline, alanine, and serine residues (53% of total residues), was digested with proteases, and the peptides were isolated and sequenced. This sequence information allowed the cloning of a 712-bp cDNA, AGPNa1. AGPNa1 encodes a 132-amino acid protein with three domains: an N-terminal secretion signal sequence, which is cleaved from the mature protein; a central sequence, which contains most of the hydroxyproline/proline residues; and a C-terminal hydrophobic region. AGPNa1 is expressed in many tissues of N. alata and related species. The arrangement of domains and amino acid composition of the AGP encoded by AGPNa1 are similar to that of an AGP from pear cell suspension culture filtrate, although the only sequence identity is at the N termini of the mature proteins.

Psychosis in Systemic Lupus Erythematosus: Results From an International Inception Cohort Study

OBJECTIVE

To determine, in a large, multiethnic/multiracial, prospective inception cohort of patients with systemic lupus erythematosus (SLE), the frequency, attribution, clinical, and autoantibody associations with lupus psychosis and the short- and long-term outcomes as assessed by physicians and patients.

METHODS

Patients were evaluated annually for 19 neuropsychiatric (NP) events including psychosis. Scores on the Systemic Lupus Erythematosus Disease Activity Index 2000, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and the Short Form 36 (SF-36) were recorded. Time to event and linear regressions were used as appropriate.

RESULTS

Of 1,826 SLE patients, 88.8% were female and 48.8% were Caucasian. The mean ± SD age was 35.1 ± 13.3 years, the mean ± SD disease duration was 5.6 ± 4.2 months, and the mean ± SD follow-up period was 7.4 ± 4.5 years. There were 31 psychotic events in 28 of 1,826 patients (1.53%), and most patients had a single event (26 of 28 [93%]). In the majority of patients (20 of 25 [80%]) and events (28 of 31 [90%]), psychosis was attributed to SLE, usually either in the year prior to or within 3 years of SLE diagnosis. Positive associations (hazard ratios [HRs] and 95% confidence intervals [95% CIs]) with lupus psychosis were previous SLE NP events (HR 3.59 [95% CI 1.16-11.14]), male sex (HR 3.0 [95% CI 1.20-7.50]), younger age at SLE diagnosis (per 10 years) (HR 1.45 [95% CI 1.01-2.07]), and African ancestry (HR 4.59 [95% CI 1.79-11.76]). By physician assessment, most psychotic events resolved by the second annual visit following onset, in parallel with an improvement in patient-reported SF-36 summary and subscale scores.

CONCLUSION

Psychosis is an infrequent manifestation of NPSLE. Generally, it occurs early after SLE onset and has a significant negative impact on health status. As determined by patient and physician report, the short- and long-term outlooks are good for most patients, although careful follow-up is required.

Malignancies in juvenile idiopathic arthritis: a preliminary report

OBJECTIVE

To present preliminary data on incidence of malignancy in juvenile idiopathic arthritis (JIA), compared to general population rates.

METHODS

We examined cancer occurrence within JIA registries at 3 Canadian pediatric rheumatology centers. The subjects in the clinic registries were linked to regional tumor registries to determine the occurrence of invasive cancers over the observation period (spanning 1974-2006). The total number of cancers expected was determined by multiplying the person-years in the cohort by age, sex, and calendar year-specific cancer rates. The standardized incidence ratio (SIR, ratio of cancers observed to expected) was generated, with 95% confidence intervals.

RESULTS

The study sample consisted of 1834 patients. The female proportion was 67.6%; average age at entry to cohort was 8.6 years (SD 5.1). The majority were Caucasian. Subjects contributed 22,341 patient-years (average 12.2, SD 7.8). Within this observation period, one invasive cancer occurred, compared to 7.9 expected (SIR 0.12, 95% CI 0.0, 0.70). This was a hematological cancer (Hodgkin's lymphoma), representing a SIR for hematological malignancies of 0.76 (95% CI 0.02, 4.21).

CONCLUSION

Only one invasive cancer was identified in this large sample of individuals with JIA, observed for an average of 12.2 years each. These data suggest that, at least in the initial years following diagnosis of JIA, the risk of invasive cancers overall is not markedly increased. The results do not rule out the possibility of a baseline increased risk of hematological malignancies.

Counterbalancing patient demands with evidence: results from a pan-Canadian randomized clinical trial of brief supportive-expressive group psychotherapy for women with systemic lupus erythematosus

OBJECTIVE

To evaluate the effect of Brief Supportive-Expressive Group Psychotherapy as an adjunct to standard medical care in reducing psychological distress, medical symptoms, and health care costs and improving quality of life in women with systemic lupus erythematosus (SLE).

METHODS

A randomized clinical trial was conducted with 133 SLE female patients from 9 clinics across Canada. Clinical and psychosocial measures were taken at baseline, posttreatment, and 6 and 12 months posttreatment. Outcomes assessed were psychological distress, quality of life, disease activity, health service utilization, and diminished productivity.

RESULTS

Intention-to-treat analyses revealed that there were no clinically important group differences on any of the outcome measures.

CONCLUSION

Although both groups improved over time on several measures (e.g., decreases in psychological distress, stress, and emotion-oriented coping), these changes could not be attributed to the psychotherapeutic intervention. Thus, evidence does not support the referral of these patients to this type of intervention.

Peanut challenge: a retrospective study of 140 patients

BACKGROUND

Accurate diagnosis of peanut allergy is essential given that it is a lifelong and potentially fatal food allergy. Diagnosis relies on patient history, prick skin test (PST), and in many situations, food challenge. More information is required on the safety of food challenge and the informational value of a PST.

OBJECTIVES

Primary: to assess the safety of peanut challenges. Secondary: to estimate the sensitivity, specificity, and the positive and negative predictive values of PST to peanut performed in those who underwent a peanut challenge.

METHODS

A retrospective study of peanut challenges performed at a tertiary care paediatric hospital allergy clinic between January 1994 and November 1998.

RESULTS

Of the 140 peanut challenges performed on 140 patients, 18 were positive. The most frequent adverse clinical effects of positive peanut challenges were: urticaria, oropharyngeal irritation, rhinitis, vomiting and abdominal pain. Among the 18 patients who had a positive result, 10 required medical treatment (antihistamines, +/- epinephrine, +/- salbutamol) to control the allergic reaction. The sensitivity, specificity, and the positive and negative predictive values of PST to peanut in this group of children undergoing a peanut challenge were 100%, 62.3%, 28.1% and 100%, respectively.

CONCLUSIONS

Given the poor positive predictive value and specificity of PST, a peanut challenge is usually required to diagnose peanut allergy with certainty when the PST is positive. In cases of a clear history of anaphylaxis to peanut and a positive PST, challenges are unwarranted. When the history is strongly suggestive and the PST is borderline positive, i.e. 3 or 4 mm, peanut challenge is generally necessary to confirm the diagnosis. Given the excellent negative predictive value and sensitivity of PST, a blinded peanut challenge is usually unnecessary in the context of a negative PST except for patients with a history strongly suggestive of immediate hypersensitivity. These patients should be individually assessed for the need to undergo a blinded challenge. The peanut challenge is a useful and safe diagnostic tool when performed by qualified personnel under appropriate conditions.

Enzymic hydrolysis of barley and other beta-glucans by a beta-(1--4)-glucan hydrolase

1. A barley glucan with 68% of beta-(1-->4)-linkages and 32% of beta-(1-->3)-linkages was exhaustively hydrolysed with an Aspergillus niger beta-(1-->4)-glucan 4-glucanohydrolase (EC 3.2.1.4) (Clarke & Stone, 1965b). The hydrolysis products were separated and estimated. 2. The lower-molecular-weight products were identified as: glucose, 1.4%; cellobiose, 11.9%; 3(2)-O-beta-glucosylcellobiose, 45.0%; a tetrasaccharide(s), which was a substituted cellobiose, 16.4%. A series of unidentified higher-molecular-weight products (26.5%) were also found. 3. The identity of the products suggests that the A. niger beta-(1-->4)-glucan hydrolase hydrolyses beta-glucosidic linkages joining 4-O-substituted glucose residues. 4. When an enzyme fraction containing the beta-(1-->4)-glucan hydrolase and an exo-beta-(1-->3)-glucan hydrolase was used, the same products were found, but the higher-molecular-weight products were observed to have only a transient existence in the hydrolysate and were virtually absent after prolonged incubation. It is suggested that these oligosaccharides are resistant to attack by beta-(1-->4)-glucan hydrolase but are partially hydrolysed by the exo-beta-(1-->3)-glucan hydrolase and therefore possess one or more (1-->3)-linked glucose residues at their non-reducing end.

Lung cancer in systemic lupus erythematosus

BACKGROUND

Evidence points to a link between systemic lupus erythematosus (SLE) and an increased risk of lung cancer. Our objective was to provide a brief report of the lung cancer cases from an SLE cohort, with respect to demographics, histology, and exposures to smoking and immunosuppressive medications.

METHODS

Data were obtained from a multi-site international cohort study of over 9500 SLE patients from 23 centres. Cancer cases were ascertained through linkage with regional tumor registries.

RESULTS

We analyzed information on histology subtype for 30 lung cancer cases that had occurred across five countries. Most (75%) of these 30 cases were female, with a median age of 61 (range 27-91) years. In eight cases, the histological type was not specified. In the remainder, the most common histological type reported was adenocarcinoma (N=8; two of the adenocarcinomas were bronchoalveolar carcinoma) followed by small cell carcinoma (N=6), and squamous cell carcinoma (N=6) with one case each of large cell carcinoma and carcinoid tumor. Most (71%) of the lung cancer cases were smokers; only the minority (20%) had been previously exposed to immunosuppressive agents.

CONCLUSIONS

The histological distribution of the lung cancers from the SLE sample appeared similar to that of lung cancer patients in the general population, though the possibility of a higher proportion of more uncommon tumors (such as bronchoalveolar and carcinoid) cannot be excluded. A large proportion of the cancer cases were smokers, which is also not surprising. However, only a minority appeared to have been exposed to immunosuppressive agents. A large case-cohort study currently in progress should help shed light on the relative importance of these exposures in lung cancer risk for SLE patients.

A galactose-rich, cell-wall glycoprotein from styles of Nicotiana alata

A basic, galactose-rich style glycoprotein (GaRSGP) encoded by a previously characterized style-specific cDNA (NaPRP4) has been isolated from the styles of Nicotiana alata and structurally characterized. The glycoprotein is associated with cell walls in the transmitting tract and is composed of approximately 25% (w/w) protein and 75% (w/w) carbohydrate. The purified glycoprotein appears as a smear of between 45-120 kDa on SDS-PAGE; the deglycosylated protein backbone has an apparent molecular weight of approximately 30 kDa. The glycoprotein is rich in the amino acids lysine, proline, and hydroxyproline and in the monosaccharides galactose and arabinose. It is one of only a few proline/hydroxyproline-rich glycoproteins (P/HRGPs) to be characterized both as a cDNA-clone and protein. Glycans are attached to the protein backbone through both O- and N-glycosidic linkages with the majority of the carbohydrate being O-linked and consisting of short, highly branched chains terminating primarily in galactose residues. A carbohydrate epitope(s) is found on both GaRSGP and another style-specific glycoprotein but not on glycoproteins from other tissues. This finding provides further evidence for the existence of a style-specific carbohydrate epitope(s) which may play a role in style function.

A high proportion of hybridomas raised to a plant extract secrete antibody to arabinose or galactose

A high proportion of hybridomas, obtained from mice immunized with style extracts prepared from mature flowers of an ornamental tobacco, Nicotiana alata, secrete antibody to arabinogalactan protein (AGP). The specificity of the antibodies secreted by three cloned cell lines is primarily directed to beta-d-galactopyranose and alpha-l-arabinofuranose; antibodies from two cell lines preferentially bind beta-d-galactopyranose residues and antibodies from the other cell line preferentially bind alpha-l-arabinofuranose. As AGPs are components of most plant tissues and exudates, it is likely that attempts to raise monoclonal antibodies to other plant extracts will result in hybridomas producing antibodies to AGPs.

Systemic lupus erythematosus and risk of infection

INTRODUCTION

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death.

AREAS COVERED

This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020.

EXPERT OPINION

Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.

Acute lupus myocarditis: Clinical features and outcome

Background: Cardiomyopathy in systemic lupus erythematosus (SLE) may be secondary to myocardial inflammation (i.e. myocarditis) or to systemic complications such as hypertension. Symptomatic left ventricular dysfunction is the most common clinical presentation of cardiomyopathy and is potentially life threatening. Identifying the cause is critical as it dictates therapy.

Methods: We present three cases of left ventricular failure suggestive of myocarditis in SLE patients followed in the Lupus Clinic of the Montreal General Hospital over a 5-year period.

Results: The most frequent presentation is acute onset of a marked reduction of the left ventricular ejection fraction (LVEF). All patients were treated with cardiac support, prednisone, and additional immunosuppressive medications. Improvement of symptoms and LVEF was observed in two of three patients.

Conclusion: Myocarditis is a rare, but life-threatening, manifestation of SLE. With immunosuppressive medications and cardiovascular support, the long-term outcome is usually favorable.

Costs of rheumatoid arthritis: new estimates from the human capital method and comparison to the willingness-to-pay method

BACKGROUND

Individuals' valuation of changes in health states in monetary terms have been measured by examining changes in the direct and indirect costs of disease and by the willingness-to-pay (WTP) methodology.

METHODS

In 2002, a 2-part study was conducted in Quebec. In one part of the study, 121 rheumatoid arthritis (RA) patients from the McGill University Health Centre were mailed the Stanford Cost Assessment Questionnaire, which enabled the elicitation of direct costs and indirect costs, according to the friction cost and the human capital methods. The other part was a phone survey conducted in a representative sample of the general population and in the same sample of patients, aiming to elicit the societal WTP for a complete cure of RA in the context of 2 different scenarios: a public coverage or private insurance. These estimates were then compared.

RESULTS

Estimates of the cost of illness of RA ranged from 11,717 to 28,498 Canadian Dollars (CAD) depending on the method. These estimates are higher than those previously published in Canada from the 1990s, which is partly due to the recent and costly biological therapies and to a change in the measurement of productivity losses. These estimates are somewhat lower than the societal WTP elicited from the WTP survey, that is, 26,717 and 36,817 CAD per RA case, depending on the public or private health insurance context in which the cure would be available.

CONCLUSION

Given that neither method is ideal, data from both methods would provide an important sensitivity analysis when monetary estimates of health state changes are required.

Localization of lectins in legume cotyledons

High-resolution techniques for the localization of lectins are described. Concanavalin A (Con A) and phytohaemagglutinin (PHA) are localized using a fluorescent method with (FITC)-labelled immunoglobulins which bind to the lectins in sections of jack and red kidney bean cotyledons. Specificity is defined by the use of specific sugar inhibitors. Both Con A and PHA are found in cytoplasmic sites. Lectins with beta-glycoside specificity are detected with red-coloured artificial carbohydrate antigens. The beta-galactosyl and beta-glucosyl antigens bind specifically to clusters of spherical bodies in the intercellular spaces, to cell wall sites, and to the periphery of the cytoplasm associated with the cell membrane.