Immunoregulatory circuits and potential treatment of connective tissue diseases

Connective tissue diseases are generated by different immunoregulatory alterations. Their better knowledge may lead to new treatment modalities. In systemic lupus erythematosus (SLE), increased IL-10 production by non-T cells might exert an inhibitory effect on Thl CD4+ T cells which would explain the decreased T cell functions observed in these patients. In rheumatoid arthritis (RA) patients, there may be a balance within the synovium, where the local production of IFN-gamma may limit the anti-inflammatory properties of IL- 10, thus leading to chronic damage. This article shows that rational approaches to therapy need to be individualized. In SLE, the potential therapeutic use of monoclonal antibodies to IL-10 seems to be gathering strength, whereas in RA exactly the opposite is contemplated: IL-10 is tried for its potential therapeutic use.

Inherited activated protein C resistance in a patient with familial primary antiphospholipid syndrome

The mechanism of thrombophilia in patients with antiphospholipid antibodies (aPL) is not clearly understood. A number of contributing factors have been described, but more than one may be operative. It was recently found that aPL may cause the acquired activated protein C resistance phenotype, whereas in familial thrombophilia, activated protein C resistance frequently results from a point mutation in the factor V gene (replacing arginine 506 with a glutamine) that leads into the (R-506-Q), the so-called Leiden mutation, that produces a mutated factor V, resistant to the catalytic action of activated protein C, otherwise normal in its procoagulant properties. We describe one patient heterozygous for the activated protein C resistance genotype with a familial form of primary antiphospholipid syndrome, who had a nephew who died with this disease. In individuals who are heterozygous for the factor V Leiden mutation, the presence of aPL may cause further activated protein C resistance, resulting in increased thrombophilia.

The concept and classification of antiphospholipid/cofactor syndromes

In 1990, three groups simultaneously reported that putative IgG antibodies to anionic phospholipids were either not directed to phospholipids or at least required beta 2-glycoprotein-I (beta 2-GP-I) for reactivity in vitro. During the same year, our group described a patient with "idiopathic' hemolytic anemia with serum and erythrocyte-bound IgM antibodies to phosphatidylcholine later found to be independent of beta 2-GP-I for antigen recognition. Lately, the field has been expanded considerably with: (1) the description of other potential antigens such as prothrombin for some lupus anticoagulants, (2) the finding of crossreactivity between some antiphospholipid antibodies (aPL) with thrombomodulin, (3) the presence of serum antibodies to beta 2-GP-I (anti-beta 2-GP-I) in patients with SLE and thromboses, (4) the findings that the clinical manifestations of APS in SLE patients associate more strongly with anti-beta 2-GP-I than with aPL, (5) our finding of a group of SLE patients with the clinical manifestations of APS, with negative serum aPL, but with positive anti-beta 2-GP-I, (6) the description of a group of patients with the clinical manifestations of APS, without serum aPL, without serological nor clinical evidence of any autoimmune disease, but with IgG anti-beta 2-GP-I, and (7) the observation that serum anti-phosphatidylethanolamine antibodies detected in some patients with APS require kininogen (alone or complexed with the kininogen-binding protein), prekallikrein and/or factor XI for in vitro reactivity. Thus, there are antibodies that may be considered true aPL; other "aPL' require a protein cofactor for their detection in vitro, at least in the case of beta 2-GP-I it would appear that their epitope is present on the protein proper not on the phospholipid, hence these are pseudo aPL, and a third group of related anti-cofactor autoantibodies that are directed to the protein in the absence of phospholipid. Clearly, the term "antiphospholipid syndrome' has become obsolete. We propose the term "Antiphospholipid/Cofactor Syndromes' to cull the various syndromes.

Autoantibodies in systemic lupus erythematosus

Lupus anti-DNA may have higher homology with germline than those from normal subjects. However, in NZB/NZW mice, bacterial DNA is more antigenic than mammal DNA, which could indicate an antigen-driven origin. High-affinity antibodies to double-stranded DNA cross-react with small nuclear ribonucleoprotein and ribosomal P proteins. These cross-reactive anti-DNA may penetrate live cells. Antibodies to ribosomal P proteins are associated with neuropsychiatric, renal, and hepatic lupus involvement. IgG antibodies to (H2A-H2B)-DNA complexes antedate procainamide-induced lupus. Autoantibodies to some La/Ro peptides in a mother indicates that her children may develop neonatal lupus and determine who will have congenital heart block. Perinuclear antineutrophil cytoplasmic antibodies are present in 25% of systemic lupus erythematosus patients without correlation with anti-DNA or disease activity. Different antiphospholipid antibodies require different protein cofactors for reactivity. Those to anionic phospholipids require beta 2-glycoprotein I, whereas anti-phosphatidylethanolamine antibodies require kininogen or its binding protein. Antibodies to phospholipid-free beta 2-glycoprotein I are associated more strongly with clinical antiphospholipid syndrome than are antiphospholipid antibodies.

The role of HLA-DR alleles and complotypes through the ethnic barrier in systemic lupus erythematosus in Mexicans

Alleles of the major histocompatibility complex (MHC) have been recognized as genetic factors for the development of SLE. The [HLA-B8; SC01; DR3] extended haplotype seems to be relevant in patients from white European descent, pertinent alleles, however, are difficult to select on haplotypes with linkage disequilibrium. Studies in non-Caucasian patients are therefore mandatory. Admixture estimates in Mexicans have shown a proportion of 56% of Indian genes, 40% of Caucasian genes and from 4 to 12% of Black genes. In order to determine the relevant MHC loci in the genetic susceptibility for SLE we studied Class I, II and III alleles in 102 Mexican SLE patients and 350 of their first degree relatives and compared these two groups to another one composed by 200 ethnically matched normal individuals. We found significantly increased frequencies of HLA-DR3 (pC = 0.03, RR = 2.56) and DR7 (pC = 0.004, RR = 3.08) in SLE patients as compared to controls. On the other hand, first degree relatives had a significantly increased frequency of HLA-DR7 (pC = 0.01, RR = 2.98). There were 21 out of 33 HLA-DR3 haplotypes with complotypes other than SC01 and 25 out 37 SC01 haplotypes with DR alleles other than DR3. Nevertheless, [SC01; DR3] haplotypes were also increased (pC = 0.01, RR = 12.4). After removing [HLA-B8; SC01; DR3] haplotypes, DR3 was the only allele that remained significantly increased (p = 0.04, RR = 2.1). We also found in SLE patients significantly decreased frequencies of the autochthonous Mexican alleles (A30, B39 and DR4) and no deviation from normality of any of the HLA-DQ alleles. These data suggest a fundamental role of the HLA-DR3 allele in the predisposition to SLE in Mexican patients which might be hightened by genes located around the class III MHC region. They also substantiate the pertinence of ethnic admixture estimates in modern human populations.

The penetration of autoantibodies into cells may induce tolerance to self by apoptosis of autoreactive lymphocytes and cause autoimmune disease by dysregulation and/or cell damage

Autoantibodies to intracellular constituents often occur naturally. This would be difficult to understand were they unable to penetrate live cells, as was once generally accepted; however, they can and in so doing may alter cell functions, cause damage and even kill cells by apoptosis. Different autoantibodies have different effects and in this paper, further to our previous report on the penetration of anti-DNA, the penetration of anti-RNP, which may be a possible cause of apoptosis, is demonstrated. Penetration of lymphocytes by autoantibodies may play a role in the causation of autoimmune disease, influencing immune regulation and causing cell damage either directly or through nucleosomal DNA release as a result of apoptosis. This, in turn, could also further promote antigen-driven production of anti-DNA. In addition, by causing apoptosis of autoreactive cell clones, natural autoantibodies could influence tolerance during development and also later in life, thus, paradoxically, helping prevent autoimmune disease.

Factors associated with fetal losses in severe systemic lupus erythematosus

We evaluated factors associated with fetal losses in patients with severe lupus in a nested case-control study. We assessed separately 73 pregnancies that occurred in 46 women from a cohort of 633 Systemic Lupus Erythematosus (SLE) patients. They had at least one pregnancy after SLE diagnosis, one or more of our severity criteria and all had taken immunosuppressive drugs. Included data were related to disease severity, anti-phospholipid syndrome (APS), anticardiolipin antibodies (a-CL ab), and drugs received during pregnancy. Cases were pregnancies with fetal wastage; controls were pregnancies with live-born children. The mean age at pregnancy was 26.6 +/- 4.5 years. Cases had longer disease duration, 6.1 +/- 3.5 years vs 4.5 +/- 4.3 of controls (p = 0.02); higher prevalence of renal involvement, hemolysis and recurrent venous thrombosis (p < 0.05); they also tended to have a greater prevalence of a-CL ab, and previous fetal losses (p = 0.06). Cases used azathioprine more frequently than controls (p = 0.04). Univariate analysis showed an association of renal involvement, hemolytic anemia, azathioprine or cyclophosphamide prescription during pregnancy, previous fetal losses and APS with fetal wastage. Immunosuppressive drugs and the APS remained significant in the multivariate analysis (p = 0.05; F = 0.01). Factors related with fetal losses in women with severe SLE were: longer disease duration, ingestion of immunosuppressive drugs during pregnancy and any related manifestation of APS. We did not find macroscopic malformations in live-children of women that took azathioprine during pregnancy.

Activated protein C resistance phenotype and genotype in patients with primary antiphospholipid syndrome

We studied both inherited and acquired activated protein C (APC) resistance in a group of 22 patients with primary antiphospholipid syndrome (APS). The APC resistance genotype was assessed using a PCR-based analysis for the factor V R506Q (Leiden) mutation. One patient with primary APS was found to be heterozygous for the factor V Leiden mutation. He and other family members were affected by severe thrombophilia and had a familial form of primary APS. The APC resistance phenotype was assessed by measuring the prolongation of the activated partial thromboplastin clotting time in response to APC. It was found in five out of six patients with APS, in one of them transiently. We have found that the APC resistance phenotype is more frequent than the genotype in primary APS. It would seem that patients with thrombophilia should be investigated for APC resistance even if found to have antiphospholipid antibodies and/or lupus anticoagulants.

Remission of systematic lupus erythematosus

The occurrence and characteristics of remissions in patients with systematic lupus erythematosus (SLE) have not been determined. We therefore studied this in a cohort of 667 patients and found that 156 patients had achieved at least 1 period of 1 year or more of treatment-free clinical remission. This represents an incidence density of 0.028 new cases/person/year. Remission occurred within the first 2 years of disease in 62 patients. The mean duration of first remission was 4.6 years (range, 1-21 yr), and 81 patients were still in the initial remission up until cutoff time. Half of the remaining 75 patients who flared after achieving remission have not entered again in remission. Twenty-six of the 38 patients who did remained in remission, and the remaining 12 had subsequent flares and remissions. Treatment-free remission accounted for a mean of 5.8 years, corresponding to half the time of follow-up. Remission was not limited to patients with mild disease: at least 41 patients achieved remission despite renal involvement, 19 had had neuropsychiatric lupus, 15 had had thrombocytopenia, and 8 had had hemolytic anemia. We also found that the longer the time lapse between the initial manifestation and the diagnosis of SLE, the less likely it was for a patient to enter into remission. There was a continuous increase in likelihood of achieving a first remission from the beginning of disease up to 30 years of disease duration, when it reached 70%. Patients who achieved remission had increased survival, independently of the effect of other disease manifestations that cause increased mortality. We conclude that a significant proportion of patients with SLE, including those with severe organ involvement, may become symptom-free and in need of no more medication, perhaps indefinitely. Our findings support the notion that, in general, SLE is a more benign disease than previously considered.

HLA-DR6 (possibly DRB1*1301) is associated with susceptibility to Takayasu arteritis in Mexicans

Takayasu arteritis is characterized by a "pulseless" condition and occurs frequently in young females from Asian and South American countries. This disease has been found to be linked with major histocompatibility complex (MHC) antigens in Japanese individuals. In the present study we compared gene frequencies of class I, class II, and class III MHC genotypes in patients with Takayasu arteritis and ethnically matched healthy controls. Serological typing was confirmed by molecular typing at the DNA level. We found significant increases in the frequencies of human leucocyte antigen (HLA)-DR6 and HLA-B62 in patients compared to the healthy controls (P corrected [C] = 0.0007, relative risk [RR] = 5.08; PC = 0.05, RR = 3.13 respectively). However, since the number of patients was considerably lower than the number of controls this can be considered as a tendency and not a true association. On the other hand, we found a significantly decreased frequency of HLA-DR4 in patients compared to healthy controls (PC = 0.04, RR = 0.34). At the DNA level, all DR6-positive individuals were HLA-DRB1*1301 whereas controls were HLA-DRB1*1301 (4.2%). Takayasu arteritis in Mexicans is probably associated with the HLA-DR6 (DRB1*1301) gene.

Autoimmune thyroid disease in primary Sjögren's syndrome

PURPOSE

To evaluate the prevalence of autoimmune thyroid disease and thyroid dysfunction in patients with primary Sjögren's syndrome.

PATIENTS AND METHODS

Thyroid function of 33 patients with primary Sjögren's syndrome was clinically and biochemically evaluated. Thyroid hormones and autoantibodies against thyroid peroxidase, thyroglobulin, and thyroid hormones were measured.

RESULTS

Autoimmune thyroid disease and thyroid dysfunction were found in 15 cases (45%): autoimmune thyroiditis in 8 (24%); autoimmune hyperthyroidism in 2 (6%); and reversible iodine-induced hypothyroidism in the remaining 5 (15%). One or more of the evaluated autoantibodies were detected in 8 euthyroid patients (24%). Overall, the prevalence of autoantibodies against thyroid peroxidase, thyroglobulin, thyroxine, and triiodothyronine was 45%, 18%, 42%, and 36%, respectively.

CONCLUSIONS

The high prevalence of autoimmune thyroid disease and thyroid dysfunction found in primary Sjögren's syndrome, using sensitive immunologic and thyroid function tests, suggest that both diseases are more frequently associated than it was previously thought, and should be sought clinically and by laboratory tests in all patients with primary Sjögren's syndrome.

Clinical manifestations of the antiphospholipid syndrome in patients with systemic lupus erythematosus associate more strongly with anti-beta 2-glycoprotein-I than with antiphospholipid antibodies

OBJECTIVE

To investigate antibodies to phospholipid-free beta 2-glycoprotein-I (a beta 2 GP-I) in the serum of patients with systemic lupus erythematosus (SLE).

METHODS

We studied alpha beta 2 GP-I by Western blot, dot blot, and ELISA in 94 patients with SLE. Twenty-one had antiphospholipid syndrome (APS) by clinical and serological criteria, 33 had neither of these features, 18 had the clinical criteria for APS but no serum antiphospholipid antibodies (aPL). and 22 had positive aPL but no related clinical manifestations. As controls, we also studied 76 normal sera. Sera were also inhibited with cardiolipin micelles and tested for anticardiolipin antibodies (aCL) or a beta GP-I activities.

RESULTS

Thirty-five of 39 patients with SLE with clinical manifestations of APS has serum a beta 2 GP-I, while only 2 of 55 patients with SLE without such clinical manifestations had them (p = 0.000000001). Sixteen patients with SLE with clinical APS but aPL negative were a beta GP-I positive. All 35 patients with SLE who were a beta 2 GP-I positive had vascular manifestations, but these antibodies were present in only 4 of 55 patients with SLE without vascular manifestations (p = 0.00000001). No patient having either aPL or a beta 2 GP-I had clinical manifestations of APS, whereas all 19 patients positive for both antibodies had clinical APS. The a beta 2 GP-I positive, aPL negative patients with SLE had clinical APS more frequently (16/18) than did a beta GP-I negative, aPL positive patients with SLE (2/24) (p = 0.000000001). The association of clinical manifestations of APS with a beta 2 GP-I was stronger than with aPL. Inhibition studies also indicate that aPL and a beta 2 GP-I are 2 different antigen/antibody systems.

CONCLUSIONS

Our findings indicate that the so called APS associates strongly with antibodies recognizing phospholipid-free beta 2 GP-I. There are patients' sera that also recognize cardiolipin and/or its cofactor beta 2 GP-I, the latter perhaps by reacting with a neoepitope on this protein that appears after its interaction with cardiolipin. These would be the previously considered (beta 2 GP-I dependent) aCL.

Antibodies to phospholipid-free beta 2-glycoprotein-I in patients with primary antiphospholipid syndrome

OBJECTIVE

To investigate serum anti-beta 2-glycoprotein-I antibodies (a beta 2 GP-I) in patients with primary antiphospholipid syndrome (APS).

METHODS

We studied a beta 2 GP-I by Western blot, dot blot, and ELISA in the sera of 15 patients with primary APS with high titers of immunoglobulin G (IgG) and/or immunoglobulin M (IgM) anticardiolipin antibodies (aCL) at the time of study and compared findings with the sera of 13 aCL positive patients with syphilis and 76 healthy controls. Sera were also inhibited with cardiolipin micelles and tested for aCL and a beta 2 GP-I activities.

RESULTS

Twelve patients with primary APS but no syphilis patient or control subject had IgG to phospholipid-free beta 2 GP-I (p < 0.0001) for both comparisons). The aCL activity was inhibited with cardiolipin micelles but this treatment had less effect on a beta 2 GP-I activity. We found no IgM a beta 2 GP-I in any serum. Nine of 14 patients had had lupus anticoagulant activity; 8 of these had a beta 2 GP-I.

CONCLUSION

Patients with primary APS frequently have IgG a beta 2 GP-I that appear to differ from aCL. If aCL present in patients with primary APS actually react with a phospholipid induced neoepitope on beta 2 GP-I, as recently proposed, patients with primary APS have autoantibodies against 2 epitopes on beta 2 GP-I. Lack of a beta 2 GP-I in patients with syphilis might also contribute to protection from developing the APS.

Longitudinal study on the production of and cellular response to interleukin-2 in patients with systemic lupus erythematosus

Interleukin-2 (IL-2) has been proven to be a defective element in immune regulation in systemic lupus erythematosus (SLE). However, its course in time is unknown. We studied its production and cellular response in the peripheral blood cells of 30 SLE patients and 12 healthy subjects. In addition, we studied the spontaneous and lipopolysaccharide (LPS) induced production of IL-1, which have been found to be, respectively, increased and lowered in untreated SLE patients. Patients were studied at the outset, when still untreated, and at 1, 2, 6, 12, 18, and 24 months. At the outset, 18 had active disease and 12 were in remission. The decreased proliferative response of T cells to IL-2 and the deficient production of IL-1 upon LPS induction became normal after 6 months treatment, whereas the expression of high affinity IL-2 receptors took 18 months to become normal and the deficient production of IL-2 took 2 years. Despite clinical remission, the decreased capacity of T cells to absorb IL-2 persisted for 2 years. The effect of various prednisone dosages on the measured variables was evaluated. With intermediate doses of prednisone (20-45 mg), we observed the largest improvement in IL-2 production and in IL-1 production upon LPS stimulation. Higher doses of prednisone reduced also the spontaneous production of IL-1 and resulted in an increase in the expression of CD25+ cells. The addition of low doses of cytotoxic drugs (oral cyclophosphamide or azathioprine) resulted in an improvement in the capacity to absorb IL-2 and a reduction in spontaneous IL-1 production.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors associated with chronic renal failure in 121 patients with diffuse proliferative lupus nephritis: a case-control study

Lupus nephritis remains an important problem in patients with systemic lupus erythematosus (SLE). Some patients with diffuse proliferative lupus nephritis (DPLN) develop chronic renal failure (CRF). A case-control study was designed to determine the variables associated with CRF in patients with DPLN. We studied 121 patients with biopsy-proven DPLN seen in our institution from 1970 to 1988. There were 34 patients who developed CRF, the remaining were their controls. Clinical charts were reviewed and a pathologist re-scored blindly both activity and chronicity indices. The mean of age at SLE onset was 24.1 +/- 7.9 years; the mean disease duration was 9.2 +/- 6.1 years for controls and 6.1 +/- 5 years for patients. The main variables associated with CRF were male sex. HR (hazard ratio): 12.6 (95% CI 1.6-98.2); activity index, HR 2.59 (1.07-6.3); severe infections, HR 2.9 (1.2-7.3): number of antihypertensive drugs, HR 2.5 (1.4-4.7); cellular crescents, HR 1.6 (1.2-2): and interstitial inflammation, HR 2.7 (1.5-5.1). A protective effect was observed with longer use of < or = 20 mg of prednisone, HR 0.53 (95% CI 0.34-08): azathioprine, HR 0.6 (0.4-0.8); and length of formal education. HR 0.3 (0.09-0.94). Our results indicate that maleness, activity index, extracapillary proliferation and interstitial inflammation, as well as hypertension and severe infections associate with CRF in patients with DPLN, and treatment and higher education, perhaps through better therapeutic compliance, may be protective.

Association of HLA-DR5 (DR11) with systemic sclerosis (scleroderma) in Mexican patients

OBJECTIVE

To study the association between Major Histocompatibility Complex (MHC) haplotypes and systemic sclerosis (SSc) in Mexican mestizo patients.

METHODS

Class I, II and III MHC antigens were determined in 41 Mexican mestizo patients with SSc, 113 of their first degree relatives, and 85 ethnically matched controls. The significance of differences between patients and controls was tested by chi-square analysis with Yates' correction.

RESULTS

Frequencies of HLA-DR5 and HLA-DRw52 were found to be higher in SSc patients compared to ethnically matched healthy controls (p = 0.007, RR = 3.31; 95% confidence interval: 1.3-8.3 and p = 0.04, RR = 2.4; 95% confidence interval: 1.0-5.7, respectively). Sequence-specific oligotyping in DR5 positive individuals showed that 10 out of 41 patients had the DRB1*1104 subtype (24.3%) as compared to only 6 of the 85 healthy controls (7.0%) (p = 0.01, RR = 4.25). Subdividing patients according to their clinical features showed a significant increase of HLA-DR5 in diffuse (p = 0.013, RR = 3.89, 95% confidence interval: 1.27-12.0) and limited scleroderma (p = 0.0008), but not in the CREST syndrome. Segregation analysis obtained from the families showed that in the patients, DR5 was mostly part of the [HLAB35;DR5] haplotype as opposed to healthy controls.

CONCLUSION

These data support the role of DR5 (DRB1*1104) in the genetic susceptibility to develop scleroderma in Mexican patients and also sustain the notion of genetically determined clinical subgroups of SSc.

HLA-B alleles and complotypes in Mexican patients with seronegative spondyloarthropathies

OBJECTIVES

To analyse major histocompatibility complex (MHC) haplotypes in Mexican mestizo patients with seronegative spondyloarthropathies (SSpA) and normal controls, to discover if there are other antigens, besides B27, in the HLA region that might show association with the disease.

METHODS

The study included 100 Mexican mestizo patients with SSpA and 200 of their first degree relatives. These groups were compared with 85 ethnically matched controls. The class I and class III MHC antigens were obtained by standard methods. The significance of differences between patients and controls was tested by chi 2 analysis; linkage disequilibrium among the different alleles in each haplotype was estimated by computing delta values.

RESULTS

We found a significantly increased frequency of the HLA-B27 antigen (pcorr. = 1 x 10(-5), odds ratio (OR) = 33.4, 95% confidence interval (CI) = 9.3-142.0). In the group of 45 SSpA patients negative for the B27 antigen, independent increased frequencies of HLA-B49 antigen (pcorr. = 0.03, OR = 6.5, 95% CI = 1.5-32.8)) and the FC31 complotype (pcorr. = 0.04, OR = 3.7, 95% CI = 1.2-11.1) were found. Significant delta values were obtained for the [B27;SC30] haplotype (p = 0.0005) but not for haplotypes marked by the FC31 complotype. HLA-B antigens on the homologous chromosome in B27 positive patients were mainly HLA-B51 (18%) and HLA-B60 (16%); however, the observed genotypes B27/B51 and B27/B60 were not significantly different than expected from the allele frequencies alone.

CONCLUSIONS

These data suggest that in Mexicans additional genes within the MHC region besides the HLA-B27 antigen, might be related to the genetic susceptibility for developing SSpA. Relevant antigens included the HLA-B49 and the FC31 complotype.

Factors associated with disease severity in Mexican patients with rheumatoid arthritis

OBJECTIVE

To investigate clinical, demographic, laboratory, and behavioral variables associated with disease severity in rheumatoid arthritis (RA).

METHODS

A case-control study was carried out in a tertiary care center. Participants were RA patients, 16-65 years of age, with a disease duration of > or = 2 years. Selection criteria were established in advance. The sample size was calculated taking into account the prevalence of a low formal education level (< 6 years of school) in a sample of 60 patients. Controls for each case were paired according to age, sex, rheumatoid factor, and disease duration for a case/control ratio of 1:1.8. Cases were defined as those patients having at least two of the following: failure to respond to > or = 3 disease modifying anti-rheumatic drugs, score > or = 3/10 on the Disability Index of the Health Assessment Questionnaire, and disease severity > or = 4/10 as judged by the treating physician on a visual analogue scale. Controls were obtained from the same group but without such characteristics. All of the clinical charts were blindly evaluated for the clinical, demographic, laboratory, and behavioral variables. Descriptive statistics, univariate and multivariate analysis, odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

We studied 46 cases and 82 controls. Univariate analysis showed that severity was associated with a low level of formal education (OR 3.15, CI 1.38-7.13), use of non-conventional therapy (OR 2.7, CI 1.34-5.49), treatment with oral steroids (OR 2.6, CI 1.28-6.8), compliance, and disease duration before a confirmed diagnosis of RA. These variables remained in the multivariate model. A low hemoglobin level and an increased platelet count were the biological variables associated with severity.

CONCLUSIONS

The evaluation of RA must be conducted in a socio-cultural context since this is in some way linked to disease severity.

The treatment of systemic lupus erythematosus

Because no two SLE patients are identical, the treatment of this disease should be individualized. SLE patients, however, can be grouped by subsets, either throughout the course of the disease or at certain episodes. A number of syndromes, such as antiphospholipid or Sjögren's, also occur within SLE and may require distinct forms of treatment. The intensity of treatment in each circumstance depends on its severity and its life threatening potential. When two manifestations coexist the level of treatment usually required is determined by the most serious one. At present, the ultimate goal of treatment is achieving remission, which we define as a period of at least a year without disease activity and thus requiring no treatment. About one fourth of SLE patients achieve remission lasting a median of over 5 years, with more than half of them remaining in remission indefinitely. Current treatment of SLE is based mostly on some form of generalized immune suppression and takes little into account what is known about immune regulation in SLE. Future treatment of SLE should be tailor-made and could include use of various monoclonal antibodies, gene therapy, the administration of biological response modifiers, or the use of various hormones that may influence immune system reactivity. Also, the use of anti-idiotypic antibodies, affinity columns or injectable anionic compounds to elute or distract autoantibodies are being considered. Some of these forms of therapy are at hand but require in their application the judicious collaboration of clinicians and investigators.

The contribution of resting heart rate and routine blood tests to the clinical assessment of disease activity in systemic lupus erythematosus

OBJECTIVE

To contrast the contribution of simple clinical tests, such as resting heart rate (HR), complete blood count (CBC), and erythrocyte sedimentation rate (ESR), versus immunological tests in the assessment of disease activity in systemic lupus erythematosus (SLE).

METHODS

During an evaluation of disease activity indices in SLE, 39 patients had a full clinical evaluation in 99 visits including a disease activity index (MEX-SLEDAI), and serial measurements of HR, ESR, CBC, complement (C3, C4) and anti-dsDNA antibody levels (Farr).

RESULTS

Resting HR exhibited the highest correlation with MEX-SLEDAI scores (rs = 0.62). Thus, the disease was active (MEX-SLEDAI score of 2 or more) in all but one of 15 patients (93.3%) that had an HR > 90/min during the study. Hemoglobin levels (Hb) and ESR showed the second highest correlation (rs = -0.51, and 0.50, respectively). Seventeen patients had an Hb < 13 g/dl at least once; 14 (82.4%) had active disease during the study. Lymphocyte count, C3 levels, and anti-dsDNA levels correlated less strongly with disease activity (rs = -0.27, -0.29, and 0.30 respectively). Forward stepwise multiple regression analysis showed that HR, Ht, and C3 were independent markers of disease activity in this population (R2 = 0.51, p < 0.0001).

CONCLUSION

Closer attention to resting HR and CBC results may improve the assessment of disease activity in SLE.

Tween 20 detaches cardiolipin from ELISA plates and makes anticardiolipin antibodies undetectable regardless of the presence of beta 2-glycoprotein-I

We investigated the effects of polyoxyethylene sorbitan monolaurate (Tween 20) in the detection of IgG anticardiolipin antibodies (aCL) by the CL-beta 2-glycoprotein-I and the standard aCL solid-phase immunoassays. We found that Tween 20 disengages cardiolipin from a variety of microtiter wells rendering aCL undetectable by both methods. Our results agree with a previous report but are discordant with others. We offer rationale that may explain some of the discrepancies. Based in our findings, we do not recommend the use of Tween 20 for the detection of aCL.