Genetic association of CD247 (CD3ζ) with SLE in a large-scale multiethnic study

A classic T-cell phenotype in systemic lupus erythematosus (SLE) is the downregulation and replacement of the CD3ζ chain that alters T-cell receptor signaling. However, genetic associations with SLE in the human CD247 locus that encodes CD3ζ are not well established and require replication in independent cohorts. Our aim was therefore to examine, localize and validate CD247-SLE association in a large multiethnic population. We typed 44 contiguous CD247 single-nucleotide polymorphisms (SNPs) in 8922 SLE patients and 8077 controls from four ethnically distinct populations. The strongest associations were found in the Asian population (11 SNPs in intron 1, 4.99 × 10(-4) < P < 4.15 × 10(-2)), where we further identified a five-marker haplotype (rs12141731-rs2949655-rs16859085-rs12144621-rs858554; G-G-A-G-A; P(hap) = 2.12 × 10(-5)) that exceeded the most associated single SNP rs858554 (minor allele frequency in controls = 13%; P = 4.99 × 10(-4), odds ratio = 1.32) in significance. Imputation and subsequent association analysis showed evidence of association (P < 0.05) at 27 additional SNPs within intron 1. Cross-ethnic meta-analysis, assuming an additive genetic model adjusted for population proportions, showed five SNPs with significant P-values (1.40 × 10(-3) < P< 3.97 × 10(-2)), with one (rs704848) remaining significant after Bonferroni correction (P(meta) = 2.66 × 10(-2)). Our study independently confirms and extends the association of SLE with CD247, which is shared by various autoimmune disorders and supports a common T-cell-mediated mechanism.

Healthcare costs of pregnancy in systemic lupus erythematosus: retrospective observational analysis from a US health claims database

OBJECTIVE

Systemic lupus erythematosus is a complex autoimmune disease, most frequently affecting women of childbearing age. Women with lupus are at increased risk of pregnancy complications that are exacerbated by active disease. Despite this, their use of medications and hospital resources has not been extensively studied.

METHODS

Retrospective analyses of the Truven Health MarketScan database (2006-2012) aimed to quantify drug and resource utilization in pregnant women with lupus, as well as the incidence of pregnancy complications in these patients. Records of women aged 12-54 were reviewed and both lupus patients and pregnancies identified. Pregnant women with lupus were matched 1:5 with either pregnant women without lupus, or non-pregnant women with lupus.

RESULTS

Pregnancies with lupus were associated with increased complications when compared to pregnancies without lupus. During pregnancy, the use of immunosuppressants decreased in pregnant women with lupus, as did rheumatologist visits, while the number of women not treated with any immunosuppressant increased. Pregnant women with lupus showed higher overall treatment costs than controls. However, compared to non-pregnant women with lupus, medication costs actually dropped, possibly due to the withdrawal of medications from these patients or women becoming pregnant while disease activity was low.

CONCLUSIONS

The large database analyses reported here revealed that pregnancies in women with lupus were associated with a higher risk of complications, higher healthcare costs, and fewer prescribed medications, including immunosuppressants, than the control groups. The increased risk of complications and decreased immunosuppressant use suggest that patients require additional guidance from physicians to give them the best chance of experiencing a safe pregnancy. Indeed, despite the recognized role active lupus plays in increasing pregnancy complications, women with lupus had fewer rheumatology visits during pregnancy, although their visits to their general practitioner/primary healthcare provider increased, highlighting the need for team-based co-ordination care between OBGYN physicians and rheumatologists.

Renal biopsy in the management of lupus nephritis during pregnancy

The differential diagnosis of proteinuria and hematuria in pregnancy is broad and includes active lupus nephritis. Identification of the correct diagnosis often has a profound therapeutic impact on not only the mother but also the fetus. To date, relatively few reports exist on the role of renal biopsy during pregnancy among women with systemic lupus erythematosus (SLE). We present a case series of 11 pregnant women with SLE who underwent a renal biopsy to evaluate a presumptive flare of lupus nephritis. The electronic medical record was retrospectively analyzed for pre-biopsy serum creatinine, proteinuria, hematuria, antinuclear antibodies (ANA), and antibodies to double-stranded DNA (anti-dsDNA); histologic findings on renal biopsy; and the clinical course of each mother and fetus. From 2001 to 2012, 11 pregnant women with SLE flares during pregnancy underwent a renal biopsy at an academic tertiary medical center. At the time of biopsy, median gestational age was 16 weeks (range 9 to 27), median serum creatinine was 0.6 mg/dl (interquartile range 0.5 to 0.9), six (55%) had hematuria, and all had proteinuria >500 mg/24 hours. Proliferative lupus nephritis was found in 10 (91%) of 11 biopsies (five with ISN/RPS Class III; five with ISN/RPS Class IV). All but one individual underwent a change in management guided by information gleaned from renal biopsy. No apparent biopsy-related complications occurred to mother or fetus. Three women elected to terminate their pregnancy; although many factors were involved, the findings on renal biopsy informed the decision-making process. Among the remaining cases, there were three pre-term deliveries, one fetus with complete heart block, one in utero demise, and one maternal death. Renal biopsy is helpful at informing the management of patients with lupus nephritis during pregnancy.

Biomechanical properties of femoral posterior cruciate ligament fixations

PURPOSE

The success of reconstructions of the posterior cruciate ligament (PCL) mainly depends on the fixation strength of the tendon-bone interface. Reliable data about the mechanical characteristics of PCL fixation techniques are sparse. The aim of this study was to investigate the biomechanical properties of different femoral PCL fixation techniques.

METHODS

Fresh human cadaver quadriceps (Q) and hamstring (H) tendons were harvested and fixed into porcine femora with a press-fit fixation suturing the tendon over a bone bridge (group A), a novel implant post-fixation (group B) or an interference screw fixation (group C). Each group consisted of 10 specimens. The constructs were cyclically stretched and eventually loaded until failure. Elongation during cyclic loading, stiffness, failure mode and maximum failure load was evaluated.

RESULTS

Elongation during cyclical loading was significantly larger between the 1st and the 20th cycle than between the 20th and the 500th cycle in all groups (p < 0.05). Maximum failure load was 409 ± 71 (336-517) N in group QA, 456 ± 58 (347-510) N in group QB, 548 ± 116 (400-798) N in group QC, 472 ± 114 N (316-676 N) in group HA, 494 ± 98 N (371-668 N) in group HB and 498 ± 87 N (391-687 N) in group HC (significantly higher for QB compared to QA, p < 0.05).

CONCLUSION

This is the first study investigating the biomechanical properties of femoral PCL fixations. Implant-free fixation techniques like press-fit or post-fixations are able to withstand equal biomechanical forces compared to interference screw fixation. The novel fixations described in this study can be considered as a reliable alternative for the reconstruction of PCL using either hamstring or quadriceps tendons.

Anti-C1q antibodies in systemic lupus erythematosus

OBJECTIVE

Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study.

METHODS

Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA.

RESULTS

Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% (49/389) in controls (OR = 2.7, 95% CI: 1.8-4, p < 0.001). Anti-C1q was associated with proteinuria (OR = 3.0, 95% CI: 1.7-5.1, p < 0.001), red cell casts (OR = 2.6, 95% CI: 1.2-5.4, p = 0.015), anti-dsDNA (OR = 3.4, 95% CI: 1.9-6.1, p < 0.001) and anti-Smith (OR = 2.8, 95% CI: 1.5-5.0, p = 0.01). Anti-C1q was independently associated with renal involvement after adjustment for demographics, ANA, anti-dsDNA and low complement (OR = 2.3, 95% CI: 1.3-4.2, p < 0.01). Simultaneously positive anti-C1q, anti-dsDNA and low complement was strongly associated with renal involvement (OR = 14.9, 95% CI: 5.8-38.4, p < 0.01).

CONCLUSIONS

Anti-C1q was more common in patients with SLE and those of Asian race/ethnicity. We confirmed a significant association of anti-C1q with renal involvement, independent of demographics and other serologies. Anti-C1q in combination with anti-dsDNA and low complement was the strongest serological association with renal involvement. These data support the usefulness of anti-C1q in SLE, especially in lupus nephritis.

Burden of corticosteroid use in patients with systemic lupus erythematosus: results from a Delphi panel

Corticosteroid-related adverse events (AEs) are commonly reported in systemic lupus erythematosus (SLE), but are often under-represented in claims data. The most common corticosteroid-related AEs are not necessarily the most costly. The present study aimed to examine corticosteroid-related AE rates and identify the associated cost consequences in patients with SLE from the perspective of rheumatologists treating SLE in the United States (US). A modified Delphi process and RAND Appropriateness Method was used to estimate corticosteroid-related AEs and costs based on data from SLE-treating US rheumatologists and estimates from alternative sources. The panel (n=10) participated in two web-based questionnaires, covering disease severity, corticosteroid use, corticosteroid-related AEs, and resource utilization associated with treatment of the AEs. Eight members of the panel then participated in a guided discussion by interactive teleconference, in which the costs associated with specific corticosteroid-related AEs were also discussed. Consensus was achieved in the teleconference when a single response category (consensus values from 1 to 4 [4=strongly agree, 1=strongly disagree]) accounted for ≥80% of responses. Thirteen consensus statements were developed following two Delphi rounds. Costs were estimated for eight corticosteroid-associated AEs from the panel of rheumatologists. In the patients with SLE treated by these physicians, 41.5% were considered to have mild disease, 36.5% moderate disease, and 22.0% severe disease. The number of specialist visits, corticosteroid use, and corticosteroid dose increased with disease severity. The estimated rates of all AEs (except for cataracts) were at least doubled in patients receiving corticosteroid doses>20 mg/day compared with ≤20 mg/day. The highest estimated mean total costs of an event (for the required treatment duration for one patient) were for avascular necrosis ($14,460) and serious infection ($11,660). The costs of more common AEs, such as osteoporosis, obesity, diabetes, and fractures, ranged from $1190 to $8220. Ten rheumatologists concluded that as disease severity increases, corticosteroid doses increased. Greater utilization of resources is needed to manage patients and corticosteroid-related AEs.

Oral candidiasis in systemic lupus erythematosus

OBJECTIVES

We assessed the frequency of oral candidiasis and the association between demographic variables, disease-related variables, corticosteroid treatment, other treatments and the occurrence of oral candidiasis in the Hopkins Lupus Cohort.

METHODS

In this large prospective cohort study of 2258 patients with systemic lupus erythematosus (SLE), demographic and clinical associates of oral candidiasis were estimated by univariate, multivariate and within-person regression models.

RESULTS

There were 53,548 cohort visits. Oral candidiasis was diagnosed at 675 visits (1.25%) in 325 (14%) of the patients. In the multivariate analyses, oral candidiasis was associated with African-American ethnicity, SELENA-SLEDAI disease activity, high white blood cell count, a history of bacterial infection, prednisone use and immunosuppressive use. The urine protein by urine dip stick was higher in SLE patients with oral candidiasis. Considering only patients who had candidiasis at some visits in a 'within-person' analysis, candidiasis was more frequent in visits with higher SELENA-SLEDAI disease activity, high white blood cell count, proteinuria by urine dip stick, a history of bacterial infection and prednisone use. The use of hydroxychloroquine was associated with a lower risk of oral candidiasis, but was not statistically significant (p = 0.50) in the within-person analysis models.

CONCLUSION

This study identified multiple risk factors for oral candidiasis in SLE. Inspection of the oral cavity for signs of oral candidiasis is recommended especially in SLE patients with active disease, proteinuria, high white blood cell count, taking prednisone, immunosuppressive drugs or antibiotics.

The American College of Rheumatology and the Systemic Lupus International Collaborating Clinics Classification criteria for systemic lupus erythematosus in two multiethnic cohorts: a commentary

The authors offer some comments on the advantages and possible drawbacks of using the SLICC criteria in longitudinal observational studies and clinical trials after applying and comparing them to the ACR criteria in two multinational, multiethnic lupus cohorts.

Mechanisms of motor vehicle crashes related to burns--an analysis of the German In depth Accident Study (GIDAS) database

BACKGROUND

Patients of motor vehicle crashes (MVCs) suffering burns are challenging for the rescue team and the admitting hospital. These patients often face worse outcomes than crash patients with trauma only. Our analysis of the German In-depth Accident Study (GIDAS) database researches the detailed crash mechanisms to identify potential prevention measures.

METHODS

We analyzed the 2011 GIDAS database comprising 14,072 MVC patients and compared individuals with (Burns) and without (NoBurns) burns. Only complete data sets were included. Patients with burns obviously resulting of air bag deployment only were not included in the Burns group. Data acquisition by an on call team of medical and technical researchers starts at the crash scene immediately after the crash and comprises technical data as well as medical information until discharge from the hospital. Statistical analysis was done by Mann-Whitney-U-test. Level of significance was p < 0.05.

RESULTS

14,072 MVC patients with complete data sets were included in the analysis. 99 individuals suffered burns (0.7%; group "Burns"). Demographic data and injury severity showed no statistical significant difference between the two groups of Burns and NoBurns. Injury severity was measured using the Injury Severity Score (ISS). Direct frontal impact (Burns: 48.5% vs. NoBurns: 33%; p < 0.05) and high-energy impacts as represented by delta-v (m/s) (Burns: 33.5 ± 21.4 vs. NoBurns: 25.2 ± 15.9; p < 0.05) were significantly different between groups as was mortality (Burns: 12.5% vs. NoBurns: 2.1%; p < 0.05). Type of patients' motor vehicles and type of crash opponent showed no differences.

CONCLUSIONS

Our results show, that frontal and high-energy impacts are associated with a frequency of burns. This may serve automobile construction companies to improve the burn safety to prevent flames spreading from the motor compartment to the passenger compartment. Communities may impose speed limits in local crash hot spots.

Transient ischemic attack and stroke in systemic lupus erythematosus

Ischemic stroke is increased in systemic lupus erythematosus (SLE) patients. The differential diagnosis of stroke in SLE is complex. Transient ischemic attack and ischemic stroke share pathophysiologic mechanisms, but prognosis may vary depending on severity and cause, and definitions are dependent on the timing and extent of the diagnostic evaluation. In SLE patients with a history of transient ischemic attacks, stroke occurred in 57%. Cerebrovascular events account for 20% to 30% of deaths in patients with SLE. In SLE, both disease-specific and traditional stroke risk factors are important.

Toll-like receptor 2/6-dependent stimulation of mesenchymal stem cells promotes angiogenesis by paracrine factors

Reconstruction of critical size bone defects represents a major challenge in orthopaedic surgery. Insufficient angiogenesis is a limiting factor for engraftment of large-scale tissue transplants. Transplantation or stimulation of local mesenchymal stem cells (MSCs) represents a potential solution to enhance angiogenesis. We recently identified angiogenic properties for the Toll-like receptor (TLR) 2/6 agonist MALP-2 and now investigated if MALP-2 could be used to stimulate MSCs in order to promote angiogenesis in vitro and in vivo. Human MSCs from the bone marrow of healthy subjects were isolated, cultured and expanded in vitro and were shown to be positive for mesenchymal stem cells markers as well as for the MALP-2 receptors TLR2 and TLR6. MALP-2 directly enhanced migration but not proliferation of human MSCs. Conditioned medium from MALP-2 stimulated MSCs significantly increased proliferation, migration and tube formation of endothelial cells. Analysis of the conditioned medium from MSCs revealed that MALP-2 stimulation enhanced the secretion of several chemokines and growth factors including vascular endothelial growth factors (VEGF) and granulocyte-macrophage colony-stimulating factor (GM-CSF). Finally, we studied MALP-2 effects on MSCs in a sheep model of tissue engineering in vivo. Therefore, MSCs were isolated from the iliac crest of black head sheep and co-cultivated with MALP-2 ex vivo. Implantation of autologous MSCs within a scaffold cylinder into the M. latissimus dorsi significantly enhanced vessel density of these constructs after 6 months. We here present the first evidence that TLR2/6-dependent stimulation of MSCs promotes angiogenesis in vitro and in vivo offering a novel strategy for therapeutic angiogenesis, e.g., for tissue engineering of bone.

X-ray scattering experiments with high-flux X-ray source coupled rapid mixing microchannel device and their potential for high-flux neutron scattering investigations

Small-angle X-ray scattering provides global, shape-sensitive structural information about macromolecules in solution. Its extension to time dimension in the form of time-resolved SAXS investigations and combination with other time-resolved biophysical methods contributes immensely to the study of protein dynamics. TR-SAXS can also provide unique information about the global structures of transient intermediates during protein dynamics. An experimental set-up with low protein consumption is essential for an extensive use of TR-SAXS experiments on protein dynamics. In this direction, a newly developed 20-microchannel microfluidic continuous-flow mixer was combined with SAXS. With this set-up, we demonstrate ubiquitin unfolding dynamics after rapid mixing with the chaotropic agent Guanidinium-HCl within milliseconds using only ∼ 40 nanoliters of the protein sample per scattering image. It is suggested that, in the future, this new TR-SAXS platform will help to increase the use of time-resolved small-angle X-ray scattering, wide-angle X-ray scattering and neutron scattering experiments for studying protein dynamics in the early millisecond regime. The potential research field for this set-up includes protein folding, protein misfolding, aggregation in amyloidogenic diseases, function of intrinsically disordered proteins and various protein-ligand interactions.