[Course of Revision of the Diagnosis and Treatment Protocol for COVID-19 and the Forensic Contribution]

Abstract

From January 15 to March 3, 2020, seven editions of the guidelines for the diagnosis and treatment of COVID-19 have been issued successively by the National Health Commission of the People's Republic of China, and the guidelines' name was changed from Guidelines for Diagnosis and Treatment of Novel Coronavirus Pneumonia to Diagnosis and Treatment for COVID-19. It optimized and perfected the etiology, clinical manifestations and types, diagnostic procedures and specific treatment measures of the disease, so that the clinical management of the cases was more scientific. In the revision process of guidelines for diagnosis and treatment, forensic medicine experts have also made some positive suggestions on clinical diagnosis and treatment. Especially regarding the pathological changes of COVID-19, they have repeatedly called for rapid autopsy at different levels. With the support, understanding and cooperation of all parties, pathological examination of more than ten cases of the remains were carried out, which made an important contribution to the understanding of the clinical characteristics and pathological characteristics of the disease and the improvement of treatment plans.

[Application of Two Kinds of Automatic Nucleic Acid Purifiers]

Abstract

Objective To investigate the effect of automatic nucleic acid purifiers QIAsymphony SP and QIAcube in the DNA extraction of samples of trace amount or mixed with inhibitors. Methods Different kinds of purification methods using QIAsymphony SP and QIAcube were applied to extract swabs which contained 30, 100, 150 and 300 cells and other samples which contained six types of inhibitors-heme, humic acid, lard, soil, rust and grease. PCR amplification and STR typing were performed on the extracted DNA templates to compare extracting efficiency and inhibitor removal ability of four different purification methods. Results Different purification methods showed similar extraction effects, 70.83%-100.00% of loci could be detected by amplification of DNA extracted from samples with 30, 100 and 300 cells, and the six types of inhibitors could be removed well. Conclusion The two automatic nucleic acid purifiers have a good inhibitor removal effect. For swabs with only 30 cells, after DNA extraction and amplification, the locus detection rate of samples can still be high, which can meet the requirements of local DNA laboratory work, and realize the standardization construction of the laboratory.

Analysis and Classification of Hepatitis Infections Using Raman Spectroscopy and Multiscale Convolutional Neural Networks

Hepatitis infections represent a major health concern worldwide. Numerous computer-aided approaches have been devised for the early detection of hepatitis. In this study, we propose a method for the analysis and classification of cases of hepatitis-B virus ( HBV), hepatitis-C virus (HCV), and healthy subjects using Raman spectroscopy and a multiscale convolutional neural network (MSCNN). In particular, serum samples of HBV-infected patients (435 cases), HCV-infected patients (374 cases), and healthy persons (499 cases) are analyzed via Raman spectroscopy. The differences between Raman peaks in the measured serum spectra indicate specific biomolecular differences among the three classes. The dimensionality of the spectral data is reduced through principal component analysis. Subsequently, features are extracted, and then feature normalization is applied. Next, the extracted features are used to train different classifiers, namely MSCNN, a single-scale convolutional neural network, and other traditional classifiers. Among these classifiers, the MSCNN model achieved the best outcomes with a precision of 98.89%, sensitivity of 97.44%, specificity of 94.54%, and accuracy of 94.92%. Overall, the results demonstrate that Raman spectral analysis and MSCNN can be effectively utilized for rapid screening of hepatitis B and C cases.

Catching and killing of airborne SARS-CoV-2 to control spread of COVID-19 by a heated air disinfection system

Airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via air-conditioning systems poses a significant threat for the continued escalation of the current coronavirus disease (COVID-19) pandemic. Considering that SARS-CoV-2 cannot tolerate temperatures above 70 °C, here we designed and fabricated efficient filters based on heated nickel (Ni) foam to catch and kill SARS-CoV-2. Virus test results revealed that 99.8% of the aerosolized SARS-CoV-2 was caught and killed by a single pass through a novel Ni-foam-based filter when heated up to 200 °C. In addition, the same filter was also used to catch and kill 99.9% of Bacillus anthracis, an airborne spore. This study paves the way for preventing transmission of SARS-CoV-2 and other highly infectious airborne agents in closed environments.

Catching and killing of airborne SARS-CoV-2 to control spread of COVID-19 by a heated air disinfection system

Airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via air-conditioning systems poses a significant threat for the continued escalation of the current coronavirus disease (COVID-19) pandemic. Considering that SARS-CoV-2 cannot tolerate temperatures above 70 °C, here we designed and fabricated efficient filters based on heated nickel (Ni) foam to catch and kill SARS-CoV-2. Virus test results revealed that 99.8% of the aerosolized SARS-CoV-2 was caught and killed by a single pass through a novel Ni-foam-based filter when heated up to 200 °C. In addition, the same filter was also used to catch and kill 99.9% of Bacillus anthracis, an airborne spore. This study paves the way for preventing transmission of SARS-CoV-2 and other highly infectious airborne agents in closed environments.

[Study on the best entry region and trajectory of anterior transpedicular root screws]

Objective: To evaluate the best entry region and trajectory of anterior transpedicular root screws (ATPRS). Methods: From January 2018 to May 2019, 50 cervical CT date integral of healthy people were selected from Ningbo No. 6 Hospital and were confirmed no obvious defect. Of these, 24 cases were males and 26 were females, aged 20-49 (32±5) years. The CT data was imported into Mimics by DICOM format, then 3D reconstruction was performed. In the coronal plane, the area from the centreline of the anterior of C(3-7) to the left Z-line(marked a line through the intersection of the anterior of the luschak joint and upper endplates, parallel to the centralline of the anterior of the vertebral body) was divided into nine areas. Then virtual screw with diameter of 3.5 mm was inserted. Record the length of screw of each area (L), the angle between screw and the posterior of the vertebral body in horizontal plane(α), the angle between screw and the anterior of the vertebral body in sagittal plane (β), individually. The data between groups were compared by independent sample t test. Results: The best regions were zone 9 of C(3), C(4); zone 8, 9 of C(5); zone 2-3, 5-9 of C(6); zone 1-9 of C(7) in men. And these were zone 9 of C(3); zone 3, 6, 8 and 9 of C(4), C(5); zone 2-3, 5-9 of C(6); zone 1-9 of C(7) in women. The distribution of best region was almost the same in men and women, zone 9 of each segment was the best region, and the screw length was the longest. It increased gradually from C(3) to C(7). C(3) had the least region, C(4) and C(5) had less, while C(6) and C(7) had the most. The horizontal angle of C(3-7) in men and women were 44.0°-47.2°, 40.2°-45.3° in zone 1, 4 and 7, respectively; 35.1°-41.4°, 34.6°-38.7° in zone 2, 5 and 8, respectively; 30.0°-37.2°, 30.2°-34.5° in zone 3, 6 and 9, respectively; and it demonstrated a gradually decreased trend. The sagittal angle of C(3-7) in men and women was 85.3°-97.4°, 80.5°-88.9° in zone 1-3, respectively; 101.2°-113.7°, 101.0°-109.3° in zone 4-6, respectively; 116.6°-128.8°, 119.9°-125.3° in zone 7-9, respectively; and it demonstrated a gradually increased trend. There was no significant difference in the horizontal and sagittal angle between men and women (both P>0.05). Conclusions: Anterior transpedicular root screw is a feasible internal fixation technique. It has wide region and the Z-line can be used as a reference for screw placement.

Biomarkers of Exposure for Dual Use of Electronic Cigarettes and Combustible Cigarettes: Nicotelline, NNAL, and Total Nicotine Equivalents

INTRODUCTION

Dual use of electronic cigarettes (e-cigarettes) and combustible cigarettes is a major public health issue. It is generally accepted that exclusive e-cigarette use is less harmful than exclusive combustible cigarette use, but most e-cigarette users continue to smoke combustible cigarettes as well. To what extent the use of e-cigarettes reduces harm in people who continue to smoke combustible cigarettes has been debated. The aim of this study was to explore the utility of biomarkers as measures of dual use.

METHODS

In two human studies of participants who used e-cigarettes only or both combustible cigarettes and e-cigarettes, we measured urine concentrations of the metabolites of nicotine (total nicotine equivalents) as well as two biomarkers of tobacco exposure: 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a tobacco-specific carcinogen metabolite, and nicotelline, a tobacco alkaloid not found in significant concentrations in e-cigarette products.

RESULTS

The presence of nicotine metabolites indicates either e-cigarette or combustible cigarette use. Nicotelline (half-life of 2-3 hours) indicates recent combustible cigarette use and NNAL (half-life of 10 days or more), indicates combustible cigarette use occurring within several weeks prior to sample collection.

CONCLUSIONS

Nicotelline and NNAL are useful biomarkers for combustible tobacco use in users e-cigarettes. The application of these biomarkers provides a tool to help assess whether, or to what extent, dual use of e-cigarettes and combustible cigarettes reduces harm compared to sole use of combustible cigarettes. These biomarkers can also verify exclusive use of e-cigarettes over short (24 hour) or long (several week) time periods.

IMPLICATIONS

To what extent dual use of e-cigarettes and combustible cigarettes reduce harm compared to smoking combustible cigarettes only is of considerable public health interest. We show that the levels of the minor tobacco alkaloid nicotelline and the nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) are extremely low in electronic cigarette fluids. The urine biomarkers nicotelline and the NNK metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) are indicative of cigarette smoking and can be used to assess recent and past smoking in dual users.

Community diversity and abundance of ammonia-oxidizing archaea and bacteria in shrimp pond sediment at different culture stages

AIMS

Ammonia oxidation is a significant process of nitrogen cycles in a lot of ecosystems sediments while there are few studies in shrimp culture pond (SCP) sediments. This paper attempted to explore the community diversity and abundance of ammonia-oxidizing archaea (AOA) and ammonia-oxidizing bacteria (AOB) in SCP sediments at different culture stages.

METHODS AND RESULTS

We collected SCP sediments and analysed the community diversity and abundance of AOA and bacteria in shrimp pond sediment at different culture stages using the ammonia monooxygenase (amoA) gene with quantitative PCR (qPCR) and 16S rRNA gene sequencing. The AOB-amoA gene abundance was showed higher than AOA-amoA gene abundance in SCP sediments on Day 50 and Day 60 after shrimp larvae introducing into the pond, and the diversity of AOA in SCP sediments was higher than that of AOB. The phylogenetic tree revealed that the most of AOA were the member of Nitrosopumilus and Nitrososphaera, and the majority of AOB sequences were clustered into Nitrosospira, Nitrosomonas clusters 6a and 7. The AOA community has close relationship with total organic carbon (TOC), pH, total phosphorus (TP), nitrate reductase, urease, acid phosphatase and β-glucosidase. The AOB community was related to TOC, C/N and nitrate reductase.

CONCLUSIONS

AOA and AOB play the different ecological roles in SCP sediments at different culture stages.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results suggested that the different community diversity and abundance of AOA and AOB in SCP sediments, which may improve our ecological cognition of shrimp culture stages in SCP ecosystems.

[Efficacy and safety of generic azacitidine in Chinese patients with higher-risk myelodysplastic syndromes: a multicenter, prospective, single-arm study]

Objective: To evaluate the efficacy, safety, and pharmacokinetics of the generic azacitidine in Chinese patients with higher-risk myelodysplastic syndromes(MDS). Methods: Between October 2013 and 2016, 72 patients were eligible for enrollment at 9 sites from China received generic subcutaneous azacitidine 75 mg·m(-2)·d(-1) for 7 days per 28-day cycle, for ≥6 cycles. Pharmacokinetic blood samples were collected on day 1 of a single-dose. Results: For each patient at cycle 6 or at the time of study discontinuation, whichever came first, the overall response rate, which included complete remission (CR)and partial remission(PR), was 6.9%(5/72), the rate of patients who had the best effect with CR or PR during the treatment was 12.5%(9/72). Patients who were dependent on red-blood-cell transfusions and platelet transfusions at baseline became transfusion independent were 46.3%(19/41)and 41.2% (7/17), respectively. The median time of treatment was 6 cycles, and the median OS was 16.1 months (95%CI 10.9-20.6 months). For 36 patients(50%)received treatment at ≥6 cycles, and the median OS was 22.3 months(95%CI 16.1- not evaluative). Most common grade Ⅲ-Ⅳ hematologic treatment-emergent adverse events were neutropenia(55%), leukopenia(47%), and thrombocytopenia(61%). Pharmacokinetic profiles were similar for generic and original azacitidine in Chinese patients. Conclusion: Generic azacitidine treatment was favorable and safe and can be used as a standard treatment for patients with higher-risk MDS.

Let-7 participates in the regulation of inflammatory response in spinal cord injury through PI3K/Akt signaling pathway

OBJECTIVE

To study the potential mechanism of let-7 in participating in the regulation of inflammatory response in spinal cord injury (SCI).

MATERIALS AND METHODS

A total of 40 male Sprague-Dawley rats were randomly divided into four groups: group A (Sham, n=10), group B (SCI+NC, n=10), group C (SCI+antagomir, n=10), and group D (SCI+mimics, n=10). The SCI model was established via operation in all groups. After successful modeling, let-7-antagomir negative control (80 mg/kg) was intraperitoneally injected in SCI+NC group at 5 d, an equal amount of let-7-antagomir was intraperitoneally injected in SCI+antagomir group at 5 d, and an equal amount of let-7-mimics was intraperitoneally injected in SCI+mimics group at 5 d. The inflammatory cells in experimental groups and control group were observed via hematoxylin-eosin (HE) staining. At the same time, the expression of let-7 in the four groups was detected via Reverse Transcription-Polymerase Chain Reaction (RT-PCR), the expressions of phosphatidylinositol 3-hydroxy kinase (PI3K) and protein kinase B (Akt) in all groups were detected via Western blotting, and the inflammatory index levels in each group were detected via enzyme-linked immunosorbent assay (ELISA).

RESULTS

In Sham group, it was observed via HE staining that there were only a few bleeding or inflammatory cells. In SCI+NC group, bleeding and inflammatory cells basically tended to be stable. There were a large number of inflammatory cells in SCI+mimics group, while there were some inflammatory cells in SCI+antagomir group, but showing a decreasing trend compared with SCI+NC group. It was found in the RT-PCR detection of let-7 expression level in all groups that the expression of let-7 significantly declined in SCI+antangomir group compared with that in Sham group and SCI+NC group, and there were significant differences (p<0.01). The expression of let-7 was significantly increased in SCI+mimics group compared with that in Sham group and SCI+NC group, and there were significant differences (p<0.01). The results of Western blotting revealed that the PI3K and Akt protein expressions were significantly decreased in SCI+mimics group compared with those in SCI+antagomir group, SCI+NC group, and Sham group (p<0.05). The ELISA results showed that the levels of inflammatory factors in SCI+mimics group, SCI+antagomir group, and SCI+NC group were significantly higher than those in Sham group. In SCI+mimics group, the levels of inflammatory factors were abnormally high and reached extremely significant levels (p<0.05), indicating that let-7 promotes the inflammatory response after SCI.

CONCLUSIONS

Let-7 participates in the regulation of inflammatory response in SCI through the PI3K/Akt signaling pathway.

LINC00968 accelerates the progression of epithelial ovarian cancer via mediating the cell cycle progression

OBJECTIVE

The aim of this study was to clarify the potential role of LINC00968 in the progression of epithelial ovarian cancer (EOC) and the underlying mechanism.

PATIENTS AND METHODS

The relative expression level of LINC00968 in EOC tissues (n=40) and normal ovarian tissues (n=40) was determined by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). LINC00968 expression in human-derived ovarian cancer cell lines was examined by qRT-PCR as well. After transfection of LINC00968 small-interfering RNA (siRNA) in ovarian cancer cells, cell cycle progression and cell proliferation were evaluated through flow cytometry, Cell Counting Kit-8 (CCK-8) and colony formation assay, respectively. Tumor xenograft was conducted in nude mice to elucidate the function of LINC00968 in EOC tumorigenesis in vivo. Furthermore, the relative expression levels of cell cycle factors and protein kinase B/extracellular-signal-regulated kinase (AKT/ERK) in ovarian cancer cells influenced by LINC00968 were detected by Western blot.

RESULTS

LINC00968 was significantly up-regulated in EOC tissues when compared with normal control tissues. Meanwhile, LINC00968 expression was positively correlated with the prognosis of EOC. Transfection of LINC00968 siRNA in HEY and HO8910 cells markedly attenuated proliferative ability and arrested cell cycle in the G1 phase. Knockdown of LINC00968 remarkably suppressed tumor growth of EOC in nude mice. The silence of LINC00968 significantly downregulated Cyclin D, Cyclin E and CDK4, whereas upregulated p16 and p21. In addition, AKT and ERK pathways were inhibited by knockdown of LINC00968 in ovarian cancer cells.

CONCLUSIONS

LINC00968 expression is markedly upregulated in EOC. Meanwhile, it arrests the cell cycle in the G1 phase by inhibiting the ERK and AKT pathways, thus accelerating EOC progression.

[Blood pressure control and influencing factors in hypertension patients with metabolic syndrome]

Objective: To investigate the blood pressure control and its influencing factors in hypertension patients with MS. Methods: Between January 2017 and December 2018, more than 78 000 residents aged 35-75 years selected through convenient sampling were invited to participant in China Patient-Centered Evaluative Assessment of Cardiac Event Million Persons Project in Fujian province, physical and laboratory tests were conducted for them, and their basic information were recorded. A total of 5 281 hypertension patients with MS were included in the study. Results: The treatment rate of hypertension patients with MS was 55.5%, and the control rate was 7.2%. The control rate was higher in patients who were older, women, had advanced education level, had history or family history of cardiovascular disease. The results of multivariate analysis indicated that living area (urban or rural), cardiovascular history, diabetes, urine protein, BMI had impacts on both treatment and control of hypertension. Family history of cardiovascular disease, age, self-management of hypertension, dyslipidemia, waist circumference and drinking had impacts on the treatments, and gender had effects on the control. Conclusions: The treatment rate of hypertension patients with MS was unsatisfactory and the control rate was low. Intervention should be strengthened in rural area, males and young age groups, and activity of self-management group of hypertension should be conducted regularly.

[Interpretation for the group standards in guidelines for personal protection against coronavirus disease 2019 for diseases control person]

As an emerging infectious disease, the COVID-19 threatened the safety of personnel in the prevention and control during the COVID-19 pandemic. Beijing Association of Preventive Medicine organizes the Beijing CDC and other organizations drafted the group standard entitled "Guidelines for personal protection against coronavirus disease 2019 for diseases control person (T/BPMA 0002-2020)" , according to years of scientific research on personal protection. Based on the principles of emphasizing the scientific, normative and safe nature, the standard was drafted to put forward the reasonable selection and correct use of personal protective equipment for disease control personnel, as well as the procedures for personal protective equipment. The standard provided a standardized basis for ensuring the safety of disease control personnel in contacting and handling of the new coronary pneumonia outbreaks with high risks.

Stillbirths in China: a nationwide survey

Objective

To estimate a stillbirth rate at 24 or more gestational weeks in 2015–2016 and to explore potentially preventable causes in China.

Design

A multi‐centre cross‐sectional study.

Setting

Ninety‐six hospitals distributed in 24 (of 34) provinces in China.

Population

A total of 75 132 births at 24 completed weeks of gestation or more.

Methods

COX Proportional Hazard Models were performed to examine risk factors for antepartum and intrapartum stillbirths. Population attributable risk percentage was calculated for major risk factors. Correspondence analysis was used to explore region‐specific risk factors for stillbirths.

Main outcome measures

Stillbirth rate and risk factors for stillbirth.

Results

A total of 75 132 births including 949 stillbirths were used for the final analysis, giving a weighted stillbirth rate of 13.2 per 1000 births (95% CI 7.9–18.5). Small for gestational age (SGA) and pre‐eclampsia/eclampsia increased antepartum stillbirths by 26.2% and 11.7%, respectively. Fetal anomalies increased antepartum and intrapartum stillbirths by 17.9% and 7.4%, respectively. Overall, 31.4% of all stillbirths were potentially preventable. Advanced maternal age, pre‐pregnant obesity, chronic hypertension and diabetes mellitus were important risk factors in East China; low education and SGA were major risk factors in Northwest, Southwest, Northeast and South China; and pre‐eclampsia/eclampsia and intrapartum complications were significant risk factors in Central China.

Conclusions

The prevalence of stillbirth was 13.2 per 1000 births in China in 2015–2016. Nearly one‐third of all stillbirths may be preventable. Strategies based on regional characteristics should be considered to reduce further the burden of stillbirths in China.

Tweetable abstract

The stillbirth rate was 13.2 per 1000 births in China in 2015–2016 and nearly one‐third of all stillbirths may be preventable.

The stillbirth rate was 13.2 per 1000 births in China in 2015–2016 and nearly one‐third of all stillbirths may be preventable.

The FDA-Approved Drug Nelfinavir Inhibits Lytic Cell-Free but Not Cell-Associated Nonlytic Transmission of Human Adenovirus

Adenoviruses (AdVs) are prevalent and give rise to chronic and recurrent disease. Human AdV (HAdV) species B and C, such as HAdV-C2, -C5, and -B14, cause respiratory disease and constitute a health threat for immunocompromised individuals. HAdV-Cs are well known for lysing cells owing to the E3 CR1-β-encoded adenovirus death protein (ADP). We previously reported a high-throughput image-based screening framework and identified an inhibitor of HAdV-C2 multiround infection, nelfinavir mesylate. Nelfinavir is the active ingredient of Viracept, an FDA-approved inhibitor of human immunodeficiency virus (HIV) aspartyl protease that is used to treat AIDS. It is not effective against single-round HAdV infections. Here, we show that nelfinavir inhibits lytic cell-free transmission of HAdV, indicated by the suppression of comet-shaped infection foci in cell culture. Comet-shaped foci occur upon convection-based transmission of cell-free viral particles from an infected cell to neighboring uninfected cells. HAdV lacking ADP was insensitive to nelfinavir but gave rise to comet-shaped foci, indicating that ADP enhances but is not required for cell lysis. This was supported by the notion that HAdV-B14 and -B14p1 lacking ADP were highly sensitive to nelfinavir, although HAdV-A31, -B3, -B7, -B11, -B16, -B21, -D8, -D30, and -D37 were less sensitive. Conspicuously, nelfinavir uncovered slow-growing round HAdV-C2 foci, independent of neutralizing antibodies in the medium, indicative of nonlytic cell-to-cell transmission. Our study demonstrates the repurposing potential of nelfinavir with postexposure efficacy against different HAdVs and describes an alternative nonlytic cell-to-cell transmission mode of HAdV.

Older age of childhood type 1 diabetes onset is associated with islet autoantibody positivity >30 years later: the Pittsburgh Epidemiology of Diabetes Complications Study

AIMS

To examine the association between islet autoantibody positivity and clinical characteristics, residual β-cell function (C-peptide) and prevalence of complications in a childhood-onset (age <17 years), long-duration (≥32 years) type 1 diabetes cohort.

METHODS

Islet autoantibodies (glutamic acid decarboxylase, insulinoma-associated protein 2 and zinc transporter-8 antibodies) were measured in the serum of participants who attended the 2011-2013 Pittsburgh Epidemiology of Diabetes Complications study follow-up examination (n=177, mean age 51 years, diabetes duration 43 years).

RESULTS

Prevalences of islet autoantibodies were: glutamic acid decarboxylase, 32%; insulinoma-associated protein 2, 22%; and zinc transporter-8, 4%. Positivity for each islet autoantibody was associated with older age at diabetes onset (glutamic acid decarboxylase antibodies, P=0.03; insulinoma-associated protein 2 antibodies, P=0.001; zinc transporter-8 antibodies, P<0.0001). Older age at onset was also associated with an increasing number of autoantibodies (P = 0.001). Glutamic acid decarboxylase antibody positivity was also associated with lower HbA_1c (P = 0.02), insulinoma-associated protein 2 antibody positivity was associated with lower prevalence of severe hypoglycaemic episodes (P=0.02) and both distal and autonomic neuropathy (P=0.04 for both), and zinc transporter-8 antibody positivity was associated with higher total and LDL cholesterol (P=0.01). No association between autoantibody positivity and C-peptide was observed.

CONCLUSIONS

The strong association between islet autoantibody positivity and older age at type 1 diabetes onset supports the hypothesis of a less aggressive, and thus more persistent, immune process in those with older age at onset. This observation suggests that there may be long-term persistence of heterogeneity in the underlying autoimmune process.