Euthyroid graves' ophthalmopathy in a Chinese population: A cross-sectional follow-up study

OBJECTIVES

A subtype of patients with thyroid eye disease (TED) were found to be euthyroid without prior thyroid dysfunction or treatment, known as Euthyroid Graves' Ophthalmopathy (EGO). We report the prevalence, clinical and serological phenotypes of EGO in a Chinese population.

METHODS

A cross-sectional follow-up study. Ethnic Chinese TED patients were managed at the Thyroid Eye Clinic(TEC), Prince of Wales Hospital and TEC, the Chinese University of Hong Kong between September 2007 and July 2021.

RESULTS

A total of 66 (5%) patients among the 1266 ethnic Han Chinese TED cohort were diagnosed as EGO, and 6 (9%)of them become dysthyroid over an average of 74-month follow-up. EGO patients were associated with a longer duration between onset of the symptoms to our first consultation (P < 0.0001), a higher male-to-female ratio (P = 0.0045) and a higher age of disease onset (P = 0.0092). Family history of thyroid disease was more common in TED patients (P = 0.0216) than in EGO patients. EGO patients were more likely to present unilaterally (P < 0.0001), and they have a larger difference in MRD1 (P < 0.0001), and extraocular motility (P < 0.0001) between the 2 eyes when compared to the TED patients. Notably, the extraocular motility restriction of the worst eye was more affected in EGO patients (P = 0.0113). The percentages of patients who received IVMP, ORT and emergency or elective surgeries(decompression or squint operation) between EGO and TED were similar.

CONCLUSIONS

Understanding the important clinical phenotypes of EGO may help the clinician to make the correct diagnosis. Further study to compare EGO and TED is warranted.

AB0458 SURVIVAL OF SCLERODERMA PATIENTS WITH INTERSTITIAL LUNG DISEASE: OBSERVATION DATA FROM A MALAYSIAN TERTIARY CENTRE

Background:

Interstitial lung disease (ILD) is the leading cause of death in scleroderma (SSc) with decline in FVC as a predictor of mortality in patients with SSc-ILD, especially in the early course of the disease.

Objectives:

The aim of this study is to determine the survival rate of SSc-ILD in a Malaysian cohort of patients from University Malaya Medical Centre (UMMC).

Methods:

61 patients clinically diagnosed with SSc-ILD were identified and prospectively recruited. Baseline demographic data were collected. Kaplan-Meier analysis was used to estimate the survival.

Results:

Females were predominant (56, 91.8%). 39 (64%) had limited cutaneous SSc. Majority were ethnicity Chinese 30 (49.2%), followed by Malays 20 (32.8%), Indians 7 (11.4%) and others 4 (6.6%). Mean age was 56.25 (SD ± 12.5) years while mean duration of disease (non-Raynaud’s disease onset) was 10.5 years (SD ± 9.2) (range of 1 year to 44 years) years. 29 (47.5%) patients were positive for anti-ScL-70, whereas 6 (9.8%) patients were anti-centromere positive. There were 16 (26.2%) deaths. Median survival was 24 years. Patients had a sharper drop in survival probability for the first 10 years compared to the next 20 years (Figure 1). Median survival in limited subset was 24 years whereas in diffuse subset was 11 years. Patients from the limited subset appeared to have higher chance of surviving for 10 years and above, compared to those in the diffuse subset (Figure 2).

Conclusion:

The results demonstrate the poor survival in SSc-ILD patients. The survival rate tends to be worse in the first 10 years of SSc disease duration. Survival rate was poorer in patients with diffuse cutaneous subset.

References:

[1]Parelas A et al. Lancet Resp Med 2020

[2]Goh NS et al. Am J Respir Crit Care Med 2008

Disclosure of Interests:

JASMIN RAJA Speakers bureau: For Boehringer Ingelheim for topic on Scleroderma-ILD, Grant/research support from: From Boehringer Ingelheim for scleroderma research, Shantini Muthusamy: None declared., CHOUNG MIN NG: None declared.

SAT0597 EARLY DAMAGE AS MEASURED BY SLICC/ACR DAMAGE INDEX IS A PREDICTOR OF HOSPITALIZATION IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

Hospital admissions and re-admissions in lupus patients are common occurrences that can lead to mortality. The predictive factors influencing hospitalizations and mortality are variable in literature.

Objectives:

We evaluated the leading causes of hospitalizations and mortality and their predictive factors in the multi-ethnic SLE patients.

Methods:

A retrospective study was done on SLE patients from University Malaya Medical Centre and diagnosed for at least 1 year. Data were collected from 1988 until 2019. Demographic and disease details, causes of hospital admissions and mortality were reviewed from electronic medical records. Baseline and latest disease activity (SLEDAI 2K) and SLICC/ACR damage index (SDI) scores were evaluated.

Results:

A total of 300 SLE patients, 285 (95%) of whom were females were included in this study. Majority were of Chinese ethnicity 150 (50%), followed by Malays 108 (36%), Indians 39 (13%) and others 3 (1%). The cohort’s median age was 48 (18-82) years and median disease duration was 14 (1-72) years. Median age at SLE diagnosis was 27.5 (6-72) years. 133 (44.3%) had SDI score of ≥1 at baseline (early damage). 23% had developed new organ damage during this study period.

There were 222 (74%) patients ever hospitalized and 12 (5.4%) deaths from this cohort. The main cause of hospitalization was lupus flare which included concurrent infection (n=415 admissions, 46%), followed by elective admissions for procedures and others (n=284 admissions, 31.5%). 17% of admissions were due to infections with concurrent flare (8.7% were due to infection alone). Admissions for treatment and disease related complications were 13.8%. Median length of stay for SLE related cause admissions was longer compared to non-SLE related causes, 10 (range 1-113) vs 7.5 (range 1-130) days. Causes of death included SLE flare without features of infection (25%), concurrent lupus flare and infection (25%), and non-SLE causes (50%). Malignancy (33.3%) was the main cause of death in non-SLE deaths. Independent predictive factors for hospitalization and mortality are shown in Table 1 and Table 2.

Table 1.

Multivariate logistic regression analysis for the predictors of hospitalization

HOSPITALIZATIONParametersB CoefficientOR (95% C. I)p valueEthnicity Malay2.0057.428 (0.181-226.883)0.26 Chinese1.2873.623 (0.089-106.163)0.47 Indian1.6955.446 (0.126-177.222)0.35Disease Duration- 0.0150.985 (0.953-1.020)0.40Comorbids ≥ 21.6735.328 (0.843-105.481)0.14APLS1.7845.956 (1.883-26.685)0.001*Serology markers Anti-Smith1.8406.298 (1.733-40.638)0.01* Anti-SSA1.2113.360 (1.758-6.640)<0.001*ACR Serositis2.65614.248 (2.555-275.071)0.01* Neurological1.7065.506(1.403-36.834)0.01*SCORES SDI Baseline0.5521.737 (1.062-3.048)0.01*Table 2.

Multiple logistic regression analysis of the predictors for mortality

MORTALITYParametersB CoefficientOR (95% C. I)p valueDisease duration0.0951.099 (1.031-1.183)0.001*Comorbids ≥23.16123.618 (1.997-344.533)0.01*APLS2.55612.888 (1.592-136.512)0.01*SDI Renal2.1678.734 (1.385-80.528)0.01* Malignancy3.93651.218 (6.725-616.957)0.001* Pulmonary1.6965.452 (0.684-41.395)0.1SCORES SLEDAI latest0.2751.316 (1.161-1.556)0.001*

Conclusion:

Early damage in lupus as measured by SDI is of predictive value of hospitalization. Optimization in managing patients with pre-existing damage is crucial to reduce hospitalization risk and subsequent complications.

References:

[1]GP Rosa,et al. Causes and factors related to hospitalizations in patients with SLE: analysis of a 20-year period (1995–2015) from a single referral centre in Catalonia.Lupus. 2019;28(9):1158-66.

[2]P Rahman,et al.Early damage as measured by the SLICC/ACR damage index is a predictor of mortality in SLE.Lupus. 2001;10(2), 93-6.

Disclosure of Interests:

None declared

Associations of pre-pregnancy body mass index, middle-upper arm circumference, and gestational weight gain

OBJECTIVES

An optimal gestational weight gain is essential for maternal health and to reduce adverse birth outcomes. Current guidelines to monitor gestational weight gain are based on pre-pregnancy body mass index (BMI). However, middle-upper arm circumference (MUAC) is increasingly used as an alternative nutritional status measure for pregnant women. Hence, this study aimed to determine associations of MUAC and pre-pregnancy BMI with gestational weight gain rate among Malaysian pregnant women.

STUDY DESIGN

A cross-sectional study was conducted among 444 pregnant women (≥20 weeks gestation).

MAIN OUTCOMES MEASURES

Women completed questionnaires on sociodemographic data, maternal characteristics and pre-pregnancy weight. Height, current weight and MUAC were measured at study visit (from 1st February 2016 to 31st January 2017).

RESULTS

About a third (34.24%) of pregnant women were overweight or obese prior to pregnancy. MUAC was inversely associated with an inadequate rate of gestational weight gain (OR = 0.77; 95% CI: 0.68, 0.87) as compared to normal gestational weight gain. In contrast, a higher MUAC was associated with a higher odds ratio (OR = 1.28; 95% CI: 1.11, 1.49) of having excessive rate of gestational weight. No associations were found for pre-pregnancy BMI categories for gestational weight gain rate.

CONCLUSION

Our findings revealed that women with low MUAC were more likely to have an inadequate gestational weight gain rate during pregnancy whereas higher MUAC was associated with an excessive gestational weight gain rate. MUAC may be a useful indicator of nutritional status associated with GWG. Routine measurement of MUAC in pregnant women may help health professionals, particularly in middle-income countries, to counsel women about gestational weight gain.

Clinical utility of late-night and post-overnight dexamethasone suppression salivary cortisone for the investigation of Cushing's syndrome

INTRODUCTION

There is a pressing need to identify diagnostic testing for Cushing's syndrome that can be achieved with ease and at low cost. This study aimed to explore the usefulness of late-night and post-overnight 1-mg dexamethasone suppression salivary cortisone, as measured by liquid chromatography-tandem mass spectrometry, for investigation of hypercortisolism.

METHODS

Salivary cortisone data of subjects were investigated according to a pre-specified protocol. Subjects were classified as having 'hypercortisolism' or 'eucortisolism' on the basis of histological or biochemical criteria. Receiver operating characteristic curves were drawn to identify the cut-off values and study their performance characteristics. We measured 24-hour urinary free cortisol; late-night salivary cortisol and cortisone; and post-overnight 1-mg dexamethasone suppression serum cortisol, and salivary cortisol and cortisone. Saliva and urine samples were assayed by liquid chromatography-tandem mass spectrometry.

RESULTS

In this study, 21 subjects were classified as having hypercortisolism and 78 as having eucortisolism. A late-night salivary cortisone cut-off of 13.50 nmol/L had a sensitivity of 94.7% and a specificity of 87.2%. After taking 1-mg dexamethasone the night before, a salivary cortisol cut-off of 0.85 nmol/L had a sensitivity of 76.2% and a specificity of 96.2%; a salivary cortisone cut-off of 7.45 nmol/L had a sensitivity of 85.7% and a specificity of 94.9%, while a salivary cortisone cut-off of 3.25 nmol/L had a sensitivity of 95.2% and a specificity of 79.5%. Many salivary cortisol samples were below the detection limit of liquid chromatography-tandem mass spectrometry. In comparison with salivary cortisol, salivary cortisone had a better correlation with total serum cortisol and better diagnostic performance following dexamethasone suppression.

CONCLUSIONS

Both late-night and post-overnight dexamethasone suppression salivary cortisone levels are of diagnostic value in the investigation of hypercortisolism.

Novel hybrid GPU-CPU implementation of parallelized Monte Carlo parametric expectation maximization estimation method for population pharmacokinetic data analysis

The development of a population PK/PD model, an essential component for model-based drug development, is both time- and labor-intensive. A graphical-processing unit (GPU) computing technology has been proposed and used to accelerate many scientific computations. The objective of this study was to develop a hybrid GPU-CPU implementation of parallelized Monte Carlo parametric expectation maximization (MCPEM) estimation algorithm for population PK data analysis. A hybrid GPU-CPU implementation of the MCPEM algorithm (MCPEMGPU) and identical algorithm that is designed for the single CPU (MCPEMCPU) were developed using MATLAB in a single computer equipped with dual Xeon 6-Core E5690 CPU and a NVIDIA Tesla C2070 GPU parallel computing card that contained 448 stream processors. Two different PK models with rich/sparse sampling design schemes were used to simulate population data in assessing the performance of MCPEMCPU and MCPEMGPU. Results were analyzed by comparing the parameter estimation and model computation times. Speedup factor was used to assess the relative benefit of parallelized MCPEMGPU over MCPEMCPU in shortening model computation time. The MCPEMGPU consistently achieved shorter computation time than the MCPEMCPU and can offer more than 48-fold speedup using a single GPU card. The novel hybrid GPU-CPU implementation of parallelized MCPEM algorithm developed in this study holds a great promise in serving as the core for the next-generation of modeling software for population PK/PD analysis.

Hypertriglyceridaemia-induced pancreatitis: a contributory role of capecitabine?

Capecitabine is an orally administered pro-drug of 5-fluorouracil that confers superior disease-free survival and presumably has a more favourable side-effect profile. Here we report on a patient who developed acute necrotising pancreatitis and very high triglyceride levels as well as hand-foot syndrome after receiving capecitabine for colonic cancer. Increased awareness of this potential side-effect and close monitoring of lipid levels may be warranted, especially in patients who have other conditions predisposing them to severe secondary hyperlipidaemia when using this drug.

The Chinese version of the pelvic pain and urgency/frequency symptom scale: a useful assessment tool for street-ketamine abusers with lower urinary tract symptoms

OBJECTIVE

To investigate the use of a translated Chinese version of the pelvic pain and urgency/frequency symptom scale as an assessment and prognostic tool to evaluate the severity of street-ketamine-associated lower urinary tract symptoms and their reversibility after abstinence.

DESIGN

Cross-sectional study.

SETTING

A special designated out-patient clinic in a regional hospital in Hong Kong.

PARTICIPANTS

There were 50 patients with street-ketamine-associated lower urinary tract symptoms and 20 healthy individuals.

MAIN OUTCOME MEASURES

Reliability and validity of the questionnaire; frequency of individual lower urinary tract symptoms, cystoscopic, urodynamic and radiological abnormalities, and their correlation with pelvic pain and the urgency/frequency score.

RESULTS

The test-retest reliability coefficient was 0.755 (P<0.001). Cronbach's alpha was 0.974. Mann-Whitney U test proved the discriminatory ability of the questionnaire (P<0.001). Patients with specific lower urinary tract symptoms had a higher mean pelvic pain and urgency/frequency total score compared to those without them: frequency (23.8 vs 17.3), nocturia (22.4 vs 14.0), urgency (22.5 vs 15.1), dysuria (22.7 vs 13.3), and haematuria (24.8 vs 16.2). The number of daytime voids and nocturia episodes correlated well with pelvic pain and urgency/frequency scores. With an increasing score, the likelihood of having cystitis changes, urodynamic abnormalities and hydronephrosis increased, while the cystometrically determined bladder capacity decreased. None of the patients with a score of 16 or below had urodynamic abnormality or hydronephrosis. The mean score change in the abstinence group was -4.33, versus +3.33 in their counterparts.

CONCLUSIONS

The Chinese version of the pelvic pain and urgency/frequency questionnaire is reliable and valid for assessment in patients with street-ketamine-associated lower urinary tract symptoms. The pelvic pain and urgency/frequency score correlates well with symptom severity as well as endoscopic, urodynamic and radiological abnormalities in patients with street-ketamine-associated lower urinary tract symptoms. A cut-off total pelvic pain and urgency/frequency score of 17 may suggest more serious urological sequelae from ketamine abuse. Abstinence from ketamine reduced lower urinary tract symptoms, but the extent of reversibility of urinary tract damage is yet to be evaluated.

Structural and magnetic properties of ZnO nanocrystals in (Zn, Al)O films using pulse laser deposition

In this manuscript, we reported that the room temperature ferromagnetism was observed in (Zn0.70, Al0.30)O film, which was fabricated by a novel physical method (pulse laser deposition (PLD)). The film was deposited from (Zn0.80, Al0.20)O ceramic target onto quartz (110) substrate by PLD at 400 degrees C under an oxygen partial pressure of 10(-4) torr. TEM result shows ZnO NCs with diameter of 4-5 nm and they are quite uniformly embedded into amorphous ZnO-Al2O3 phase. The SAED shows clearly that ZnO NCs possess polycrystalline structure. The SQUID measurement shows that the film has room temperature ferromagnetism (saturation magnetization = 3.6 emu/cm3) with Curie temperature above 300 K. The magnitude of magnetic moment of the films can be changed by tuning ZnO NCs size. Both oxygen partial pressure and film thickness studies show that the origin of ferromagnetism is possibly related to the oxygen defects at the surface of ZnO NCs.

Prevalence and significance of white-coat hypertension and masked hypertension in type 2 diabetics

OBJECTIVES

To explore the prevalence of various categories of hypertension in diabetic patients, and assess any corresponding associations with end-organ complications.

DESIGN

Cross-sectional study.

SETTING

Tertiary centre of a regional hospital in Hong Kong.

PATIENTS

All ambulatory type 2 diabetic patients attending our clinics from January 2002 to November 2004 were invited to participate in the protocol.

RESULTS

A total of 133 diabetic patients were included; 82 had normal clinic blood pressures, 15 (18%) of whom had masked hypertension, the remaining 67 (82%) had 'normotension'. The remaining 51 patients had high clinic blood pressures, of whom 28 (55%) had white-coat hypertension and 23 (45%) had sustained hypertension. Urinary albumin excretion rate was higher in patients with masked hypertension (10 mg/day; range, 7-580 mg/day) and sustained hypertension (7 mg/day; 7-3360 mg/day) in comparison to those with white-coat hypertension (7 mg/day; 7-109 mg/day) or 'normotension' (7 mg/day; 7-181 mg/day) [P<0.01]. Likewise, the prevalence of albuminuria was significantly higher in patients with masked hypertension (40%) and sustained hypertension (26%) than in those with 'normotension' (6%) and white-coat hypertension (11%) [P<0.01]. The prevalence of left ventricular hypertrophy was significantly higher in subjects with masked hypertension (38%) and sustained hypertension (26%) compared to patients with 'normotension' (8%) or white-coat hypertension (11%) [P<0.01]. Left ventricular diastolic dysfunction was more prevalent in patients with masked hypertension (46%), sustained hypertension (48%), and white-coat hypertension (43%) in comparison to subjects with 'normotension' (18%) [P=0.01].

CONCLUSION

Masked hypertension is associated with a higher prevalence of albuminuria, left ventricular diastolic dysfunction, and hypertrophy. White-coat hypertension carries a more benign prognosis than sustained hypertension and masked hypertension. Our cross-sectional study supports the recommendation to performing ambulatory blood pressure measurements in type 2 diabetic patients.

Bilateral epidural extension of thoracic capillary vertebral (intraosseous) hemangioma mimicking spinal meningioma

We describe a rare case of vertebra (intraosseous) hemangioma with bilateral and symmetrical epidural extension causing cord compression in a 24-year-old woman. The epidural component was isointense to cord on both T1 and T2 sequences, and enhanced markedly and homogenously following gadolinium administration. The gradual in onset and progressive nature with the typical enhancing pattern lead the neurosurgeon to the more common diagnosis of spinal meningioma. Epidural extension of vertebral hemangiomas causing cord compression is rarely reported. Review of literatures reveal that cases that have been reported are of unilateral extension into epidural space and of cavernous type. This is the first case report of capillary vertebral (intraossous) hemangioma with bilateral extension through both intervetebral foramen into the epidural space causing myelopathy.

Semi-physiological pharmacokinetic-pharmacodynamic (PK/PD) models for troxacitabine-induced neutropenia and thrombocytopenia

13002

Background: Neutropenia and thrombocytopenia are the dose-limiting toxicities of troxacitabine in Phase 1 studies. The present study’s aim was to develop a novel semi-physiological PK/PD model that can simultaneously describe the time course of the absolute neutrophil and platelet count changes in cancer patients receiving troxacitabine. Methods: The mixed-effect modeling was performed using the Monte-Carlo Parametric Expectation Maximization algorithm implemented in SADAPT program. The analysis was based on PK/PD data from 31 subjects who received troxacitabine/cisplatin combination every 28 days at five different dose levels (4.8/50, 4.8/75, 6.4/50, 6.4/75, 8.0/75 mg/m2). The PD model consisted of 1) a troxicatabine-sensitive uncommitted progenitor cell compartment, which differentiates into committed neutrophil and platelet progenitor cells that are also sensitive to the troxacitabine, and 2) transit compartments for neutrophils and platelets that represent maturation stages in bone marrow. To capture the rebound phenomena and maintain the hemostasis, the model included a feedback mechanism for both neutrophils and platelets. The troxacitabine concentrationtion-time profiles affected the proliferation of sensitive progenitor cells through an inhibitory sigmoidal Emax model. A three-compartment linear pharmacokinetic model was developed to describe the troxaicibatine concentration-time profile. Results: The PD model described the time-course of troxacitabine- induced neutrophil and platelet cytopenias and accounted for the large observed inter-patient variability. The model predicted that neutrophil progenitor cells were more sensitive to troxacitabine therapy compared to platelet progenitor cells. Furthermore, the model suggested that the troxacitabine-induced neutropenia and thrombocytopenia are reversible and non-cumulative events. Conclusions: This novel model can describe both the intensity and duration of troxacitabine-induced thrombocytopenia and neutropenia rather than simply considering the nadir values. It may be valuable for selecting treatment regimens that minimize troxacitabine’s dose-limiting hematological toxicities.

No significant financial relationships to disclose.

Use of lithium in the treatment of thyrotoxicosis

OBJECTIVES

To evaluate the efficacy and safety of lithium in the treatment of thyrotoxicosis, and to study the dose and serum levels at which therapeutic response occurs.

DESIGN

Retrospective study.

SETTING

Thyroid clinic of a regional hospital in Hong Kong.

PATIENTS

Thirteen patients with thyrotoxicosis pending therapy with radioiodine or surgery, in whom thionamides were contra-indicated due to adverse reactions or failure of treatment.

MAIN OUTCOME MEASURES

Free thyroxine levels, time to euthyroidism, and side-effects of lithium.

RESULTS

A satisfactory response, defined as a fall by 40% or more in free thyroxine levels and clinical improvement, was achieved in eight patients within 1 to 2 weeks of lithium therapy. In four others, response occurred in 3 to 5 weeks. Response was slow and inadequate in one patient due to 'escape'. The median dosage of lithium was 750 mg daily, with a range of 500 to 1500 mg daily. The median serum lithium level was 0.63 mmol/L. Lithium toxicity was observed in one patient.

CONCLUSIONS

A relatively low dose of lithium offers a safe and effective alternative means of controlling thyrotoxicosis in patients who cannot tolerate or do not respond to thionamides.

Combined orbital irradiation and systemic steroids compared with systemic steroids alone in the management of moderate-to-severe Graves' ophthalmopathy: a preliminary study

OBJECTIVE

To assess the efficacy and safety of combined orbital irradiation and systemic steroids in the management of moderate-to-severe Graves' ophthalmopathy.

DESIGN

Single-blind randomised prospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Sixteen patients with active moderate-to-severe Graves' ophthalmopathy who were randomly assigned to steroid therapy (ST group) or combination therapy of orbital irradiation and systemic steroids (SRT group) between June 2000 and June 2003.

MAIN OUTCOME MEASURES

NOSPECS scoring system, total eye score, subjective eye score, and extra-ocular muscle thickness as determined by either computed tomographic or magnetic resonance imaging scans.

RESULTS

The study was completed by 15 of 16 patients. Both groups experienced improvement in total eye score, soft tissue swelling, ocular motility, visual acuity, and subjective eye score at 52-week follow-up. Total eye score improved earlier in the SRT group, achieving statistical significance (P<0.05) at as early as 4 weeks of follow-up. Improvement in ocular parameters was greater and led to a significantly greater reduction in total eye score than in the ST group at weeks 16, 24, and 52. Maximum extra-ocular muscle thickness was significantly reduced in the SRT group only. No change was observed in proptosis in either group. No serious adverse effect was observed with the addition of orbital irradiation to steroid therapy.

CONCLUSION

A combination of orbital irradiation and systemic steroids is well tolerated and more effective than steroids alone in the treatment of active moderate-to-severe Graves' ophthalmopathy. It achieves greater and more rapid improvement in soft tissue swelling, ocular motility, and visual acuity.

HLA-DRB1*04 alleles in psoriatic arthritis: comparison with rheumatoid arthritis and healthy controls

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis usually seronegative for rheumatoid factor. An increased frequency of HLA-DR4 has been noted in PsA, particularly among patients with a rheumatoid arthritis like (RA) arthritis. The aim of the current investigation was to compare HLA-DRB1*04 alleles in patients with PsA, patients with RA, and healthy controls. Sample size calculations based on the frequency of HLA-DR4 suggested that 90 individuals in each patient group would be sufficient to address our question. Therefore, 90 HLA-DRB1*04 positive patients from each patient group underwent high resolution molecular typing and were included in this study. Although HLA-DRB1*0401 was the most frequent allele in all groups, its frequency among the PsA patients was lower than that of RA patients and controls. HLA-DRB1*0402 was higher among patients with PsA. Patients with RA were more likely to have more than one shared epitope allele than either PsA or the healthy control group. HLA-DQB1 alleles did not contribute further information. We suggest that the differences in the class II HLA epitope(s) may also be related to interaction specificity with another molecule functioning in the immune response to a putative arthritogenic antigen and result in differences in disease expression.

HLA-C locus alleles in patients with psoriatic arthritis (PsA)

The aim of this investigation was to compare the frequency of alleles at the HLA-C locus in patients with psoriatic arthritis to that in the disease free population and to relate the HLA genes to disease phenotype in psoriatic arthritis (PsA). Ninety-four consecutive patients seen in the (PsA) clinic between April and July 1996 and 100 disease-free controls had HLA typing performed by both serologic and molecular techniques. Patients' disease was assessed according to a standard protocol. Fisher's exact test was used to compare the frequency of HLA alleles in the patients and controls. HLA-C determined by PCR-SSP decreased the frequency of non-identified, that is, "blank" (or null) alleles to 6% in patients and controls. HLA-Cw*0602 was present in 32 patients and 18 controls: allele frequency of 17% in the patients versus 9% in the controls (p < 0.01). Amongst patients with psoriatic arthritis, those who carried the HLA-Cw*0602 allele had a significantly earlier mean age of onset of their psoriasis (p = 0.003). This study confirms that molecular DNA techniques improve detection of C-locus alleles. The HLA-Cw*0602 is increased amongst patients with psoriatic arthritis compared to controls. The HLA-Cw*0602 is associated with an earlier age of onset of psoriasis.

Acute intestinal graft-versus-host disease in a syngeneic bone marrow transplant recipient

BACKGROUND

We report a case of intestinal graft-versus-host disease (GVHD) in a syngeneic bone marrow transplant patient.

METHODS

Several days after receiving a bone marrow transplant from his identical twin for treatment of non-Hodgkin's lymphoma, a 47-year-old man developed a skin rash and diarrhea.

RESULTS

A colonic biopsy on day +15 revealed characteristic changes of acute intestinal GVHD. Molecular studies (microsatellite DNA and HLA sequence-specific primer polymerase chain reaction analyses) confirmed the genotypic identity of donor and host and the improbability of transfusion-associated GVHD.

CONCLUSION

This case illustrates that pathological evidence of GVHD does not absolutely require the presence of genetic differences between host and donor and questions existing concepts about the nature of cyclosporine-induced GVHD.

Meta-analysis of streptokinase and heparin in deep vein thrombosis

The efficacy and safety of streptokinase and heparin in deep vein thrombosis (DVT) were compared in a meta-analysis. Randomized trials in which streptokinase (followed by heparin) and heparin alone were compared in treating phlebographically documented acute DVT were identified from MEDLINE and other sources for a meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) based on the logit method were computed for each study. A fixed-effect model was used to combine the study results, enabling differences between streptokinase recipients and recipients of heparin alone to be expressed as summary ORs with 95% CIs. Significantly more streptokinase recipients achieved thrombolysis than recipients of heparin alone (summary OR, 6.24; 95% CI, 3.62 to 10.78). One study was identified as an outlier and excluded from the analysis. The meta-analysis then showed that streptokinase recipients were significantly less likely to have postthrombotic changes (summary OR, 0.40; 95% CI, 0.18 to 0.88) and postphlebitic changes (summary OR, 0.32; 95% CI, 0.12 to 0.86) in phlebographic evaluation. The frequency of major bleeding was significantly higher among streptokinase recipients than recipients of heparin alone (summary OR, 3.78; 95% CI, 1.26 to 11.32). A meta-analysis showed that, compared with heparin alone, streptokinase therapy for DVT was associated with significantly more frequent thrombolysis and major bleeding; after exclusion of one outlying study, analysis showed that streptokinase therapy was associated less frequently than heparin alone with postthrombotic changes (assessed by phlebographic evaluation) and postphlebitic syndrome.

HLA-DR 52- and 51-associated DRB1 alleles in Kenya, east Africa

The genes of the major histocompatibility complex (MHC) are amongst the most polymorphic loci known in the human population. The population genetics of the MHC encoded HLA loci of sub-Saharan Africa are of major interest because of their particular genetic diversity. Here we report on the HLA-DR 52- and 51-associated determinants of the DRB1 loci observed in 165 East African individuals studied in Nairobi, Kenya. The HLA-DR typing was done by serologic and by molecular DNA techniques (PCR-SSOP). The most frequent allele identified was DRB1*1101, followed by DRB1*1503 and DRB1*1302. Some unexpected alleles were repeatedly identified: DRB1*1108, DRB1*1316 and DRB1*1421. Most of the DR 52- and 51-associated DRB1 alleles were correctly identified by serology as part of the DR3, DR5, DR6 and DR2 groups respectively. The HLA-DRB1 profile reported here corroborates previous genetic and linguistic data supporting the concept that the Eastern African Black population is genetically distinct from other African Black populations. This has important implications in public health issues related to the genetic profile of a population (transplantation, vaccine design for example).

Microsecond rotational dynamics of F-actin in ActoS1 filaments during ATP hydrolysis

Rabbit skeletal muscle F-actin labeled at Cys374 with the triplet probe erythrosin-5-iodoacetamide had a steady-state phosphorescence anisotropy (rp) of 0.090 +/- 0.005 at 20 degrees C in 100 mM KCl, pH 7.0, buffer. Titration with skeletal muscle S1 fragment increased rp to 0.138 +/- 0.006 at a mole ratio of 1:1. In the presence of ATP, the anisotropy of the actoS1 complex initially decreased to 0.050 +/- 0.005, a value significantly smaller than the anisotropy of pure F-actin; rp subsequently increased to 0.126 +/- 0.002. The time course of the increase matched that expected from the measured actin-activated ATPase of S1. The plateau value at long time, 0.126, was identical to that of actoS1 in the presence of exogenous ADP or ADP plus phosphate. Characterization of the spectroscopic properties of the erythrosin probe indicated that the changes in rp were not due to changes in fast probe motions on the surface of the filament or the phosphorescence emission lifetime, or in the orientation of the probe on the surface of F-actin, suggesting that they reflect large-scale changes in the microsecond rotational dynamics of actin. ATP hydrolysis by actoS1 thus appeared to induce rotational motions of or within F-actin on the phosphorescence time scale (approximately 300 microseconds). Although the precise physical origin of the induced rotational motions is unknown, this study provides direct evidence that large-scale conformational fluctuations of the actin filament are associated with the force-generating event in actomyosin.

Comparison of the QuadFERM+ 2-hr identification system with conventional carbohydrate degradation tests for confirmatory identification of Neisseria gonorrhoeae

The QuadFERM+ (Analytab Products, Plainview, NY) rapid identification system was evaluated for its ability to identify correctly Neisseria gonorhoeae isolates from specimens obtained at a sexually transmitted disease clinic. One hundred eighty-five isolates (115 N. gonorrhoeae, 45 Neisseria meningitidis, 16 Neisseria species, and nine Branhamella catarrhalis; fresh isolates, frozen stock cultures, and cultures referred from local health agencies) were tested with the QuadFERM+ system and conventional biochemical tests. The two discrepant results were obtained with QuadFERM+, for a lactose-positive isolate of Neisseria sicca and a maltose-positive N. meningitidis. Both were negative by conventional sugar degradation tests. The N. sicca was negative when repeated in the QuadFERM+, and the N. meningitidis reverted from maltose-positive to maltose-negative after 3 hr. Twelve beta-lactamase positive organisms (six N. gonorrhoeae plus six B. catarrhalis) and 173 beta-lactamase-negative organisms showed 100% agreement between the acidometric QuadFERM+ beta-lactamase test and the conventional starch-iodine method. Thus the QuadFERM+ is a rapid and acceptable alternative for the identification of N. gonorrhoeae in a sexually transmitted disease clinic.

The effect of exogenous lymphokines on immunoglobulin production and lymphocyte proliferation in renal transplant patients

Peripheral blood mononuclear cells from stable long-term kidney transplant patients were activated in vitro by Staphylococcus Aureus Cowan I (SAC) (a B cell mitogen). The effect of exogenous interleukin 2 and/or B cell growth factor (BCGF) on these cells was measured by 3H-thymidine incorporation and immunoglobulin production. Both proliferation and Ig production were lower in SAC-activated cells from transplanted patients compared to controls (P less than 0.01). BCGF significantly enhanced blastogenesis (P less than 0.01) and Ig production (P less than 0.01) in SAC-treated cells from either patients or controls; however, the SAC- and BCGF-treated cells of transplant patients did not reach normal proliferation or immunoglobulin production values (P less than 0.001, P less than 0.01, respectively). The addition of IL-2 to SAC-activated cells also increased proliferation and Ig production both in controls (P less than 0.05) and patients (P less than 0.005). However, cells from transplant patients treated with SAC and IL-2 did not reach the normal levels of proliferation or immunoglobulin production (P less than 0.05 for both). IL-2 did not enhance the increase of immunoglobulin production brought about by BCGF. SAC-activated B cells from transplant patients do not proliferate normally and do not produce normal amounts of Ig. The addition of IL-2 and BCGF results in a partial but subnormal improvement in both proliferation and Ig production. We conclude that the B cell abnormality in transplant patients may be due to lack of T cell lymphokines and an intrinsic B cell defect. These results suggest that the administration of exogenous lymphokines to transplant patients with B cell dysfunction may be clinically useful.

Pretransplant crossmatch status and immunoglobulin production in renal transplant recipients

The factors responsible for B cell regulation in stable renal transplant patients are unknown. To examine these control mechanisms, the B cell responses to 4 mitogens (pokeweed, wheat germ agglutinin, lipopolysaccharide, and SAC-1), which are known to stimulate B cells by different mechanisms, were measured in two groups of stable long-term (greater than 1 year post-transplant) renal transplant recipients. The first group were patients who had been transplanted under conditions of a negative crossmatch on all available pretransplant sera (negative crossmatch group) and the second group were patients who might have a unique regulation of B cell function in that they had been successfully transplanted under the conditions of a negative crossmatch using sera at the time of transplant but with pretransplant sera that gave a positive donor-specific T cell crossmatch (positive crossmatch group). Stable transplant patients were found to have significantly impaired responses to all four mitogens tested. Furthermore there were no differences in the responses of the negative crossmatch patients as compared with the positive crossmatch patients. The lack of response to mitogens was not due to a lack of proliferation of cells or to a loss of viability in culture. The number of cells in culture was the same in negative crossmatch patients and controls but was significantly less than controls in positive crossmatch patients (P less than 0.001). These findings suggest an intrinsic B cell defect in all stable transplant patients, and that the degree of the impaired B cell responses is the same in positive and negative crossmatch patients. In addition in positive crossmatch patients, there is a decrease in the percentage B cells that resulted after separation on a Ficoll-Paque gradient.

HLA-B8, immunoglobulins, and antibody responses in alcohol-related liver disease

Ninety-two British, caucasian, alcoholic patients with liver disese were grouped on the basis of hepatic histology into fatty change, hepatitis with or without cirrhosis, and cirrhosis alone. Men with alcoholic hepatitis with or without cirrhosis showed an increased incidence of the histocompatibility antigen HLA-B8 (P less than 0.02). Increased measles antibody titres were found in patients without cirrhosis with or without hepatitis and were associated with the B8 phenotype in both sexes. Rubella antibody titres and percentage DNA-binding were raised in patients with cirrhosis and showed no association with the B8 phenotype. Concentrations of IgM and IgA were were raised in patients with stetosis and with hepatitis, while in patients with cirrhosis IgG concentrations were also increased. Low titres of autoantibodies were found in all histological groups. It is possible that the development of hepatitis in response to alcohol abuse may be influenced, at least in men, by a gene linked to the B locus. Otherwise, immune processes associated with alcohol-related liver disease are probably secondary phenomena.