Long-standing and poorly controlled disease in juvenile dermatomyositis is associated with calcinosis: a real-world experience from a low-middle income country

To study the prevalence and predictors of calcinosis in Juvenile Dermatomyositis (JDM). Medical records over 20 years at a tertiary care rheumatology center in Northern India were reviewed to identify patients with JDM and clinical details were recorded. The frequency of calcinosis, predictors, specific treatment, and its outcomes were studied. Data are expressed as median and interquartile range. In eighty-six patients (median age 10) of JDM, the frequency of calcinosis was 18.2% (8.5% at presentation). Younger age at presentation, longer follow-up, heliotrope rash [Odds Ratio (95% confidence interval), 11.4 (1.4-92.12)], chronic or polycyclic course [4.4 (1.2-15.5)] and cyclophosphamide use [8.2 (1.6-41.9)] were associated with calcinosis. Dysphagia [0.14 (0.02-1.2)] and elevated muscle enzymes [0.14 (0.04-0.5)] were negatively associated with calcinosis. Treatment with pamidronate had a good to moderate response to calcinosis in five of seven children. Calcinosis in JDM is associated with long-standing, poorly controlled disease, and the use of bisphosphonates like pamidronate offer promise in the future for its treatment.

Tuberculosis remains a leading contributor to morbidity due to serious infections in Indian patients of SLE

INTRODUCTION

Infections are a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). We assessed the incidence and risk factors for major infections in SLE in India.

METHODS

A retrospective review of a cohort of 1354 patients of adult SLE (ACR 1997 criteria) seen between 2000 and 2021 at a single center was conducted. Serious infections (need for hospitalisation, prolonged intravenous antibiotics, disability, or death) were recorded. Cox regression was used to determine factors associated with serious infection and the effects of serious infection on survival and damage.

RESULTS

Among the 1354 patients (1258 females, mean age of 30.3 years, follow-up of 7127.89 person-years), there were 439 serious infections in 339 patients (61.6 per 1000 person-years follow-up). Bacterial infections (N = 226) were the most common infection followed by mycobacterial infections (n = 81), viral (n = 35), and then invasive fungal infections (N = 13). Mycobacterium tuberculosis was the single most common microbiologically confirmed organism with incidence of 1136.4/100,000 person-years with 72.8% of them being extrapulmonary. Infection free survival at 1 year and 5 years was 82.9% and 73.8%. There were 119 deaths with infection attributable mortality in 65 (54.6%). On multivariable Cox regression analysis, higher baseline activity (HR 1.02, 1.01-1.05), gastrointestinal involvement (HR 2.75, 1.65-4.69), current steroid dose (HR 1.65, 1.55-1.76), and average cumulative steroid dose per year (HR 1.007, 1.005-1.009) were associated with serious infection and higher albumin (HR 0.65, 0.56-0.76) was protective. Serious infections led to greater damage accrual (median SLICC damage index of 1 vs. 0) and mortality (HR was 18.2, 32.7 and 81.6 for the first, second, and third infections).

CONCLUSION

Serious infections remain a major cause of mortality and damage accrual in SLE and higher disease activity, gastrointestinal involvement, hypoalbuminemia, current steroid dose, and cumulative steroid dose are the risk factors for it.

Peripheral T helper subset profiling in idiopathic inflammatory myositis: Proof of concept

INTRODUCTION

There is a dearth of biomarkers in Idiopathic Inflammatory Myopathies (IIM) to recognize ongoing muscle inflammation and distinguish damage from activity. Since IIM is an autoantibody-mediated disease with tertiary lymphoid organogenesis reported in the diseased muscles, we aimed to study the peripheral blood T helper (Th) subset profiling as a plausible reflection of ongoing muscle inflammation.

METHODS

Fifty-six patients of IIM were compared with 21 healthy controls (HC) and 18 patients with sarcoidosis. Th1, Th17, Th17.1, and Treg cells were identified after stimulation assays (BD Biosciences). Myositis autoantibodies were tested by line immunoassay (Euroimmune, Germany).

RESULTS

All Th subsets were elevated in IIM as compared with HC. As compared to HC, PM had elevated Th1 and Treg while Th17 and Th17.1 populations were higher in OM. Patients with sarcoidosis had higher Th1 and Treg but lower Th17 population as compared to IIM {Th1(69.1% vs 49.65%, p<0.0001), {Treg (12.05% vs 6.2%, p<0.0001), {Th17 (2.49% vs 4.4%, p<0.0001)}. Similar results were obtained when sarcoidosis ILD was compared with IIM ILD with a higher Th1 and Treg population but lower Th17 population in the former. No difference in T cell profile was observed after stratification for MSA positivity, type of MSA, clinical features of IIM and disease activity.

CONCLUSION

Th subsets in IIM are distinct from sarcoidosis and HC with a TH17 predominant paradigm, creating a case of exploring Th17 pathway and IL-17 blockers for the treatment of IIM. However, cell profiling cannot distinguish active from inactive disease limiting its predictive potential as a biomarker of activity in IIM.

P248 Tuberculosis is still a major contributor to serious infection in juvenile SLE

Background/Aims

Infections are a major cause of morbidity and mortality in juvenile systemic lupus erythematosus (SLE). We assessed the incidence and risk factors for major infections in juvenile SLE.

Methods

We carried out a retrospective review of 175 patients of juvenile SLE (ACR 1997 criteria) with age &lt;18 years visiting the rheumatology clinic at a single centre between 2010 and 2020. Clinical details were retrieved from clinical case records and supplemented with data from the hospital's electronic health records. Major infections (defined as need for hospitalization, prolonged antibacterial therapy &gt;1 week, resulting in disability or death) were recorded. Predictors of infection and their outcomes were determined using multivariate logistic regression and Kaplan Meier survival analysis.

Results

Among 175 patients (154 were girls) with a mean age of 14.79±3.1 years, there were a total of 52 major infections in 43 patients with an incidence rate of 8.83 per 100 person-years. The respiratory tract (19) was the most commonly involved site followed by skin and soft tissue (10), gastrointestinal tract (6), systemic bacteremia (5), ear nose and throat (4), disseminated infection (3), urinary tract (2), central nervous system (1), joint (1) and dengue shock syndrome (1). Organisms isolated were Mycobacterium tuberculosis (11) which was the most common and predominantly extrapulmonary, followed by enterobacteria (12), Staphylococcus aureus (5), cytomegalovirus (3), Herpes zoster (2), Herpes simplex (1), MRSA (1), and Candida (1).

Gastrointestinal involvement (OR 4.21), major organ involvement (OR 2.5), use of cyclophosphamide (OR 7.63), higher baseline SLEDAI (16[11.5-21] vs 12[8.75-16.25]) and a higher daily dose of prednisolone (16.1±15.1mg vs 6.1±5.8mg) at the time of the infection were predictors of a major infection. On multivariate analysis, only higher daily doses of corticosteroids (OR1.09, 95% CI 1.05-1.14) and gastrointestinal involvement (OR 4.98, 1.05-23.65) were significant predictors.

Major infection-free survival at 1 year and 5 years was 82.5% (95% CI 76.8-88.7) and 72.5% (95% CI 65-80.9) respectively. There were eight deaths with five directly attributable to infection. Overall survival was worse in those who had an episode of major infection.

Conclusion

The risk of major infections in juvenile SLE is significant and associated with higher daily corticosteroid use and gastrointestinal involvement at baseline.

Disclosure

R. Chatterjee: None. S. Pattanaik: None. L. Gupta: None. D.P. Misra: None. V. Agarwal: None. A. Lawrence: None. A. Aggarwal: None.

Patient-Reported Outcome Measures in Takayasu Arteritis: A Systematic Review and Meta-Analysis

INTRODUCTION

We conducted a systematic review of patient-reported outcome measures (PROMs) regarding quality of life, disability, mood abnormalities (anxiety, depression), fatigue, illness perceptions and fibromyalgia in Takayasu arteritis (TAK). Wherever available, comparisons with healthy controls, disease controls or longitudinal changes in PROMs were noted.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science and Pubmed Central databases, major recent international rheumatology conference abstracts, clinical trial databases and the Cochrane library were searched for relevant articles. Wherever possible, outcome measures across studies were pooled using the restricted maximum likelihood model. Inter-group differences were pooled and compared using standardized mean differences (SMD) with 95% confidence intervals (95% CI). Heterogeneity was assessed using the I2 statistic. Quality of randomized controlled trials was assessed using the Cochrane risk of bias tool. For cross-sectional and cohort studies, the Joana Briggs Institute checklist and Newcastle-Ottawa scale were used, respectively. GRADE methodology was used to determine the certainty of evidence for outcomes.

RESULTS

Twenty-one studies (all but one observational) involving 1311 patients with TAK and 308 healthy controls were identified. Ten studies (559 TAK patients, 182 healthy controls were synthesized in a meta-analysis. Patients with TAK had worse quality of life (pooled SMD - 6.66, 95% CI - 10.08 to - 3.23 for individual domains; - 0.64, 95% CI - 1.19 to - 0.09 for pooled physical and mental component scores of 36-item Short Form Survey), depression (SMD 0.26, 95% 0.05-0.47) and anxiety (SMD 0.34, 95% CI - 0.06 to 0.75) scores and higher disability (SMD 0.64, 95% CI 0.43-0.84) than healthy controls. Patients with active TAK had worse quality of life, depression and work impairment when compared with those with inactive disease. Included studies were of moderate to high quality. Certainty of evidence for individual outcomes was low to very low.

CONCLUSION

Literature on PROMs in TAK, albeit sparse, appears to indicate worse scores in patients with TAK compared to healthy individuals. These results, however, require cautious interpretation. Development of a TAK-specific PROM is an important focus of the research agenda.

Multimodality carotid plaque tissue characterization and classification in the artificial intelligence paradigm: a narrative review for stroke application

Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality in the United States of America and globally. Carotid arterial plaque, a cause and also a marker of such CVD, can be detected by various non-invasive imaging modalities such as magnetic resonance imaging (MRI), computer tomography (CT), and ultrasound (US). Characterization and classification of carotid plaque-type in these imaging modalities, especially into symptomatic and asymptomatic plaque, helps in the planning of carotid endarterectomy or stenting. It can be challenging to characterize plaque components due to (I) partial volume effect in magnetic resonance imaging (MRI) or (II) varying Hausdorff values in plaque regions in CT, and (III) attenuation of echoes reflected by the plaque during US causing acoustic shadowing. Artificial intelligence (AI) methods have become an indispensable part of healthcare and their applications to the non-invasive imaging technologies such as MRI, CT, and the US. In this narrative review, three main types of AI models (machine learning, deep learning, and transfer learning) are analyzed when applied to MRI, CT, and the US. A link between carotid plaque characteristics and the risk of coronary artery disease is presented. With regard to characterization, we review tools and techniques that use AI models to distinguish carotid plaque types based on signal processing and feature strengths. We conclude that AI-based solutions offer an accurate and robust path for tissue characterization and classification for carotid artery plaque imaging in all three imaging modalities. Due to cost, user-friendliness, and clinical effectiveness, AI in the US has dominated the most.

Clinical spectrum of active tuberculosis in patients with systemic lupus erythematosus

INTRODUCTION

There is paucity of data on tuberculosis in Indian patients with systemic lupus erythematosus (SLE). We retrospectively studied clinical features and outcome of tuberculosis in SLE.

METHODS

Medical records of patients who developed tuberculosis simultaneous or after the diagnosis of SLE were retrospectively reviewed. All patients fulfilled 1997 ACR and/or SLICC 2012 classification criteria for SLE. A diagnosis of tuberculosis required bacteriological, histopathological or CT/MRI suggestive of tuberculosis and initiation of four drug antituberculous therapy. Baseline parameters were compared with the rest of cohort to identify predictors of tuberculosis.

RESULTS

In our cohort of 1335 SLE patients, 48 (3.6%) developed tuberculosis. Incidence of tuberculosis was calculated to be 733 per 100,000 patient years and occurred after a mean disease duration of 3.0 ± 4.1 years. Extrapulmonary tuberculosis (n = 37) was commoner than pulmonary tuberculosis (n =11). Most common radiological pattern in pulmonary tuberculosis was miliary and musculoskeletal TB was most common extrapulmonary TB. A microbiological diagnosis was obtained in 52.1% patients. Male gender was associated with higher risk of tuberculosis [OR 3.30 (1.55-7.05)]. Mortality was 14.5% and all patients who died had either disseminated (n = 5) or central nervous system (CNS) tuberculosis (n = 2).

CONCLUSION

Incidence of tuberculosis in SLE is higher than general population and is associated with different phenotype and higher mortality. Male gender was associated with increased risk of tuberculosis in SLE.

MO919THE INTERPLAY BETWEEN IL-6 AND IL-17 MIGHT PLAY A SIGNIFICANT ROLE IN CHRONIC ANTIBODY MEDIATED REJECTION IN RENAL ALLOGRAFT RECIPIENTS

Background and Aims

Chronic antibody-mediated rejection (CABMR) plays a critical role in kidney allograft loss and consider among one of the most important barriers that is responsible for late term graft loss. Previously we believed that alloreactive T-cell and de-novo DSA responsible for late term graft loss but recent study suggested that not only immune cell, non-immune cells like fibroblast also plays important role in chronic inflammation and allograft rejection via IL-6 amplifier loop (IL-6+IL-17). The interaction between non-immune tissues/cells and the immune system plays a critical role in chronic inflammation and late graft rejection. In chronic inflammation IL-6 enhance the production of acute phase proteins, T cell Subset differentiation, Maturation of Plasma cells, Generation of cellular and humoral immune responses and Control the transition from acute to chronic inflammation by changing the nature of leucocyte infiltration (from neutrophils to monocyte).

We sought to see whether IL-6 and IL-17A mediated synergistic activation of inflammation amplifier is operational in CABMR.

Method

Recruitment of patients according to Banff 2017criteria and biopsy was taken from consented patients and establishment of fibroblast culture from renal biopsy of patients with CABMR.

Fibroblast culture from CABMR patients were cultured to purity and pre stimulated with IL-6 (20ng/ µl), IL-17(50ng/ µl), IL-6 plus IL-17 for 24 hours and culture supernatant were collected for IL-6 ELISA to see synergistic activation.

Serum IL-6, MCP1 and CCL20 levels of Healthy control (HC), CABMR and Non-CABMR patients and MCP1, CCL20 level in culture supernatant were measured by ELISA. m-RNA expression of IL-6, MCP1, CCL20 and SOCS3 gene were measured by real time PCR (Syber-green method)

One-way ANOVA and Non-parametric Student t tests (two-tailed) were used for the statistical analysis of differences between groups.

Results

In comparison to IL-6 and IL-17 alone these cytokines synergistically induced more IL-6 production from renal fibroblasts. (Fig 1) also, we found that concentrations of effectors of inflammation amplifiers like IL-6, CCL-20 & MCP-1 in sera were significantly higher in CABMR patients compared to Non rejection patients, while their concentration in culture supernatant was higher when fibroblast cell stimulated with IL-6 and IL-17 together as compared either IL-6 or IL-17 alone. (Fig 2)

Gene expression analysis of IL-6, MCP1 and CCL20 was significant higher (p&lt;0.001) with synergistic activation of IL-6 and IL-17 as compared to either IL-6 or IL-17 alone, while SOCS3 gene expression was downregulated. (Fig 3) There was significant reduction in IL-6 concentration in culture supernatant with IL-6 and IL-17 inhibitor together (Fig 4) and m-RNA expression of IL-6 and MCP-1 was significantly reduced. (Fig 5)

Conclusion

CABMR is perpetuated by inflammation amplifier loop or synergistic induction of IL-6 and IL-17. Inhibition of IL-6 with Anti-IL-6 (Tocilizumab) and IL-17 with Anti-IL-17 reduces the tissue injury marker (IL-6, MCP1, CCL20) and allograft rejection.

Infections Are Leading Cause of In-Hospital Mortality in Indian Patients With Inflammatory Myopathy

OBJECTIVES

We explored causes of in-hospital mortality in patients with inflammatory myositis at a tertiary care center in Northern India.

METHODS

Records of adults and children diagnosed with dermatomyositis (DM), polymyositis, or anti-synthetase syndrome (ASSD) who died between 2000 and 2018 were reviewed, and causes of death were determined.

RESULTS

Of the 38 patients, 20 had DM (including 2 clinically amyopathic DM), 4 juvenile DM, 12 polymyositis, whereas 2 had ASSD. Median age at death was 42.0 (interquartile range, 32.8-52.5) years. Median disease duration at death was 18.5 (interquartile range, 2.0-23.5) months. Twenty-four (63.2%) had infection as the primary cause of death. Other causes of death included pharyngeal muscle weakness and aspiration (n = 6), myocarditis (n = 2), respiratory failure (n = 2), cerebral bleed (n = 2), and pulmonary embolism (n = 1). One patient succumbed to rapidly progressive interstitial lung disease, whereas another patient with ASSD died following respiratory distress after rituximab infusion. In post hoc analysis, although thrombocytopenia appeared to be a risk factor for early mortality (odds ratio, 13.3; 95% confidence interval, 1.4-123.8; p = 0.01), this was not supported in the multivariate analysis.

CONCLUSIONS

Infections are the most common cause of in-hospital mortality in myositis patients.

Spectrum of Myelitis in Systemic Lupus Erythematosus: Experience from a Single Tertiary Care Centre over 25 Years

BACKGROUND

Inflammatory myelitis rarely occurs in Systemic Lupus Erythematosus (SLE).

METHODS

Medical records from a tertiary care centre in India (1989-2018) were reviewed to identify patients with myelitis in SLE and their clinical characteristics and outcomes were compared with two matching comparators drawn from adjacent hospital registration numbers in the SLE database.

RESULTS

Ten patients had myelitis from a cohort of 1768 patients with SLE. Myelitis was the first manifestation of lupus in 7 (70%). Cervicothoracic cord was most frequent site of involvement. ANA was negative at onset in 2 cases. One of 4 was positive for Anti-Aquaporin 4 antibody. Four had relapsing disease (16 events) with a median time to relapse of 0.65 years (0.3- 7 years). All cases received steroid sparing agents over the follow-up duration (78.5 patient years). Lupus nephritis (20% vs. 75%, p=0.004) and haematologic manifestations (0 vs. 25%, p=0.02) were less common. Higher frequency of anti-Ro antibodies was noted in the group with myelitis (p=0.05).

CONCLUSION

Myelitis can be a presenting feature of SLE with lupus nephritis and hematologic involvement being rare. Relapses are common that mandate long-term immunosuppression.

In-hospital mortality and its predictors in a cohort of SLE from Northern India

BACKGROUND

Mortality in SLE has a bimodal peak with early deaths mainly related to disease activity and infection. Although mortality has reduced over years, it is still two to three folds compared to the general population. In India due to increased burden of infection and limited access to health care, the causes may be different.

METHODS

Retrospective, review of records of all adult SLE patients fulfilling ACR 1997 criteria, who died in hospital between 2000-2019 at a teaching hospital in India was done. In addition, baseline clinical features were extracted for all adult SLE patients seen during this period.Infections were either bacteriologically proven or based on clinicradiological or serologic evidence. Active disease was defined as SLEDAI 2k ≥ 5. Logistic regression was performed to ascertain risk factors for mortality.

RESULTS

A total of 1337 (92% females) patient records were reviewed .The mean age at presentation was 29.9 ± 9 years.60-75% of patients had fever, mucocutaneous disease and arthritis, while nephritis, hematologic, serositis and neurologic involvement was seen in 48.6%, 43.2%, 16% and 10.3% respectively as presenting mainfestations. There were 80 in hospital deaths .Infection was the most common cause of death, with 37 due to infection alone and in 24 disease activity also contributed. Only 18 deaths were due to active disease. Among bacterial infections lung was the most common site and gram negative organism were the most common pathogens. There were 10 deaths due to Tuberculosis(TB) and half of them had disseminated disease. Patients with disease activity had a SLEDAI of 14.8 ± 6.4, with neurological, renal and cardiovascular involvement being the major contributors to mortality in 11, 7 and 6 cases respectively. Higher age at onset, male gender, fever, myositis, neurological, cardiovascular, gastrointestinal involvement, vasculitis, elevated serum creatinine at baseline were independent predictors of death.

CONCLUSION

Infections are the most common cause of in-hospital mortality in SLE and TB still accounts for 15% of deaths related to infection. Vasculitis, myositis, cardiovascular and gastrointestinal involvement emerged as novel predictors of mortality in our cohort.

Insights into the knowledge, attitude and practices for the treatment of idiopathic inflammatory myopathy from a cross-sectional cohort survey of physicians

The idiopathic inflammatory myopathies (IIM) are heterogeneous and lead to high morbidity and mortality. Knowledge deficits among healthcare professionals could be detrimental to clinical care. Identifying areas of deficient Knowledge, Attitude and Practice (KAP) of IIM can improve physician education and patient outcomes. To assess the proportion of physicians treating IIM with poor KAP and identify the key areas of deficit. An anonymised and validated e-survey (57 questions) was circulated among physicians treating IIM (purposive sampling). Responses were evaluated using the Likert scale for good (> 70% correct response), poor (> 20% chose > 2 answers) and the rest as intermediate consensus. Descriptive statistics were used. Intergroup comparisons were done using non-parametric tests. Of 80 (9.1% of 883) respondents, 90% were rheumatologists and 37.5% academicians. The knowledge base of treating physicians was good in specific domains such as triggers (80-90%), clinical presentation (MDA5, statin myositis, steroid myopathy, anti-synthetase syndrome) (82-92%), IIM mimics (41-89%), investigations (23-92%) and risk of osteoporosis in IIM (79%). There is also an intermediate knowledge base/consensus for outcome measures (30-56%) and response criteria (30-53%). There was poor knowledge and consensus on trials (27-34%), EULAR/ACR criteria (31%) and exercise-based interventions (17-62%). While 90% agree on the need for muscle biopsy to diagnose polymyositis, only one-third advocated it for juvenile and adult DM. Physicians have a good understanding of the triggers, clinical presentation and mimics of IIM. Poor to intermediate knowledge and consensus exists regarding muscle biopsy, outcome measures, response criteria and exercise-based interventions, which could be addressed through future focussed educational initiatives.

3-D optimized classification and characterization artificial intelligence paradigm for cardiovascular/stroke risk stratification using carotid ultrasound-based delineated plaque: Atheromatic™ 2.0

BACKGROUND AND PURPOSE

Atherosclerotic plaque tissue rupture is one of the leading causes of strokes. Early carotid plaque monitoring can help reduce cardiovascular morbidity and mortality. Manual ultrasound plaque classification and characterization methods are time-consuming and can be imprecise due to significant variations in tissue characteristics. We report a novel artificial intelligence (AI)-based plaque tissue classification and characterization system.

METHODS

We hypothesize that symptomatic plaque is hypoechoic due to its large lipid core and minimal collagen, as well as its heterogeneous makeup. Meanwhile, asymptomatic plaque is hyperechoic due to its small lipid core, abundant collagen, and the fact that it is often calcified. We designed a computer-aided diagnosis (CADx) system consisting of three kinds of deep learning (DL) classification paradigms: Deep Convolutional Neural Network (DCNN), Visual Geometric Group-16 (VGG16), and transfer learning, (tCNN). DCNN was 3-D optimized by varying the number of CNN layers and data augmentation frameworks. The DL systems were benchmarked against four types of machine learning (ML) classification systems, and the CADx system was characterized using two novel strategies consisting of DL mean feature strength (MFS) and a bispectrum model using higher-order spectra.

RESULTS

After balancing symptomatic and asymptomatic plaque classes, a five-fold augmentation process was applied, yielding 1000 carotid scans in each class. Then, using a K10 protocol (trained to test the ratio of 90%-10%), tCNN and DCNN yielded accuracy (area under the curve (AUC)) pairs of 83.33%, 0.833 (p < 0.0001) and 95.66%, 0.956 (p < 0.0001), respectively. DCNN was superior to ML by 7.01%. As part of the characterization process, the MFS of the symptomatic plaque was found to be higher compared to the asymptomatic plaque by 17.5% (p < 0.0001). A similar pattern was seen in the bispectrum, which was higher for symptomatic plaque by 5.4% (p < 0.0001). It took <2 s to perform the online CADx process on a supercomputer.

CONCLUSIONS

The performance order of the three AI systems was DCNN > tCNN > ML. Bispectrum-based on higher-order spectra proved a powerful paradigm for plaque tissue characterization. Overall, the AI-based systems offer a powerful solution for plaque tissue classification and characterization.

Circulatory Glutamine/Glucose ratio for evaluating disease activity in Takayasu arteritis: A NMR based serum metabolomics study

Quantitative assessment of disease activity is important for effective care of patients with Takayasu arteritis (TA). Activated glutaminolysis and reduced glycolytic flux is the hallmark of active inflammation. Based on this, we hypothesize that the circulatory Glutamine/Glucose ratio (QGR) can serve as an indicant of active inflammation in TA. To probe this hypothesis, the serum samples were collected from 45 active and 53 inactive TA patients fulfilling American College of Rheumatology (ACR) criteria and assessed for disease activity according to Indian Takayasu Clinical Activity Score (ITAS) using acute phase reactant-erythrocyte sedimentation rate [ITAS-A (ESR)]. The quantitative profiles of circulatory metabolites implicated in glutaminolysis (Glutamine and Glutamate) and those which estimate glycolytic flux (i.e. glucose and lactate) were measured using high field (800 MHz) NMR spectroscopy. The recorded spectra were analyzed using CHENOMX NMR Suite and the estimated concentration profiles were compared and evaluated for their diagnostic potential using Metaboanalyst. Compared to inactive-TA patients, the sera of active-TA patients were characterized by significantly decreased serum levels of glutamine and lactate suggesting that these patients exhibit activated glutaminolysis and reduced glycolytic activity. This is further supported by significantly decreased QGR and lactate to glucose ratio (LGR) levels in active compared to inactive TA patients. The receiver operating characteristic (ROC) curve analysis revealed satisfactory accuracy, sensitivity and specificity for QGR [with area under ROC curve (AUROC) = 0.76 and 95% confidence interval (CI) = 0.66-0.84) compared to that for LGR (with AUROC = 0.67 and CI = 0.561-0.77). Therefore, we believe that the circulatory QGR has the potential to serve as surrogate marker for the assessment of disease activity in TA patients. However, the use of this ratio in clinical settings will require future studies on large patient cohorts and procedural optimization as well to improve accuracy.

Gene expression profiling of coronary artery disease and its relation with different severities

Global gene expression profiling is a powerful tool enabling the understanding of pathophysiology and subsequent management of diseases. This study aims to explore functionally annotated differentially expressed genes (DEGs); their biological processes for coronary artery disease (CAD) and its different severities of atherosclerotic lesions. This study also aims to identify the change in expression patterns of DEGs in atherosclerotic lesions of single-vessel disease (SVD) and triple-vessel disease (TVD). The weight of different severities of lesion was estimated using a modified Gensini score. The gene expression profiling was performed using the Affymetrix microarray platform. The functional annotation for CAD was performed using DAVID v6.8. The biological network gene ontology tool (BiNGO) and ClueGO were used to explore the biological processes of functionally annotated genes of CAD. The changes in gene expression from SVD to TVD were determined by evaluating the fold change. Functionally annotated genes were found in an unique set and could be distinguishing two distinct severities of CAD. The biological processes such as cellular migration, locomotion, cell adhesion, cytokine production, positive regulation of cell death etc. enriched the functionally annotated genes in SVD, whereas, wound healing, negative regulation of cell death, blood coagulation, angiogenesis and fibrinolysis were enriched significantly in TVD patients. The genes THBS1 and CAPN10 were functionally annotated for CAD in both SVD and TVD. The 61 DEGs were identified, those have changes their expression with different severities of atherosclerotic lesions, in which 13 genes had more than two-fold change in expression between SVD and TVD. The consistent findings were obtained on validation of microarray gene expression of selected 10 genes in a separate cohort using real-time PCR. This study identified putative candidate genes and their biological processes predisposing toward and affecting the severity of CAD.

Association of MICA-129 polymorphism and circulating soluble MICA level with rheumatoid arthritis in a south Indian Tamil population

INTRODUCTION

Rheumatoid arthritis (RA) is a clinically heterogeneous chronic inflammatory disorder characterized by synovitis leading to joint destruction. Both genetic and environmental factors are involved in the pathogenesis of RA. Significant dysregulation of NKG2D, an activating receptor of natural killer and certain autoreactive T cells as well as its ligand major histocompatibility complex class I chain-related gene A (MICA) has been implicated in perpetuating the pathology of RA. Since the genetic polymorphism in MICA gene (MICA-129 met/val polymorphism at codon 129) is known to affect its binding affinity to NKG2D, we explored its influence on RA susceptibility and disease severity.

METHODS

The MICA-129 met/val polymorphism was examined in 270 patients with RA and 232 healthy controls by TaqMan 5'-nuclease assay. Serum soluble MICA (sMICA) was measured in a subset of 89 patients and 80 controls by enzyme-linked immunosorbent assay.

RESULTS

We observed that the frequency of MICA-129 val allele (73% vs. 65%, Pc = 0.006, odds ratio = 1.48, 95% CI = 1.12-1.95) was higher in patients than in controls. sMICA levels were significantly higher in patients with RA than in controls (P < 0.0001). sMICA levels were higher in patients with val/val genotype than in those with met/val or met/met genotype (P = 0.03). The MICA-129 val/val genotype was associated with high titers of sMICA in patients with deforming RA phenotype (P = 0.02), suggesting a role in determination of severity of RA.

CONCLUSION

MICA-129 val/val genotype, associated with higher levels of circulating sMICA, may influence disease susceptibility and associate with increased severity of RA in south Indian Tamils.

Association of NKG2D gene variants with susceptibility and severity of rheumatoid arthritis

NKG2D (KLRK1) is a C-type lectin receptor present on natural killer (NK) cells, γδ, CD8⁺ and CD4⁺ T cells. Upon ligand binding, NKG2D mediates activatory and co-stimulatory signals to NK cells and activated CD4⁺ T cells, respectively. Polymorphisms in NKG2D predispose to infectious diseases, cancer, transplantation and autoimmune disorders. We studied the influence of this NK receptor polymorphism on predisposition to and modification of the disease phenotype in patients with rheumatoid arthritis (RA). Eight different single nucleotide polymorphisms (SNP) in the NKG2 gene were genotyped in 236 patients with RA and 187 controls using Taqman 5' nuclease assays. NKG2D genotype/allele frequency did not differ between patients and controls. Subgroup analysis showed that the frequency of A allele of NKG2D9 and T allele of NKG2D10 was significantly higher in patients with deformities (a marker of severe disease) [11 versus 5%, Pc = 0·03, odds ratio (OR) = 2·44, 95% confidence interval (CI) = 1·09-5·98 and 10 versus 4%, Pc = 0·04, OR = 2·45, 95% CI = 1·05-6·39, respectively], while the frequency of alleles G of NKG2D9 and A of NKG2D10 was greater in patients without deformities (Pc = 0·03, OR = 0·41, 95% CI = 0·17-0·91 and Pc = 0·04, OR = 0·41, 95% CI = 0·16-0·96). Similar trends of association were observed with deforming phenotype of RA in female patients and deforming young onset RA subgroups. Haplotype analysis revealed that the frequency of haplotype G-C-A-G-A-T-C-C was higher in patients than in controls (12 versus 8%, P = 0·04, OR = 1·61, 95% CI = 1·01-2·55), suggesting that it may predispose to RA. Our study suggests that the NKG2D gene polymorphisms may modify the risk of development and severity of RA.

Multiple myeloma masquerading as severe seropositive rheumatoid arthritis with subcutaneous nodules and mononeuritis multiplex

Multiple myeloma can rarely mimic seronegative rheumatoid arthritis (RA). We report a 55-year-old woman who presented with longstanding deforming polyarthritis with extensive subcutaneous nodules, tenosynovitis, anti-cyclic citrullinated peptide positivity and mononeuritis multiplex. Even though the clinical picture was consistent with seropositive RA, the absence of bone erosion or joint space narrowing on hand and knee radiographs led us to question the diagnosis of RA. Further investigation revealed a diagnosis of multiple myeloma with cutaneous amyloid deposits, based on serum immunofixation, bone marrow aspiration and biopsy of a subcutaneous nodule. The only clue to suspect myeloma from the basic investigations and clinical examination was mild hypercalcemia. This case serves to reiterate the need to maintain a heightened suspicion for other diagnoses even when RA appears most likely.

Unusual co-existence of dural sinus thrombosis and aneurysmal subarachnoid hemorrhage in a patient with lupus

Subarachnoid hemorrhage and dural sinus thrombosis are important manifestations of neuropsychiatric lupus erythematosus. We report the case of a woman with relapsed lupus nephritis, in partial remission, who presented with the unusual combination of dural sinus thrombosis (due to protein S functional deficiency) and aneurysmal subarachnoid hemorrhage. She had a fatal outcome, as has often been reported with subarachnoid hemorrhage in the context of active lupus. To our knowledge, this is the first report of such an unusual association in lupus, and highlights unique challenges in the management of intracranial hemorrhage in the context of dural sinus thrombosis.

Relationship of hepatic and renal dysfunction with haemorrheological parameters in Plasmodium falciparum malaria

OBJECTIVES

The present study was designed to assess hepatic and renal dysfunction in Plasmodium falciparum malaria, and evaluate if such abnormalities had any bearing with the hemorrheological dysfunction.

METHODS

Sixty consecutive patients of Plasmodium falciparum malaria with hepatic and renal dysfunction (Group A) and twenty consecutive cases of uncomplicated falciparum malaria (Group B) were studied. Patients with past history of alcoholism, jaundice, chronic renal failure, bleeding diathesis or coagulopathy were excluded from the study. Laboratory investigations done were liver and renal function tests, complete blood count and coagulation profile. The data collected was analysed to inter - correlate parameters of hepatic, renal and hemorrheological dysfunction.

RESULTS

In Group A, all had rigor and chill, icterus while 57% had oliguria and hepatomegaly, 37% splenomegaly, with less than 2% having overt bleeding diathesis. On evaluation, in Group A, 57% had acute renal failure, mean value of bilirubin was 13.91 (+/- 12.53) mg/dL, ALT 76.92 (+/- 37.48) IU/ml, AST 135.32 (+/- 97.33) IU/ml, mean PT was 13.03 (+/- 2.22) seconds, mean aPTT was 31.69 +/- 6.76 seconds, FDP by D-dimer was raised in 53% and LDH was raised in 78% respectively. In Group B mean PT was 11.93 (+/- 1.51) seconds, mean APTT was 29.39 +/- 2.89 seconds and FDP by D-dimer was raised in 30% respectively. Thrombocytopenia was seen in 26% cases in Group A and 15% cases in Group B. On analysis, in Group B, there was statistically significant negative correlation of total platelet count with serum AST (p = .010) and serum ALT (p = .036), serum ALP with BT (p = .036), but positively with CT (p = .006) and aPTT (p = .036). In Group A, serum bilirubin was found to have significant negative correlation with haemoglobin (p = .019),positive correlation with aPTT (p = .037), urea (p = .000) and serum creatinine (p = .000), serum ALP Positively with serum urea (p = .025) and serum creatinine (p = .037), serum urea negatively with haemoglobin(p = .015), so also did serum creatinine (p = .025),prothrombin time positively with serum urea(p = 0.037) and serum creatinine (p = 0.013), serum FDP positively with serum urea (p = 0.038) and serum creatinine (p = 0.022), bleeding time positively with serum AST(p = .002).

CONCLUSION

Despite less than 2% of patients in Group A having clinically overt bleeding diathesis, raised FDP (53%), prolonged aPTT (67%), low total platelet count (26%) and anemia (87%) were found in a significant number of patients, suggesting subclinical DIC. Therefore patients with Plasmodium falciparum malaria have high incidence of subclinical haemorrheological disorders which do not amount to overt DIC but adversely affect renal function contributing to acute renal failure.

Placental surface shape, function, and effects of maternal and fetal vascular pathology

GOAL

In clinical practice, variability of placental surface shape is common. We measure the average placental shape in a birth cohort and the effect deviations from the average have on placental functional efficiency. We test whether altered placental shape improves the specificity of histopathology diagnoses of maternal uteroplacental and fetoplacental vascular pathology for clinical outcomes.

MATERIALS AND METHODS

1225 Placentas from a prospective cohort had chorionic plate digital photographs with perimeters marked at 1-2 cm intervals. After exclusions of pre-term (n = 202) and velamentous cord insertion (n = 44), 979 (95.7%) placentas were analyzed. Median shape and mean perimeter were estimated. The relationship of fetal and placental weight was used as an index of placental efficiency termed "β". The principal placental histopathology diagnoses of maternal uteroplacental and fetoplacental vascular pathologies were coded by review of individual lesion scores. Acute fetal inflammation was scored as a "negative control" pathology not expected to affect shape. ANOVA with Bonferroni tests for subgroup comparisons were used.

RESULTS

The mean placental chorionic shape at term was round with a radius estimated at 9.1 cm. Increased variability of the placental shape was associated with lower placental functional efficiency. After stratifying on placental shape, the presence of either maternal uteroplacental or fetoplacental vascular pathology was significantly associated with lower placental efficiency only when shape was abnormal.

CONCLUSIONS

Quantifying abnormality of placental shape is a meaningful clinical tool. Abnormal shapes are associated with reduced placental efficiency. We hypothesize that such shapes reflect deformations of placental vascular architecture, and that an abnormal placental shape serves as a marker of maternal uteroplacental and/or fetoplacental vascular pathology of sufficiently long standing to impact placental (and by extension, potentially fetal) development.

Non-linear and gender-specific relationships among placental growth measures and the fetoplacental weight ratio

GOALS

Fetal growth depends on placental growth; the fetoplacental weight ratio (FPR) is a common proxy for the balance between fetal and placental growth. Male and female infants are known to have differing vulnerabilities in fetal life, during parturition and in infancy. We hypothesized that these differences may be paralleled by differences in how birth weight (BW) and the fetoplacental weight ratio (FPR) are affected by changes in placental proportions.

MATERIALS AND METHODS

Placental proportion measures (disk shape, larger and smaller chorionic diameters, chorionic plate area calculated as the area of an ellipse with the 2 given diameters, disk thickness, cord eccentricity and cord length) were available for 24,601 participants in the Collaborative Perinatal Project delivered between >34 and <43 completed weeks. The variables were standardized and entered into multiple automated regression splines (MARS 2.0, Salford Systems, Vista CA) to identify nonlinearities in the relationships of placental growth measures to BW and FPR with results compared for male and female infants.

RESULTS

Changes in chorionic plate growth in female compared to male infants resulted in a greater change in BW and FPR. The positive effects of umbilical cord length on BW reversed at the mean umbilical cord length in females and at +0.08 SD in male infants.

CONCLUSIONS

Female infants' BW and FPR are each more responsive to changes in placental chorionic plate growth dimensions than males; this may account for greater female resilience (and greater male vulnerability) to gestational stressors. The effect of umbilical cord length on FPR may be due to longer cords carrying greater fetal vascular resistance. Again male fetuses show a higher "threshold" to the negative effects of longer cords on FPR.

Allometric metabolic scaling and fetal and placental weight

BACKGROUND

We tested the hypothesis that the fetal-placental relationship scales allometrically and identified modifying factors of that relationship.

MATERIALS AND METHODS

Among women delivering after 34 weeks but prior to 43 weeks' gestation, 24,601 participants in the Collaborative Perinatal Project (CPP) had complete data for placental gross proportion measures, specifically, placental weight (PW), disk shape, larger and smaller disk diameters and thickness, and umbilical cord length. The allometric metabolic equation was solved for alpha and beta by rewriting PW = alpha(BW)beta as ln(PW) = ln alpha + beta[ln(BW)]. alpha(iota) was then the dependent variable in regressions with p < 0.05 significant.

RESULTS

Mean beta was 0.78 + 0.02 (range 0.66, 0.89), which is consistent with the scaling exponent 0.75 predicted by Kleiber's Law. Gestational age, maternal age, maternal BMI, parity, smoking, socioeconomic status, infant sex, and changes in placental proportions each had independent and significant effects on alpha.

CONCLUSIONS

We find an allometric scaling relation between the placental weight and the birthweight in the CPP cohort with an exponent approximately equal to 0.75, as predicted by Kleiber's Law. This implies that: (1) placental weight is a justifiable proxy for fetal metabolic rate when other measures of fetal metabolic rate are not available; and (2) the allometric relationship between placental and birthweight is consistent with the hypothesis that the fetal-placental unit functions as a fractal supply limited system. Furthermore, our data suggest that the maternal and fetal variables we examined have at least part of their effects on the normal balance between placental weight and birth weight via effects on gross placental growth dimensions.

Rates of preterm delivery among Black women and White women in the United States over two decades: an age-period-cohort analysis

The authors assessed the influence of age, period, and cohort effects on rates of preterm delivery in the United States. Rates of preterm delivery for singleton births (<37 weeks) in seven age groups (15-19, 20-24,., 45-49 years), five periods (1975, 1980, 1985, 1990, 1995), and 11 maternal birth cohorts (1926-1930, 1931-1935,., 1976-1980) were examined. Over the 20-year study interval, preterm delivery increased by 3.6% among Blacks (from 15.5% in 1975 to 16.0% in 1995) and by 22.3% among Whites (from 6.9% to 8.4%). Among Black primigravid women, rates of preterm delivery increased from 1975 to 1990 and began to decline thereafter; among Whites, the rates increased between 1975 and 1995. In Blacks, women aged 25-29 years had the lowest rates for the first and second births, and women aged 30-34 years had the lowest rate for subsequent births. In Whites, the age groups with the lowest preterm delivery rates were 20-24 years for first births and 25-29 years for subsequent births. Cohort-specific rates of preterm delivery remained fairly constant across age strata and periods for Whites, but a small trend was apparent for Blacks aged 30-44 years. The consistency of the observed age effects across periods and cohorts suggests that the age effect is partly due to biologic factors. The presence of period effects might be linked to the increased survival of premature infants or to increased viability among births occurring at lower lengths of gestation.

Testing a sociomedical model for preterm delivery

The study purpose was to contribute to the development of a model for preterm birth that brings together social, psychosocial and biomedical factors. The three research questions were: (a) Which social and psychosocial factors influence the risk of preterm delivery? (b) Are the effects of social and psychosocial factors independent? (c) Do the biomedical factors identified and measured here explain the effect of social and psychosocial factors? The sample comprised 739 low-income black non-Hispanic women. Interviews were conducted after delivery, and medical records were abstracted. Nearly a quarter of the women delivered preterm (23.5%). Two social factors strongly predicted risk of preterm delivery: inadequacy of time and money for non-essentials. The effect of both was stronger than expected from each alone and was partially mediated by psychosocial factors. Several psychosocial factors also predicted preterm delivery risk but only stress and locus of control were independent predictors. With the inclusion of biomedical factors, stress (OR = 1.86, P = 0.005) and locus of control (OR = 1.75, P = 0.007) continued to be strongly associated with preterm delivery. The effect of inadequate resources for non-essentials was no longer significant, suggesting mediation. These strong effects of social and psychosocial factors should be examined in future studies.

An intersection of women's and perinatal health: the role of chronic conditions

This paper has three objectives: 1) to review data on the prevalence of chronic disease among women of reproductive age; 2) to establish that chronic diseases are an important influence on perinatal health; and 3) to emphasize opportunities where women's health and perinatal health can intersect. This involves broadening strategies aimed at improving perinatal health to emphasize a woman's overall health, regardless of childbearing status or plans, and using perinatal health care as a bridge to ongoing care for women. These issues are discussed in the context of a continuum often used to organize perinatal health interventions.

Environmental tobacco smoke and low birth weight: a hazard in the workplace?

Low birth weight (LBW) increases infant morbidity and mortality worldwide. One well-established risk factor is maternal smoking. Environmental tobacco smoke (ETS) exposure has recently been focused on as another potential risk factor. In this article, we review epidemiologic literature on the effects of ETS on LBW and intrauterine growth retardation (IUGR), the cause of LBW related to maternal smoking. As we consider the feasibility of modifying women's exposure, we focus our discussion on workplace exposure to ETS. The workplace is particularly important to consider because women of child-bearing age are present in the workplace in greater numbers now than ever before. In addition, certain subgroups of working women may be particularly at risk from the effects of ETS on pregnancy because they work in environments with higher exposure or they are more susceptible to its effects. We conclude that there is consistent evidence to relate maternal ETS exposure to an increased risk of adverse pregnancy outcomes and that this association may be generalized to the work environment. In studies with positive findings, infants exposed to ETS antenatally were 1.5-4 times more likely to be born with LBW, but few studies examined LBW. Most studies looked at measures of IUGR. ETS was associated with reductions in birth weight (adjusted for gestational age) ranging from 25 to 90 g. Infants born to women exposed to ETS were generally 2-4 times more likely to be born small-for-gestational age. ETS exposure in the workplace can and should be minimized to protect pregnant women from its adverse effects.

Risk factor profiles of placental abruption in first and second pregnancies: heterogeneous etiologies

The objective of this study was to identify risk factors for placental abruption in first and second pregnancies and to compare the risk-factor profiles for evidence of etiologic heterogeneity. A prospective cohort design was used. The study took place at university-based medical centers that participated in the U.S. Collaborative Perinatal Project (1959-1965). A total of 10,774 first pregnancies only and 6529 first and second pregnancies of women were enrolled in the study. Participation rate was 96%. All pregnancies were selected at some centers, whereas other centers used either random or systematic sampling. The main outcome measure was placental abruptions in first and second pregnancies. The placental abruption rate was 1.7% (n = 182) for first and 2.2% (n = 143) for second pregnancies. Prior abruption increased risk in second pregnancies significantly (odds ratio [OR] = 3.2, 95% confidence interval [CI]: 1.7-5.8) after adjusting for other risk factors. Placental infarcts and smoking duration were associated with an increased risk for abruption in second but not first pregnancies. Effect of placental infarcts was modified by gestational age with strongest risk for abruption at shortest gestations. For each year of smoking prior to pregnancy, risk of abruption increased 40% (OR = 1.4, 95% CI 1.0-1.8). Etiologies of placental abruption for first and second pregnancies were different, indicating heterogeneity in their risk-factor profiles. Future research would best consider abruption as a heterogeneous complication to further knowledge of its etiology.