Glucocorticoid treatment and clinical outcomes in patients with polymyalgia rheumatica: A cohort study using routinely collected health data

OBJECTIVE

We aimed to describe the following in patients with polymyalgia rheumatica (PMR): (1) real-world glucocorticoid (GC) therapy, (2) improvement in inflammatory parameters associated with disease activity (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), and (3) incidence of GC-related adverse events (AEs).

METHODS

A cohort study was conducted using a Japanese electronic medical records database. We included newly diagnosed PMR patients aged≥50years with baseline CRP levels≥10mg/L and/or ESR>30mm/h and an initial GC dose of≥5mg/day. The outcomes were GC dose, inflammatory parameters, and GC-related AEs.

RESULTS

A total of 373 PMR patients (mean age, 77.3 years) were analyzed. The median initial GC dose was 15.0mg/day, which gradually decreased to 3.5mg/day by week 52. The median cumulative GC dose at week 52 was 2455.0mg. The median CRP level on day 0 was 64.3mg/L, which decreased during weeks 4-52 (1.4-3.2mg/L). At week 52, 39.0% of patients had a CRP level>3.0mg/L. The cumulative incidence of GC-related AEs at week 52 was 49.0% for osteoporosis, 30.2% for diabetes, 14.9% for hypertension, 12.2% for peptic ulcer, 11.3% for dyslipidemia, 2.9% for glaucoma, and 4.3% for serious infection. The incidence of osteoporosis and diabetes increased with the GC dose.

CONCLUSION

The incidence of GC-related AEs was associated with the GC dose in PMR patients. Further research is required to identify treatment strategies that can effectively control PMR disease activity while minimizing GC use.

Anemia Treatment, Hemoglobin Variability, and Clinical Events in Patients With Nondialysis-Dependent CKD in Japan

Key Points

This large, contemporary study reports the management of anemia in a real-world cohort of patients with nondialysis-dependent CKD from multifaceted aspects. This study highlights the suboptimal and heterogeneous treatment of anemia in clinical practice. The findings also underscore the importance of maintaining a stable hemoglobin concentration within the target range to reduce the risk of mortality and morbidity.

Background

Anemia management in patients with nondialysis-dependent CKD has attracted attention with the introduction of novel therapeutic agents; however, few studies have provided comprehensive epidemiologic information.

Methods

A retrospective cohort study was conducted in adult patients with stage ≥3a nondialysis-dependent CKD and hemoglobin (Hb) <11 g/dl (January 2013–November 2021; N =26,626) to assess longitudinal treatment patterns, Hb, and iron parameters (ferritin and transferrin saturation) for anemia management. Time-dependent Cox proportional hazard models were applied to assess the risk of clinical events, including death, cardiovascular events, dialysis introduction, and red blood cell transfusion, associated with temporal fluctuation patterns of Hb levels.

Results

The cumulative incidence of anemia treatment initiation within 12 months was 37.1%, including erythropoiesis-stimulating agents 26.5%, iron oral 16.8%, iron intravenous 5.1%, and hypoxia-inducible factor prolyl hydroxylase inhibitor 0.2%. The mean (±SD) Hb levels were improved from 9.9±1.2 to 10.9±1.6 g/dl at 12 months. Despite erythropoiesis-stimulating agents or hypoxia-inducible factor prolyl hydroxylase inhibitor therapy, 30.1% of patients remained Hb <10 g/dl. The risks of premature death, cardiovascular events, dialysis introduction, and red blood cell transfusion were significantly higher in groups with consistently low Hb or low-amplitude Hb fluctuation around the lower limit of target Hb range than in patients with target Hb range (P < 0.05). Similarly, significantly higher risks for dialysis introduction and red blood cell transfusion were associated with high-amplitude Hb fluctuation across target Hb range were observed.

Conclusions

The findings underscore the importance of stable Hb control within the target range to reduce the mortality and morbidity risks in patients with nondialysis-dependent CKD while highlighting the suboptimal and heterogeneous treatment of anemia in clinical practice.

Functional analyses of the Physcomitrella patens phytochromes in regulating chloroplast avoidance movement

Red light-induced chloroplast movement in Physcomitrella patens (Pp) is mediated by dichroic phytochrome in the cytoplasm. To analyze the molecular function of the photoreceptor in the cytoplasm, we developed a protoplast system in which chloroplast photomovement was exclusively dependent on the expression of phytochrome cDNA constructs introduced by polyethylene glycol (PEG) transformation. YFP was fused to the phytochrome constructs and their expression was detected by fluorescence. The chloroplast avoidance response was induced in the protoplasts expressing a YFP fusion of PHY1-PHY3, but not of PHY4 or YFP alone. Phy::yfp fluorescence was detected in the cytoplasm. No change in the location of phy1::yfp or phy2::yfp was revealed before and after photomovement. When phy1::yfp and phy2::yfp were targeted to the nucleus by fusing a nuclear localization signal to the constructs, red light avoidance was not induced. To determine the domains of PHY2 essential for avoidance response, various partially-deleted PHY2::YFP constructs were tested. The N-terminal extension domain (NTE) was found to be necessary but the C-terminal histidine kinase-related domain (HKRD) was dispensable. An avoidance response was not induced under expression of phytochrome N-terminal half domain [deleting both the PAS (Per, Arnt, Sim)-related domain (PRD) and HKRD]. GUS fusion of this N-terminal half domain, reported to be fully functional in Arabidopsis for several phyA- and phyB-regulated responses was not effective in chloroplast avoidance movement. Domain requirement and GUS fusion effect were also confirmed in PHY1. These results indicate that Pp phy1-Pp phy3 in the cytoplasm mediate chloroplast avoidance movement, and that NTE and PRD, but not HKRD, are required for their function.

Four distinct photoreceptors contribute to light-induced side branch formation in the moss Physcomitrella patens

Side branch formation in the moss, Physcomitrella patens, has been shown to be light dependent with cryptochrome 1a and 1b (Ppcry1a and Ppcry1b), being the blue light receptors for this response (Imaizumi et al. in Plant Cell 14:373, 2002). In this study, detailed photobiological analyses were performed, which revealed that this response involves multiple photoreceptors including cryptochromes. For light induction of branches, blue light of a fluence rate higher than 6 micromol m(-2) s(-1) for period longer than 3 h is required. The number of branches increased with the increase in fluence rate and in the irradiation period. The number of branches also increased when red light was applied together with the blue light, although red light alone had a very few effect. By partially irradiating a cell, both receptive sites for blue and red light were found to be located around the nucleus. Further, both red and blue light determine the positions of branches being dependent upon the vibration plane of polarized light. Red light control of branch position was nullified by simultaneous far-red light irradiation. A blue light effect on branch position was not found in lines with disrupted phototropin genes. Thus, dichroic phytochrome and phototropin, possibly on the plasma membrane, regulate branch position. These results indicate that at least four distinct photoreceptor systems, namely, cryptochromes and red light receptor around or in the nucleus, dichroic phytochrome and phototropin around the cell periphery, are involved in the light induction of side branches in the moss Physcomitrella patens.

Establishment and chromosome studies of in vitro lines of chemically induced rat erythroblastic leukemia cells

Eight cultured lines with a normal diploid karyotype, no. 2 trisomy, and markers involving chromosome No. 2 were established from three 7,12-dimethylbenz[a]anthracene (DMBA)- and two N-butyl-N-nitrosourea (BNU)-induced erythroblastic leukemias in noninbred Long-Evans rats. Serial in vivo and in vitro passage of these cells frequently evoked karyotype changes in stemline cells. In both lines from DMBA- and BNU-induced leukemias, ordinary and translocation no. 2 trisomy cells appeared and gradually replaced the normal diploid stemline cells. Obvious secondary karyotypic changes were also recognized in the "cloned" leukemia cells. Nucleolar chromosomes such as chromosomes no. 3 and no. 12 were frequently involved in aneuploidy and translocation. One cell line from a BNU-induced leukemia did not change its normal diploid karyotype during 12 months of in vitro passage. The above preferential growth of cells with no. 2 trisomy and the related changes during in vivo and in vitro passage as well as in-colony formation in soft agar suggest that these chromosome changes are somehow associated with the growth behavior of the leukemia cells. No positive correlation was demonstrated between karyotype and dimethyl sulfoxide-induced erythroid differentiation of the leukemia cells.

Involvement of chromosome No. 2 in chromosome changes in primary leukemia induced in rats by N-nitroso-N-butylurea

Cytogenetic studies were done on 34 primary leukemias induced by N-nitroso-N-butylurea (NBU) in outbred Long-Evans rats. The results revealed leukemia cells with No. 2 trisomy and long No. 2 chromosome, which characterized the leukemias induced by polycyclic hydrocarbon carcinogens such as 7,12-dimethylbenz[a]anthracene and 7,8,12-trimethylbenz[a]-anthracene. These findings suggest a common mode of action of different carcinogenic chemicals at the chromosome level, although the lower incidence of these chromosome changes and of erythroblastic leukemias with NBU suggests subtle difference in their actions.

Reproducible chromosome changes of polycyclic hydrocarbon-induced rat leukemia: incidence and chromosome banding pattern

Statistical analysis of 361 cases of primary leukemia induced in outbred Long-Evans and Sprague-Dawley rats by 7,12-dimethylbenz[a]anthracene (DMBA) and 7,8,12-trimethylbenz[a]anthracene (TMBA) showed that the incidence of trisomy of chromosome No. 2 was significantly lower with TMBA (17.8%) than with DMBA (29.3%). This tendency was reproducible in both sexes. Another characteristic chromosome abnormality, long No. 2, was found in 10 cases (2.8%). Quinacrine fluorescence analysis revealed that cells with No. 2 trisomy or either of two types of long No. 2 had total and partial No. 2 trisomy, respectively. Other chromosome members of cells with long No. 2, as well as the chromosomes of cells with typical No. 2 trisomy and "normal diploid" leukemia cells, revealed no band abnormality. The phenotype of No. 2 trisomy, severe anemia of the hosts reported in DMBA-induced leukemias, was also noted in leukemias with TMBA-induced No. 2 trisomy but not in leukemias with long No. 2.

Acute cytogenetic effect of 2-(2-furyl)-3-(5-nitro-2-furyl)-acrylamide (AF-2, a food preservative) on rat bone marrow cells in vivo

The cytogenetic effects of 2(2-furyl)-3-(5-nitro-2-furyl)-acrylamide (AF-2), a food preservative used in Japan, on rat bone marrow cells in vivo were studied. The aberrant metaphase cells in the bone marrow increased and reached the peak level 6 h after intraperitoneal injection of 240 mg/kg body weight of AF-2 and returned to the normal level within 24 h. A dose-response relationship was obtained using 4-240 mg/kg of AF-2. Chromosome aberrations were also induced after oral administration of 30-240 mg/kg. The aberrations were mostly chromatid breaks and the distribution among and within chromosomes was similar to those induced by a carcinogen, 7, 12-dimethylbenz(a)anthracene (DMBA). The present results provide the first evidence of in vivo cytogenetic effects of AF-2 on mammalian cells and, together with the evidence of mutagenicity already proved in other organisms, warn of the possible genetic hazards to cells exposed to this compounds.