Blood immunophenotyping identifies distinct kidney histopathology and outcomes in patients with lupus nephritis

Lupus nephritis (LN) is a frequent manifestation of systemic lupus erythematosus, and fewer than half of patients achieve complete renal response with standard immunosuppressants. Identifying non-invasive, blood-based pathologic immune alterations associated with renal injury could aid therapeutic decisions. Here, we used mass cytometry immunophenotyping of peripheral blood mononuclear cells in 145 patients with biopsy-proven LN and 40 healthy controls to evaluate the heterogeneity of immune activation in patients with LN and to identify correlates of renal parameters and treatment response. Unbiased analysis identified 3 immunologically distinct groups of patients with LN that were associated with different patterns of histopathology, renal cell infiltrates, urine proteomic profiles, and treatment response at one year. Patients with enriched circulating granzyme B+ T cells at baseline showed more severe disease and increased numbers of activated CD8 T cells in the kidney, yet they had the highest likelihood of treatment response. A second group characterized primarily by a high type I interferon signature had a lower likelihood of response to therapy, while a third group appeared immunologically inactive by immunophenotyping at enrollment but with chronic renal injuries. Main immune profiles could be distilled down to 5 simple cytometric parameters that recapitulate several of the associations, highlighting the potential for blood immune profiling to translate to clinically useful non-invasive metrics to assess immune-mediated disease in LN.

Differences in reproductive health discussions in an urban Hispanic population with SLE: lessons from the field

OBJECTIVE

Management of reproductive health-related issues is crucial for patients with SLE, given this is a disease that primarily affects women of childbearing age. Little is known as to how the 2020 American College of Rheumatology (ACR) Reproductive Health in Rheumatic Disease Guideline is experienced by an underserved, primarily Hispanic population and their physicians as it relates to pregnancy planning and contraception conversations. Given this population experiences high rates of unplanned pregnancies and worse SLE outcomes compared with the non-Hispanic white population, it is crucial to understand how reproductive health is discussed in this setting.

METHODS

A survey based on the 2020 ACR Reproductive Health Guideline was created and distributed in English and Spanish in the outpatient setting to 151 patients with SLE to determine patients' beliefs, experiences and limitations with reproductive health discussions. Associations between categorical variables were evaluated using Pearson's χ2 or Fisher's exact test, as appropriate, and differences in continuous variables were assessed using Wilcoxon rank-sum test.

RESULTS

English language survey respondents were significantly more likely to report having conversations regarding contraception, pregnancy planning and peripartum medication use than the Spanish survey respondents. Two-thirds of all respondents relied on the rheumatologist as a top source of reproductive health information.

CONCLUSION

Disparities exist regarding reproductive health conversations on multiple topics between English-speaking and Spanish-speaking populations with SLE. Further understanding is needed to clarify why reproductive health conversations occur at lower frequencies in Spanish-speaking SLE populations.

Evaluation of Pneumonitis in a Phase II Study of Consolidation Immunotherapy with Nivolumab and Ipilimumab or Nivolumab Alone following Concurrent Chemoradiotherapy for Unresectable Stage IIIA/IIIB Non-small Cell Lung Cancer (NSCLC)

PURPOSE/OBJECTIVE(S)

Unresectable stage III Non-Small-Cell-Lung-Cancer (NSCLC) has had an evolving landscape of treatment options with the approvals of immuno-oncologic (IO) therapy. There have been relatively few studies that have evaluated the risk of pneumonitis in patients receiving IO after concurrent chemoradiation treatment (CCRT). This study is to evaluate the relationship of pneumonitis and radiation dose in patients receiving consolidative IO with Nivolumab or Nivolumab plus ipilimumab.

MATERIALS/METHODS

Patients with stage III NSCLC who underwent CCRT were enrolled on BTCRC-LUN16-081, a randomized phase II trial assessing the efficacy of nivolumab or nivolumab plus ipilimumab as consolidation therapy. These patients were evaluated for radiation dose parameters and correlation with pneumonitis was examined.

RESULTS

After CCRT, patients were enrolled to receive consolidative IO therapy on BTCRC-LUN16-081, and 104 patients had Dose Volume Histogram (DVH) information available for analysis. Of these patients, 58 (55.8%) had stage IIIA and 46 (44.2%) had stage IIIB disease according to 7th edition IASLC. During this period 29 patients (27.9%) had at least grade 2 pneumonitis. Utilizing logistic regression and evaluating different cut offs for lung V20, patients receiving a V20 of greater than 23% had a higher risk of grade 2 or greater pneumonitis (p-value 0.0246, 38% vs. 16%). There was no significant difference in rates of pneumonitis between the two different IO regimens. Traditional lung DVH cutoffs (V5>65%, V20>35%, mean >20 Gy) were not associated with pneumonitis in this study.

CONCLUSION

The use of nivolumab or nivolumab plus ipilimumab after definitive CCRT is safe and effective. Lung V20 > 23% was associated with a higher risk of Grade 2 or higher pneumonitis. Radiation dose constraints for lungs in patients receiving consolidative IO after CCRT should continue to be evaluated and optimized when feasible.

Socioeconomic Status, Reserve Capacity, and Depressive Symptoms Predict Pain in Rheumatoid Arthritis: An Examination of the Reserve Capacity Model

Background

Guided by the reserve capacity model, we examined the roles of socioeconomic status (SES), reserve capacity, and negative emotions as determinants of pain in patients with Rheumatoid Arthritis (RA).

Methods

The study used cross-sectional baseline data from 106 adults in a clinical trial comparing behavioral treatments for RA. Structural equation modeling evaluated the direct effects of SES, reserve capacity (helplessness, self-efficacy, social support) and negative emotions (stress and depressive symptoms) on pain, and the indirect effects of SES as mediated by reserve capacity and negative emotions.

Results

Results showed that low SES contributed to greater pain, through lower reserve capacity and higher negative emotions. Mediational analyses showed that reserve capacity and negative emotions partially mediated the effect of SES on pain.

Conclusions

The findings indicate that interventions that target negative emotions in patients with low SES may facilitate better pain control with RA.

Trial registration

clinicaltrials.gov NCT00072657; 02/2004.

OP0154 COMORBIDITY CLUSTERS IN ANKYLOSING SPONDYLITIS AND THEIR ASSOCIATION WITH DISEASE ACTIVITY AND FUNCTIONAL IMPAIRMENT: DATA FROM THE PSOAS COHORT

Background

Comorbidities in ankylosing spondylitis (AS) occur more frequently than in the general population and are associated with higher morbidity and mortality. Some comorbidities may occur together, making one more likely in the presence of another, and different combinations of comorbidities may have differential considerations for AS management and outcomes.

Objectives

To examine the association of baseline comorbidities with disease activity and functional status in AS.

Methods

We used baseline data from the Prospective Study Of Ankylosing Spondylitis (PSOAS) cohort, a multicenter, prospective cohort from five centers (4 in the US, 1 in Australia). AS patients ≥ 18 years fulfilling mNY criteria for AS (2002-20) were included. Patient-reported AS comorbidities (N=28) and extra-musculoskeletal manifestations (EMMs, N=2) within 3 years of enrollment (prespecified on the baseline case-report form) and only those occurring in ≥1% were included. Undocumented comorbidities were assumed to be absent if missing in <15% of patients, and those missing in >50% of patients were excluded. Comorbidity clusters were identified using K-median clustering. The optimal number of clusters was determined using scree plot of the sum of squared errors and “elbow” on the graph line. Baseline characteristics of the clusters were compared, and associations of with disease activity and functional status measures (primary outcomes: ASDAS-CRP and BASFI) were examined using linear regression adjusted for age and sex.

Results

There were 1,270 AS patients included with a mean age of 44.6 ±14.3 years, 74.4% males, and 81.2% whites. Mean AS symptom duration was 20.6±5.6 years, 81.6% HLA-B27 positive, and CRP elevated in 27.5% of patients at baseline. Depression was the most prevalent comorbidity (31.4%) followed by hypertension (26.1%); uveitis was the most common EMM (30.4%). The five clusters identified included depression (27%), no comorbidities (22%), hypertension (21%), uveitis (20%), and asthma/low bone mass (10%) (Figure 1). The cluster with no comorbidities was significantly younger, with lower symptom duration (p<0.001). Females had higher odds of being in the depression (OR=2.00, 95% CI 1.38- 2.90) and uveitis (OR=2.09, 95% CI 1.41-3.11) clusters compared to the cluster with no comorbidities. The number of comorbidities and clusters with depression and hypertension were significantly associated with worse disease activity and functional status (Table 1).

Table 1.

Age and sex adjusted associations between comorbidity clusters, compared to cluster 3, and baseline disease activity/ functional status measures in ankylosing spondylitis based on Linear regression models.

Cluster 1 (depression)Cluster 3 (hypertension)Cluster 4 (uveitis)Cluster 5 (asthma, low bone mass)OutcomesCoef (95% CI)Coef (95% CI)Coef (95% CI)Coef (95% CI)ASDAS-CRP0.98 (0.78-1.18)0.43 (0.18-0.68)0.04 (-0.19-0.27)0.16 (-0.12-0.44)BASFI (0-10)1.92 (1.51-2.34)1.00 (0.53-1.48)-0.03 (-0.49-0.42)0.64 (0.076-1.20)Enthesitis count1.17 (0.73-1.61)0.73 (0.19-1.26)0.18 (-0.32-0.68)0.48 (-0.13-1.08)Swollen joint count (0-44)0.27 (-0.08-0.62)0.43 (-0.01-0.86)0.31 (-0.09-0.71)-0.95 (-0.58-0.39)Tender joint count (0-46)1.24 (0.59-1.88)0.44 (-0.34-1.23)0.56 (-0.18-1.29)0.34 (-0.55-1.23)BASDAI (0-10)2.30 (1.88-2.71)0.88 (0.36-1.40)0.30 (-0.17-0.78)0.61 (0.03-1.19)Patient Global (0-10)2.25 (1.82-2.68)0.76 (0.21-1.30)-0.22 (-0.71-0.27)0.29 (-0.31-0.89)Patient Pain (0-10)2.45 (1.95-2.94)1.00 (0.37-1.62)0.19 (-0.38-0.75)0.16 (-0.54-0.85)Spinal pain (0-10)2.40 (1.89-2.91)1.05 (0.41-1.70)0.43 (-0.16-1.01)0.76 (0.04-1.47)Figure 1.

Comorbidity clusters in PSOAS cohort at baseline

Conclusion

Distinct comorbidity clusters were identified in AS patients in the PSOAS cohort. In addition to the number of comorbidities, the type of comorbidity seems to be important. Depression and hypertension clusters seem to be associated with worse disease activity and function.

Disclosure of Interests

Paras Karmacharya: None declared, Cynthia S. Crowson: None declared, Dilli Poudel: None declared, John M Davis III Consultant of: Dr. Davis has received consulting fees and/or honoraria from AbbVie and Sanofi-Genzyme (less than $10,000 each), Grant/research support from: Dr. Davis has received research support from Pfizer., Alexis Ogdie Consultant of: Dr. Ogdie has served as a consultant for AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB (less than 10,000 each), Grant/research support from: Dr. Ogdie has received grants from Novartis and Pfizer to Penn and from Amgen to Forward (grants more than 10,000)., Jean Liew Grant/research support from: Dr. Liew received grant/research support from Pfizer (> $10,000), Michael Ward: None declared, Mariko Ishimori: None declared, Michael Weisman Consultant of: Dr. Weisman received consulting fees for Novartis, UCB, Gilead, and GSK (< $10,000)., Matthew Brown: None declared, Mohammad Rahbar: None declared, Mark Hwang: None declared, John D Reveille Consultant of: JDR received consulting fees for UCB (< $10,000), Grant/research support from: Dr. Reveille received research support from Lilly and Janssen unrelated to this work., Lianne S. Gensler Consultant of: Dr. Gensler has received consulting fees for AbbVie, Eli Lilly, GSK, Gilead, Pfizer (< $10,000)., Grant/research support from: Dr. Gensler received grant/research support from UCB and Novartis (> $10,000).

Prevalence of sacroiliitis among patients referred for hip MR arthrography

OBJECTIVE

To determine the prevalence of sacroiliitis among patients who have been referred for MR arthrography.

MATERIALS AND METHODS

A retrospective search identified 130 consecutive MR arthrograms of the hip performed on a 1.5T Siemens Avanto at our institution from August 2013 to August 2014. Four studies were excluded due to the absence of a coronal short tau inversion recovery sequence of the pelvis, leaving 126 studies for analysis. A musculoskeletal radiology fellow and three attending musculoskeletal radiologists reviewed the images for the presence of bone marrow edema affecting the sacroiliac joints. Only cases of bone marrow edema meeting the Assessment of SpondyloArthritis international Society definition were considered positive. The two-tailed Fisher's exact test was used to compare the prevalence of positive MRI findings among age and gender groups. GraphPad InStat (GraphPad Software) was used for statistical calculations.

RESULTS

Patients less than 40 years of age demonstrated a statistically higher prevalence of positive MRI findings of sacroiliitis when compared to patients older than 40 (p = 0.0082). No difference in prevalence was found between genders. Overall prevalence of MRI signal alteration suggestive of sacroiliitis as defined by the Assessment of SpondyloArthritis international Society was 4.8%. Among the six patients with positive findings, two were subsequently diagnosed with spondyloarthritis.

CONCLUSION

Hip pain may be a presenting symptom of spondyloarthritis and attention should be paid to the sacroiliac joints during screening examinations, particularly in patients less than 40 years of age.

Does hydroxychloroquine improve patient reported outcomes in patients with lupus?

BACKGROUND

Hydroxychloroquine (HCQ) use is associated with less disease activity, flares, damage and improved survival in Systemic Lupus Erythematosus (SLE). However, its effect on patient reported health outcomes (PROs) such as quality of life (QOL) is not known.

METHODS

International data from Study on Outcomes of Lupus (SOUL) from 2,161 SLE patients were compared by HCQ use. Disease activity and damage were assessed using SELENA-SLEDAI and SLICC-ACR/SDI. QOL was evaluated using LupusPRO and Lupus Impact Tracker (LIT). Linear regression analyses were performed with LupusPRO summary scores health related HRQOL, non-health related NHRQOL and LIT as dependent and HCQ use as independent variable. Analyses were undertaken to test mediation of effects of HCQ use on QOL through disease activity.

RESULTS

Mean age was 40.5 ± 12.8 years, 93% were women. Sixty-three (1363/2161) percent were on HCQ. On univariate analysis, HCQ use was associated with (a) better QOL (LupusPRO-HRQOL: β 6.19, 95% CI 4.15, 8.24, P ≤ 0.001, LupusPRO NHRQOL: β 5.83, 95% CI 4.02, 7.64, P ≤ 0.001) and less impact on daily life (LIT: β -9.37, 95% CI -12.24, -6.50, P ≤ 0.001). On multivariate and mediational analyses, the effects of HCQ on QOL were indirectly and completely mediated through disease activity.

CONCLUSIONS

HCQ use in SLE is associated with better patient reported health outcomes (LupusPRO-HRQOL and NHRQOL and impact on daily life), and the effects are mediated through disease activity. This information can facilitate patients and physician's communication with decision-making regarding the use of HCQ for SLE management.

POS0904 FACTORS ASSOCIATED WITH SWITCHING FROM ONE ANTI-TNF AGENT TO ANOTHER ANTI-TNF, OR IL17 AGENT IN PATIENT WITH ANKYLOSING SPONDYLITIS

Background:

A recent study examining Commercial Claims Insurance database found that many patients with ankylosing spondylitis (AS) do not remain on their initial TNF inhibitor two years after initiation, particularly women and those taking opioids.

Objectives:

To examine factors associated with switching from one TNF inhibitor (i)agent to either another TNFi, IL-17i or JAKi over time (at <2years and >2 years) in a longitudinal cohort of AS patients.

Methods:

Patients enrolled in the Prospective Study of Outcomes in AS (PSOAS), an observational longitudinal study of predictors of AS severity operative since 2002-2020 including over 1250 patients meeting modified New York criteria. Data collected included age, gender, ethnicity, HLA-B27 status, disease activity (BASDAI or ASDAS), erythocyte sedimentation rate (ESR), C-reactive protein (CRP), disease severity,(functional (BASFI) or radiographic (mSASSS)), comorbidities, smoking, exercise, disease duration, depression (either by self report or by the Center for Epidemiologic Studies Depression Scale (CES-D) and other medication usage (NSAIDs, including the NSAID index, nonbiologic DMARDs, opioids, anti-depressants, anxiolytics and hypnotics). Logistic regression models were built to identify clinical and sociodemographic characterstics associated with medication switching to another TNFi, IL-17i, or other biologic therapy (another TNFi, Il-17i, or JAKi) within 2 years and after 2 years of initiation).

Results:

Of those patients in PSOAS who had at least two years of follow-up, 496 were prescribed anti-TNF, 34 anti-IL-17 and 3 anti-JAK agents. According to the multinomial logistic regression analysis, patients who switched from their original TNFito another TNFi, IL-17i or JAKi within two years after initiating their original TNFi were more likely to be older, have higher baseline subjective disease activity (BASDAI), less radiographic severity by MSASSS, exercise > 120 minutes/week and less likely to be currently smoking. Patients who switched after two years were less likely be depressed, had shorter disease duration, had greater subjective disease activity, were more likely to be exercising > 120 minutes/week, and had more comorbidities.

Conclusion:

Different factors were encountered in AS patients who switched from their initial TNFi to another TNFi, IL-17i or JAKi within 2 years versus after 2 years of treatment.

Table 1.

Factors Associated With Switching From One TNFi To A Second TNFi or IL-17i or JAKi Before or After Two Years Based On Multinomial Logistic Regression Model (N=496 Patients)

VariableSwitched within 2 years vs. not switchedp-value*Switched after 2 years vs. not switchedp-value*Gender (Male vs. Female)0.99(0.637, 1.549)0.980.95 (0.528, 1.719)0.87HLA-B27_(+ vs. -)0.99 (0.639, 1.523)0.950.66 (0.365, 1.192)0.17Depression (CESD≥ 16 or self-report)(Yes vs. No)0.99 (0.676, 1.445)0.950.35 (0.182, 0.672)0.002Disease duration at baseline (≥20 vs. <20 years)0.72 (0.485, 1.062)0.100.27 (0.146, 0.491)<0.001Age at baseline (≥40 vs. <40) (years)2.00 (1.291, 3.101)0.0021.23 (0.693, 2.193)0.48CRP (≥0.8 vs. <0.8)1.94 (1.230, 3.056)0.0040.90 (0.454, 1.789)0.77BASFI (≥40 vs. <40)1.34 0.852, 2.118)0.200.87 (0.450, 1.688)0.68BASDAI (≥4 vs. <4)1.73 (1.064, 2.797)0.032.31 (1.202, 4.427)0.01NSAID index (≥50 vs. <50)1.32 (0.822, 2.128)0.250.83 (0.437, 1.586)0.58NSAIDs used (Yes vs. No)0.84 (0.534, 1.309)0.430.85 (0.479, 1.510)0.58Exercise (≥120 vs. <120) (minutes/week)1.95 (1.396, 2.731)<0.0011.66(1.057, 2.613)0.03ASDAS (≥3 vs. <3)0.78 (0.454, 1.356)0.391.07 (0.478, 2.399)0.87Number of comorbidities (≥2 vs. <2)1.40 (0.997, 1.951)0.051.63 (1.029, 2.575)0.04mSASSS (≥4, vs. <4)0.63 (0.421, 0.957)0.030.81(0.474, 1.392)0.03Current smoker (Yes vs No)0.69 (0.385, 1.225)<0.0010.79 (0.297, 2.076)0.20

*p-values calculated based on multinomial logistic regression model when switching is defined as being prescribed a second TNFi or taking IL-17i or JAKi before or after 2 years from first TNFi initiation

Disclosure of Interests:

Mark Hwang Consultant of: UCB, Novartis, Michael Weisman Consultant of: Novartis, GSK, UCB, Lilly, Lianne S. Gensler Consultant of: AbbVie, GlaxoSmithKline, Eli Lilly, Novartis, Pfizer, UCB Pharma, Amirali Tahanan: None declared, Mariko Ishimori: None declared, Theresa Hunter Employee of: Eli Lilly, Rebecca Bolce Employee of: Eli Lilly, Jeffrey Lisse Employee of: Eli Lilly, Mohammad Rahbar: None declared, Minyang Shan Employee of: Eli Lilly, John D Reveille Consultant of: UCB, Grant/research support from: Eli Lilly

A Panel of Biomarkers Associates With Increased Risk for Cardiovascular Events in Women With Systemic Lupus Erythematosus

Objective

The increase in cardiovascular events (CVEs) in systemic lupus erythematosus (SLE) is not fully explained by traditional risk factors. We previously identified four biomarkers (proinflammatory high‐density lipoprotein, leptin, soluble TNF‐like weak inducer of apoptosis (sTWEAK), and homocysteine) that we combined with age and diabetes to create the predictors of risk for elevated flares, damage progression, and increased cardiovascular diseasein patients with SLE (PREDICTS) risk profile. PREDICTS more accurately identified patients with SLE at risk for progression of subclinical atherosclerosis than any individual variable. We examined whether PREDICTS can also identify patients with SLE at risk for future CVEs.

Methods

A total of 342 patients with SLE and 155 matched control subjects participated in this longitudinal prospective study. A high PREDICTS score was defined as three or more predictors or diabetes + one or more predictor. The biomarkers were measured at baseline using published methods. All major adverse CVEs (MACEs) were confirmed by medical record review.

Results

During 116 months of follow‐up, 5% of patients with SLE died, 12% had a cerebrovascular event, and 5% had a cardiac event. Overall, 20% of patients with lupus experienced any new MACE compared with 5% of control subjects (P < 0.0001). More patients with SLE with a new MACE had high PREDICTS score at baseline (77%) versus patients with no new events (34%) (P < 0.0001). High baseline PREDICTS score also associated with cerebrovascular (P < 0.0001) and cardiac events (P < 0.0001) in SLE. Using Cox regression, a baseline high PREDICTS score associated with a 3.7‐fold increased hazard ratio (HR) for a new MACE (P < 0.0001) in SLE. Hypertension (HR = 2.1; P = 0.006) was also a risk.

Conclusion

A high PREDICTS score and hypertension confer increased risk for new MACEs in patients with SLE.

Nonsteroidal Antiinflammatory Drug Use and Association With Incident Hypertension in Ankylosing Spondylitis

OBJECTIVE

Nonsteroidal antiinflammatory drugs (NSAIDs) increase blood pressure and potentially cardiovascular burden, which may limit their use in ankylosing spondylitis (AS). Our objective was to determine the association of NSAID use with incident hypertension in a longitudinal AS cohort.

METHODS

Adults with AS were enrolled in a prospective cohort study of patient outcomes and examined every 4-6 months. Hypertension was defined by patient-reported hypertension; antihypertensive medication use; or, on 2 consecutive visits, systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Continuous NSAID use was dichotomized based on the validated NSAID index. We assessed the association of NSAID use as a time-varying exposure with the incidence of hypertension using Cox proportional hazards models.

RESULTS

Of the 1,282 patients in the cohort, 628 patients without baseline hypertension had at least 1 year of follow-up and were included in the analysis. Of these, 72% were male, the mean age at baseline was 39 ± 13 years, and 200 patients used NSAIDs continuously. On follow-up, 129 developed incident hypertension. After controlling for other variables, continuous NSAID use was associated with a hazard ratio of 1.12 for incident hypertension (95% confidence interval 1.04-1.20), compared to noncontinuous or no use. The association did not differ in subgroups defined by age, body mass index, biologic use, or disease activity.

CONCLUSION

In our prospective, longitudinal AS cohort, continuous NSAID use was associated with a 12% increased risk for the development of incident hypertension, as compared to noncontinuous or no NSAID use.

A latent class based imputation method under Bayesian quantile regression framework using asymmetric Laplace distribution for longitudinal medication usage data with intermittent missing values

Evaluating the association between diseases and the longitudinal pattern of pharmacological therapy has become increasingly important. However, in many longitudinal studies, self-reported medication usage data collected at patients' follow-up visits could be missing for various reasons. These pieces of missing or inaccurate/untenable information complicate determining the trajectory of medication use and its complete effects for patients. Although longitudinal models can deal with specific types of missing data, inappropriate handling of this issue can lead to a biased estimation of regression parameters especially when missing data mechanisms are complex and depend upon multiple sources of variation. We propose a latent class-based multiple imputation (MI) approach using a Bayesian quantile regression (BQR) that incorporates cluster of unobserved heterogeneity for medication usage data with intermittent missing values. Findings from our simulation study indicate that the proposed method performs better than traditional MI methods under certain scenarios of data distribution. We also demonstrate applications of the proposed method to data from the Prospective Study of Outcomes in Ankylosing Spondylitis (AS) cohort when assessing an association between longitudinal nonsteroidal anti-inflammatory drugs (NSAIDs) usage and radiographic damage in AS, while the longitudinal NSAID index data are intermittently missing.

Drivers of Satisfaction With Care for Patients With Lupus

Objective

Quality of life (QOL) and quality of care (QOC) in systemic lupus erythematosus (SLE) remains poor. Satisfaction with care (SC), a QOC surrogate, correlates with health behaviors and outcomes. This study aimed to determine correlates of SC in SLE.

Methods

A total of 1262 patients with SLE were recruited from various countries. Demographics, disease activity (modified Systemic Lupus Erythematosus Disease Activity Index for the Safety of Estrogens in Lupus Erythematosus: National Assessment trial [SELENA‐SLEDAI]), and QOL (LupusPRO version 1.7) were collected. SC was collected using LupusPRO version 1.7. Regression analyses were conducted using demographic, disease (duration, disease activity, damage, and medications), geographic (eg, China vs United States), and QOL factors as independent predictors.

Results

The mean (SD) age was 41.7 (13.5) years; 93% of patients were women. On the univariate analysis, age, ethnicity, current steroid use, disease activity, and QOL (social support, coping) were associated with SC. On the multivariate analysis, Asian participants had worse SC, whereas African American and Hispanic patients had better SC. Greater disease activity, better coping, and social support remained independent correlates of better SC. Compared with US patients, patients from China and Canada had worse SC on the univariate analysis. In the multivariate models, Asian ethnicity remained independently associated with worse SC, even after we adjusted for geographic background (China). No associations between African American or Hispanic ethnicity and SC were retained when geographic location (Canada) was added to the multivariate model. Canadian patients had worse SC when compared with US patients. Higher disease activity, better social support, and coping remained associated with better SC.

Conclusion

Greater social support, coping, and, paradoxically, SLE disease activity are associated with better SC. Social support and coping are modifiable factors that should be addressed by the provider, especially in the Asian population. Therefore, evaluation of a patient's external and internal resources using a biopsychosocial model is recommended. Higher disease activity correlated with better SC, suggesting that the latter may not be a good surrogate for QOC or health outcomes.

Clinical features related to statin-associated muscle symptoms

INTRODUCTION

Statins reduce cardiovascular disease risk and are generally well tolerated, yet up to 0.5% of statin-treated patients develop incapacitating muscle symptoms including rhabdomyolysis. Our objective was to identify clinical factors related to statin-associated muscle symptoms (SAMS).

METHODS

Clinical and laboratory characteristics were evaluated in 748 statin-treated Caucasians (634 with SAMS and 114 statin-tolerant controls). Information was collected on statin type, concomitant drug therapies, muscle symptom history, comorbidities, and family history. Logistic regression was used to identify associations.

RESULTS

Individuals with SAMS were 3.6 times (odds ratio [OR] 3.60, 95% confidence interval [CI] 2.08-6.22) more likely than statin-tolerant controls to have a family history of heart disease. Additional associations included obesity (OR 3.08, 95% CI 1.18, 8.05), hypertension (OR 2.24, 95% CI 1.33, 3.77), smoking (OR 2.08, 95% CI 1.16, 3.74), and statin type.

DISCUSSION

Careful medical monitoring of statin-treated patients with the associated coexisting conditions may ultimately reduce muscle symptoms and lead to improved compliance. Muscle Nerve 59:537-537, 2019.

Sex Differences in Quality of Life in Patients With Systemic Lupus Erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) predominantly affects women. Clinical phenotype and outcomes in SLE may vary by sex and are further complicated by unique concerns that are dependent upon sex-defined roles. We aimed to describe sex differences in disease-specific quality of life (QoL) assessment scores using the Lupus Patient-Reported Outcome (LupusPRO) tool in a large international study.

METHODS

Cross-sectional data from 1,803 patients with SLE on demographics, self-identified sex status, LupusPRO, and disease activity were analyzed. The LupusPRO tool has 2 constructs: health-related QoL (HRQoL) and non-HRQoL. Disease activity and damage were evaluated using the Safety of Estrogens in Lupus Erythematosus National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, respectively. Nonparametric tests were used to compare QoL and disease activity by sex.

RESULTS

A total of 122 men and 1,681 women with SLE participated. The mean age was similar by sex, but the damage scores were greater among men. Men fared worse on the non-HRQoL social support domain than women (P = 0.02). When comparing disease and QoL among men and women ages ≤45 years, men were found to have greater damage and worse social support than women. However, women fared significantly worse on lupus symptoms, cognition, and procreation domains with trends for worse functioning on physical health and pain-vitality domains.

CONCLUSION

In the largest study of a diverse group of SLE patients, utilizing a disease-specific QoL tool, sex differences in QoL were observed on both HRQoL and non-HRQoL constructs. Although men performed worse in the social support domain, women (especially those in the reproductive age group) fared worse in other domains. These observations may assist physicians in appropriately addressing QoL issues in a sex-focused manner.

Trans-Ethnic Mapping of BANK1 Identifies Two Independent SLE-Risk Linkage Groups Enriched for Co-Transcriptional Splicing Marks

BANK1 is a susceptibility gene for several systemic autoimmune diseases in several populations. Using the genome-wide association study (GWAS) data from Europeans (EUR) and African Americans (AA), we performed an extensive fine mapping of ankyrin repeats 1 (BANK1). To increase the SNP density, we used imputation followed by univariate and conditional analysis, combined with a haplotypic and expression quantitative trait locus (eQTL) analysis. The data from Europeans showed that the associated region was restricted to a minimal and dependent set of SNPs covering introns two and three, and exon two. In AA, the signal found in the Europeans was split into two independent effects. All of the major risk associated SNPs were eQTLs, and the risks were associated with an increased BANK1 gene expression. Functional annotation analysis revealed the enrichment of repressive B cell epigenomic marks (EZH2 and H3K27me3) and a strong enrichment of splice junctions. Furthermore, one eQTL located in intron two, rs13106926, was found within the binding site for RUNX3, a transcriptional activator. These results connect the local genome topography, chromatin structure, and the regulatory landscape of BANK1 with co-transcriptional splicing of exon two. Our data defines a minimal set of risk associated eQTLs predicted to be involved in the expression of BANK1 modulated through epigenetic regulation and splicing. These findings allow us to suggest that the increased expression of BANK1 will have an impact on B-cell mediated disease pathways.

Serologic features of cohorts with variable genetic risk for systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease with genetic, hormonal, and environmental influences. In Western Europe and North America, individuals of West African descent have a 3-4 fold greater incidence of SLE than Caucasians. Paradoxically, West Africans in sub-Saharan Africa appear to have a low incidence of SLE, and some studies suggest a milder disease with less nephritis. In this study, we analyzed sera from African American female SLE patients and four other cohorts, one with SLE and others with varying degrees of risk for SLE in order to identify serologic factors that might correlate with risk of or protection against SLE.

METHODS

Our cohorts included West African women with previous malaria infection assumed to be protected from development of SLE, clinically unaffected sisters of SLE patients with high risk of developing SLE, healthy African American women with intermediate risk, healthy Caucasian women with low risk of developing SLE, and women with a diagnosis of SLE. We developed a lupus risk index (LRI) based on titers of IgM and IgG anti-double stranded DNA antibodies and levels of C1q.

RESULTS

The risk index was highest in SLE patients; second highest in unaffected sisters of SLE patients; third highest in healthy African-American women and lowest in healthy Caucasian women and malaria-exposed West African women.

CONCLUSION

This risk index may be useful in early interventions to prevent SLE. In addition, it suggests new therapeutic approaches for the treatment of SLE.

Disease-specific quality of life in patients with lupus nephritis

Background

Patient-reported outcomes in lupus nephritis (LN) are not well studied. Studies with disease-targeted PRO tool in LN do not exist. Herein, we describe quality of life (QOL: HRQOL & non-HRQOL) among LN patients using LupusPRO.

Methods

International, cross-sectional data from 1259 patients with systemic lupus erythematosus (SLE) and LupusPRO were compared, stratified by (a) presence of LN (ACR classification criteria (ACR-LN)) at any time and, (b) active LN (on SLEDAI) at study visit. Damage was assessed by SLICC/ACR-SDI. Multivariate regression analyses for QOL against ACR-LN (active LN) after adjusting for age, gender, ethnicity and country of recruitment were performed.

Results

Mean (SD) age was 41.7 (13.5) yrs, 93% were women. Five hundred and thirty-nine of 1259 SLE patients had ACR-LN. ACR-LN group was younger, were more often on immunosuppressive medications, had worse QOL on lupus medications and procreation than non-ACR-LN patients. HRQOL and non-HRQOL scores were similar in both groups. One hundred and twenty-nine of 539 ACR-LN patients had active LN. Active LN group was younger, had greater disease activity and had worse HRQOL and non-HRQOL compared to patients without active LN. Specific domains adversely affected were lupus symptoms, lupus medications, procreation, emotional health, body image and desires-goals domains. Patients with ACR-LN and active LN fared significantly worse in lupus medications and procreation HRQOL domains, even after adjusting for age, ethnicity, gender and country of recruitment.

Conclusions

Lupus nephritis patients have poor QOL. Patients with active LN have worse HRQOL and non-HRQOL. Most domains affected are not included in the generic QOL tools used in SLE. LN patients must receive discussion on lupus medications and procreation issues. Patients with active LN need comprehensive assessments and addressal of QOL, along with treatment for active LN.

Extremity fractures associated with ATVs and dirt bikes: a 10-year national epidemiologic study

BACKGROUND

Morbidity and mortality of all-terrain vehicles and dirt bikes have been studied, as well as the association of helmet use and head injury.

HYPOTHESIS/PURPOSE

The purpose of this study is to compare and contrast the patterns of extremity fractures associated with ATVs and dirt bikes. We believe there will be unique and potentially preventable injury patterns associated with dirt bikes and three-wheeled ATVs due to the poor stability of these vehicles.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The National Electronic Injury Surveillance System (NEISS) was used to acquire data for extremity fractures related to ATV (three wheels, four wheels, and number of wheels undefined) and dirt bike use from 2007 to 2012. Nationwide estimation of injury incidence was determined using NEISS weight calculations.

RESULTS

The database yielded an estimate of 229,362 extremity fractures from 2007 to 2012. The incidence rates of extremity fractures associated with ATV and dirt bike use were 3.87 and 6.85 per 1000 participant-years. The largest proportion of all fractures occurred in the shoulder (27.2%), followed by the wrist and lower leg (13.8 and 12.4%, respectively). There were no differences in the distribution of the location of fractures among four-wheeled or unspecified ATVs. However, three-wheeled ATVs and dirt bikes had much larger proportion of lower leg, foot, and ankle fractures compared to the other vehicle types.

CONCLUSIONS

While upper extremity fractures were the most commonly observed in this database, three-wheeled ATVs and dirt bikes showed increased proportions of lower extremity fractures. Several organizations have previously advocated for better regulation of the sale and use of these specific vehicles due to increased risks. These findings help illustrate some of the specific risks associated with these commonly used vehicles.

MicroRNA-302d targets IRF9 to regulate the IFN-induced gene expression in SLE

Systemic lupus erythematosus (SLE) is a complex disease targeting multiple organs as a result of overactivation of the type I interferon (IFN) system, a feature currently being targeted by multiple biologic therapies against IFN-α. We have identified an estrogen-regulated microRNA, miR-302d, whose expression is decreased in SLE patient monocytes and identify its target as interferon regulatory factor (IRF)-9, a critical component of the transcriptional complex that regulates expression of interferon-stimulated genes (ISGs). In keeping with the reduced expression of miR-302d in SLE patient monocytes, IRF9 levels were increased, as was expression of a number of ISGs including MX1 and OAS1. In vivo evaluation revealed that miR-302d protects against pristane-induced inflammation in mice by targeting IRF9 and hence ISG expression. Importantly, patients with enhanced disease activity have markedly reduced expression of miR-302d and enhanced IRF9 and ISG expression, with miR-302d negatively correlating with IFN score. Together these findings identify miR-302d as a key regulator of type I IFN driven gene expression via its ability to target IRF9 and regulate ISG expression, underscoring the importance of non-coding RNA in regulating the IFN pathway in SLE.

A Randomized, Double-Blind Trial of Abatacept (CTLA-4Ig) for the Treatment of Takayasu Arteritis

OBJECTIVE

To compare the efficacy of abatacept to that of placebo for the treatment of Takayasu arteritis (TAK).

METHODS

In this multicenter trial, patients with newly diagnosed or relapsing TAK were treated with abatacept 10 mg/kg intravenously on days 1, 15, and 29 and week 8, together with prednisone administered daily. At week 12, patients in remission underwent a double-blinded randomization to continue to receive abatacept monthly or switch to placebo. Patients in both study arms received a standardized prednisone taper, reaching a dosage of 20 mg daily at week 12, with discontinuation of prednisone at week 28. All patients remained on their randomized assignment until meeting criteria for early termination or until 12 months after enrollment of the last patient. The primary end point was duration of remission (relapse-free survival).

RESULTS

Thirty-four eligible patients with TAK were enrolled and treated with prednisone and abatacept; of these, 26 reached the week 12 randomization and underwent a blinded randomization to receive either abatacept or placebo. The relapse-free survival rate at 12 months was 22% for those receiving abatacept and 40% for those receiving placebo (P = 0.853). Treatment with abatacept in patients with TAK enrolled in this study was not associated with a longer median duration of remission (median duration 5.5 months for abatacept versus 5.7 months for placebo). There was no difference in the frequency or severity of adverse events, including infection, between the treatment arms.

CONCLUSION

In patients with TAK, the addition of abatacept to a treatment regimen with prednisone did not reduce the risk of relapse.

A Randomized, Double-Blind Trial of Abatacept (CTLA-4Ig) for the Treatment of Giant Cell Arteritis

OBJECTIVE

To compare the efficacy of abatacept to that of placebo for the treatment of giant cell arteritis (GCA).

METHODS

In this multicenter trial, patients with newly diagnosed or relapsing GCA were treated with abatacept 10 mg/kg intravenously on days 1, 15, and 29 and week 8, together with prednisone administered daily. At week 12, patients in remission underwent a double-blinded randomization to continue to receive abatacept monthly or switch to placebo. Patients in both study arms received a standardized prednisone taper, with discontinuation of prednisone at week 28. All patients remained on their randomized assignment until meeting criteria for early termination or until 12 months after enrollment of the last patient. The primary end point was duration of remission (relapse-free survival rate).

RESULTS

Forty-nine eligible patients with GCA were enrolled and treated with prednisone and abatacept; of these, 41 reached the week 12 randomization and underwent a blinded randomization to receive abatacept or placebo. Prednisone was tapered using a standardized schedule, reaching a daily dosage of 20 mg at week 12 with discontinuation in all patients at week 28. The relapse-free survival rate at 12 months was 48% for those receiving abatacept and 31% for those receiving placebo (P = 0.049). A longer median duration of remission was seen in those receiving abatacept compared to those receiving placebo (median duration 9.9 months versus 3.9 months; P = 0.023). There was no difference in the frequency or severity of adverse events, including infection, between the treatment arms.

CONCLUSION

In patients with GCA, the addition of abatacept to a treatment regimen with prednisone reduced the risk of relapse and was not associated with a higher rate of toxicity compared to prednisone alone.

A Case of Henoch-Schonlein Purpura Associated with Rotavirus Infection in an Elderly Asian Male and Review of the Literature

Patient: Male, 73

Final Diagnosis: Henoch-Schönlein purpura (HSP)

Symptoms: Abdominal pain • bloating • blood in stool • nausea • vomiting

Medication: —

Clinical Procedure: EGD • colonoscopy • kidney biopsy • skin biopsy • arthrocentesis

Specialty: Rheumatology

A multi-group confirmatory factor analyses of the LupusPRO between southern California and Filipino samples of patients with systemic lupus erythematosus

Introduction Systemic lupus erythematosus (SLE) leads to a range of biopsychosocial health outcomes through an unpredictable and complex disease path. The LupusPRO is a comprehensive, self-report measure developed specifically for populations with SLE, which assesses both health-related quality of life and non-health related quality of life. Given its increasingly widespread use, additional research is needed to evaluate the psychometric integrity of the LupusPRO across diverse populations. The objectives of this study were to evaluate the performance of the LupusPRO in two divergent patient samples and the model fit between both samples. Methods Two diverse samples with SLE included 136 patients from an ethnically-diverse, urban region in southern California and 100 from an ethnically-homogenous, rural region in Manila, Philippines. All patients met the ACR classification criteria for SLE. Confirmatory factor analysis (CFAs) were conducted in each sample separately and combined to provide evidence of the factorial integrity of the 12 subscales in the LupusPRO. Results Demographic analyses indicated significant differences in age, disease activity and duration, education, income, insurance, and medication use between groups. Results of the separate CFAs indicated moderate fit to the data for the hypothesized 12-factor model for both the Manila and southern California groups, respectively [χ² (794) = 1283.32, p < 0.001, Comparative Fit Index (CFI) = 0.793; χ² (794) =1398.44, p < 0.001, CFI = 0.858]. When the factor structures of the LupusPRO in the southern California and Manila groups were constrained to be equal between the two groups, findings revealed that the factor structures of measured variables fit the two groups reasonably well [χ² (1697) = 2950.413, df = 1697, p < 0.000; CFI = 0.811]. After removing seven constraints and eight correlations suggested by the Lagrange multiplier test, the model fit improved significantly [χ² (15) = 147.165, p < 0.000]. Conclusions This research provides significant support for the subscale structure of the LupusPRO in two disparate cultural samples of SLE patients. Despite significant sociodemographic and clinical differences between the two samples, for the most part, the LupusPRO performed similarly in both samples.

A Genome-wide Association Study Identifies Risk Alleles in Plasminogen and P4HA2 Associated with Giant Cell Arteritis

Giant cell arteritis (GCA) is the most common form of vasculitis in individuals older than 50 years in Western countries. To shed light onto the genetic background influencing susceptibility for GCA, we performed a genome-wide association screening in a well-powered study cohort. After imputation, 1,844,133 genetic variants were analyzed in 2,134 case subjects and 9,125 unaffected individuals from ten independent populations of European ancestry. Our data confirmed HLA class II as the strongest associated region (independent signals: rs9268905, p = 1.94 × 10^-54, per-allele OR = 1.79; and rs9275592, p = 1.14 × 10^-40, OR = 2.08). Additionally, PLG and P4HA2 were identified as GCA risk genes at the genome-wide level of significance (rs4252134, p = 1.23 × 10^-10, OR = 1.28; and rs128738, p = 4.60 × 10^-9, OR = 1.32, respectively). Interestingly, we observed that the association peaks overlapped with different regulatory elements related to cell types and tissues involved in the pathophysiology of GCA. PLG and P4HA2 are involved in vascular remodelling and angiogenesis, suggesting a high relevance of these processes for the pathogenic mechanisms underlying this type of vasculitis.

Treat-to-target (T2T) recommendations for gout

OBJECTIVES

The treat-to-target (T2T) concept has been applied successfully in several inflammatory rheumatic diseases. Gout is a chronic disease with a high burden of pain and inflammation. Because the pathogenesis of gout is strongly related to serum urate levels, gout may be an ideal disease in which to apply a T2T approach. Our aim was to develop international T2T recommendations for patients with gout.

METHODS

A committee of experts with experience in gout agreed upon potential targets and outcomes, which was the basis for the systematic literature search. Eleven rheumatologists, one cardiologist, one nephrologist, one general practitioner and one patient met in October 2015 to develop T2T recommendations based on the available scientific evidence. Levels of evidence, strength of recommendations and levels of agreement were derived.

RESULTS

Although no randomised trial was identified in which a comparison with standard treatment or an evaluation of a T2T approach had been performed in patients with gout, indirect evidence was provided to focus on targets such as normalisation of serum urate levels. The expert group developed four overarching principles and nine T2T recommendations. They considered dissolution of crystals and prevention of flares to be fundamental; patient education, ensuring adherence to medications and monitoring of serum urate levels were also considered to be of major importance.

CONCLUSIONS

This is the first application of the T2T approach developed for gout. Since no publication reports a trial comparing treatment strategies for gout, highly credible overarching principles and level D expert recommendations were created and agreed upon.

Altered soluble mediator levels and systemic lupus erythematosus-specific Connective Tissue Disease Screening Questionnaire (CSQ) scores differentiate unaffected relatives of lupus patients from healthy individuals with no family history of SLE (CCR4P.214)

Identifying populations at risk of SLE who remain unaffected would provide insights for potential disease prevention. Using a unique resource of SLE patient family members, first degree relatives (FDRs) of SLE patients (n = 154) with plasma samples available from previous genetic studies and who remained unaffected at follow-up evaluation (mean time = 6.8 years) were matched to healthy individuals unrelated to SLE patients (Controls). FDRs and Controls provided clinical and demographic information, and completed screening questionairres at baseline (BL) and follow-up (FU). BL and FU plasma samples were assessed for autoantibody production and soluble mediators. FDRs had significantly higher BL and FU CSQ scores (p&lt;0.0001), but no difference in the number of positive autoantibodies compared to Controls. FDRs had significant (p &lt; 0.01) increases in 38 (of 52) soluble mediators at BL and FU, including IFN-associated chemokines, TNFR ligands, and regulatory mediators (p&lt;0.002). Levels of MIP-1α (p=0.008), MIG (p=0.019), GROα (p=0.001), ICAM-1 (p=0.007), and VEGF (p=0.004), along with CSQ scores (p=0.010), best distinguished FDRs from Controls in logistic regression models. These alterations are present despite lack of progression to classified SLE, suggesting that multiple perturbations in immune-mediated inflammatory processes present in FDRs of SLE patients may be offset by inhibitory factors.

Soluble mediators and clinical features predict transition to systemic lupus erythematosus classification in previously unaffected relatives of SLE patients (HUM3P.243)

Healthy relatives of lupus patients have an increased risk of developing SLE, but predictors and mechanisms of disease transition are unknown. Unaffected relatives of SLE patients (n=409) were enrolled in this follow-up study to identify factors associated with transition to SLE. Participants provided detailed demographic and clinical information, including the Connective Tissue Disease Screening Questionnaire (CSQ). Medical records were reviewed for ACR classification criteria. Plasma samples were tested for the presence of autoantibodies and soluble mediators. Forty-five relatives (11%) transitioned to classified SLE during follow-up (mean time = 6.4 years) who had more autoantibodies (p&lt;0.0001) and higher pre-classification (baseline) CSQ scores (p&lt;0.0001). Relatives who transitioned also had elevated baseline levels of inflammatory mediators, including BLyS, SCF, and IFN-associated chemokines (p&lt;0.05), with concurrent decreased regulatory mediators, including TGF-β and IL-10 (p&lt;0.05). Logistic regression analysis revealed that baseline ACR and CSQ scores (but not autoantibodies), and baseline plasma levels of SCF and TGF-β were significant and independent predictors of SLE transition. Thus, perturbations in immune-mediated processes precede SLE clinical classification and can help identify unaffected relatives at highest risk of future SLE classification for early intervention studies.

Elevated serum anti-flagellin antibodies implicate subclinical bowel inflammation in ankylosing spondylitis: an observational study

INTRODUCTION

Ankylosing spondylitis (AS) and inflammatory bowel disease (IBD) share genetic and clinical features. IBD is associated with the presence of antibodies to a variety of commensal microorganisms including anti-Saccharomyces cerevesiae antibodies (ASCA), antineutrophil cytoplasmic antibodies (ANCA), anti-I2 (associated with anti-Pseudomonas activity), anti-Eschericia coli outer membrane porin C (anti-OmpC) and anti-flagellin antibodies (anti-CBir1). Subclinical intestinal inflammation may be present in up to 65% of patients with AS. This study evaluated the presence of antimicrobial antibodies in patients with AS alone, patients with AS and concomitant IBD (AS-IBD) and a control group of patients with mechanical back pain (MBP).

METHODS

Sera were tested by ELISA for ASCA IgG and IgA, anti-OmpC, anti-CBir1 and ANCA in 76 patients with AS alone, 77 patients with AS-IBD and 48 patients with MBP. Antibody positivity rates, median quantitative antibody levels and the proportion of patients with antibody levels in the 4th quartile of a normal distribution were compared between the three groups of patients.

RESULTS

Patients with AS alone demonstrated higher anti-CBir1 antibody positivity rates and median antibody levels than MBP patients. Anti-CBir1 positivity in AS was associated with elevation of acute phase reactants. AS-IBD patients demonstrated elevated responses when compared to AS alone for ASCA, anti-OmpC and anti-CBir1. Quartile analysis confirmed the findings.

CONCLUSIONS

These data suggest that adaptive immune responses to microbial antigens occur in AS patients without clinical IBD and support the theory of mucosal dysregulation as a mechanism underlying the pathophysiology of AS.

Pain and depression predict self-reported fatigue/energy in lupus

This study examined the contribution of pain and psychological distress to fatigue.

METHODS

One-hundred and twenty-five adult Caucasian and Hispanic lupus patients participated in this study. Demographic data, patient- and physician-reported disease activity, as well as psychological functioning, were collected. Fatigue, pain, and vitality were measured using visual analogue scales as well as a subscale of the SF-36 questionnaire. Linear and hierarchical regression analyses were conducted. In the regression analysis, ethnicity was entered at the first step, followed by age, income and education at step 2, pain and disease activity measures at step 3, and psychological measurements at step 4.

RESULTS

In the linear regression analysis, Caucasians reported more fatigue. Fatigue positively correlated with income, education, pain, patient-reported disease activity, helplessness, and depression, and negatively with internality, and the energy analysis mirrored the results of the fatigue analysis. In the first regression analysis, fatigue was the dependent variable. At step 1, Caucasians reported more fatigue. At step 2, no other demographic variables were significant. At step 3, pain and disease activity measures were significant when entered as a block; however, pain independently explained a large amount of variance. At step 4, psychological factors were significant as a block, with depression being the strongest predictor. In the second analysis, energy was the dependent variable. At step 1, Hispanics reported more energy. At step 2, demographic variables were not significant. At step 3, pain and disease activity were significant when entered as a block; however, only pain uniquely predicted energy. At step 4, psychological factors were significant as a block, with depression as the major contributor.

CONCLUSIONS

Both pain and depression were found to be strong predictors of fatigue, and negatively correlated with energy. Disease activity did not appear to play a significant role in lupus fatigue. These findings support the importance of managing depression and pain in order to reduce fatigue in patients with systemic lupus erythematosus.

Spanish LupusPRO: cross-cultural validation study for lupus

Purpose

LupusPRO is a disease-targeted, patient-reported, outcome measure that was developed and validated among US patients with systemic lupus erythematosus (SLE). To expand the availability and use of the tool, we undertook a cross-cultural adaptation and validation study of the Spanish-translated version of the LupusPRO.

Method

Forward and back translations of the 43-item English LupusPRO were undertaken and pretested in five individuals. The finalized Spanish version was administered to 211 SLE patients of Hispanic ancestry from the US and Latin America. Short Form-36 (Spanish) and Spanish LupusPRO were also administered. Disease activity was ascertained using the systemic lupus erythematosus disease activity index. A Spanish LupusPRO questionnaire that could be completed within 2–3 days was mailed to SLE patients of Hispanic ancestry and they mailed it back. Internal consistency reliability, test-retest reliability, criterion validity (against disease activity or health status) and convergent validity were tested. All reported p values are two-tailed.

Results

A total of 211 Spanish-speaking SLE patients (90% women) participated. Test-retest reliability of LupusPRO domains ranged from 0.80–0.95, while internal consistency reliability of the domains ranged from 0.71–0.96. Convergent validity with corresponding domains of the SF-36 was present. All health-related quality of life domains of the LupusPRO (except procreation) performed well against disease activity measures, establishing its criterion validity. Confirmatory factor analysis showed a good fit.

Conclusion

The Spanish LupusPRO has fair psychometric properties and is now available to be included in clinical trials and in longitudinal studies for testing of responsiveness to change.

Predictors of preterm birth in patients with mild systemic lupus erythematosus

OBJECTIVE

While increased disease activity is the best predictor of preterm birth in women with systemic lupus erythematosus (SLE), even women with low disease activity are at increased risk of this complication. Biomarkers that would identify at-risk pregnancies could allow interventions to prevent preterm birth.

METHOD

Measures of SLE activity, inflammation, placental health and renal function between 20 and 28 weeks gestation (mid-gestation) were correlated to preterm birth and gestational age at delivery in a prospective cohort of pregnant women with SLE.

RESULT

Of the 40 pregnancies in 39 women, all with mild-moderate SLE disease, 9 (23.7%) of the 38 live births were delivered preterm. Low C4 was the only marker of SLE activity associated with younger gestational age at delivery. Elevated ferritin and lower oestradiol correlated with younger gestational age at delivery. Renal function remained normal during all pregnancies at mid-gestation and did not correlate with preterm birth. Higher serum uric acid, however, correlated with younger gestational age at delivery.

CONCLUSIONS

In women with SLE with mild-moderate disease activity, ferritin, oestradiol and uric acid levels at mid-gestation may predict preterm birth. These markers may prove to be clinically useful in identifying pregnancies at particularly high risk for adverse outcomes.

High plasma leptin levels confer increased risk of atherosclerosis in women with systemic lupus erythematosus, and are associated with inflammatory oxidised lipids

Background

Patients with systemic lupus erythematosus (SLE) are at increased risk of atherosclerosis, even after accounting for traditional risk factors. High levels of leptin and low levels of adiponectin are associated with both atherosclerosis and immunomodulatory functions in the general population.

Objective

To examine the association between these adipokines and subclinical atherosclerosis in SLE, and also with other known inflammatory biomarkers of atherosclerosis.

Methods

Carotid ultrasonography was performed in 250 women with SLE and 122 controls. Plasma leptin and adiponectin levels were measured. Lipoprotein a (Lp(a)), oxidised phospholipids on apoB100 (OxPL/apoB100), paraoxonase, apoA-1 and inflammatory high-density lipoprotein (HDL) function were also assessed.

Results

Leptin levels were significantly higher in patients with SLE than in controls (23.7±28.0 vs 13.3±12.9 ng/ml, p<0.001). Leptin was also higher in the 43 patients with SLE with plaque than without plaque (36.4±32.3 vs 20.9±26.4 ng/ml, p=0.002). After multivariate analysis, the only significant factors associated with plaque in SLE were leptin levels in the highest quartile (≥29.5 ng/ml) (OR=2.8, p=0.03), proinflammatory HDL (piHDL) (OR=12.8, p<0.001), age (OR=1.1, p<0.001), tobacco use (OR=7.7, p=0.03) and hypertension (OR=3.0, p=0.01). Adiponectin levels were not significantly associated with plaque in our cohort. A significant correlation between leptin and piHDL function (p<0.001), Lp(a) (p=0.01) and OxPL/apoB100 (p=0.02) was also present.

Conclusions

High leptin levels greatly increase the risk of subclinical atherosclerosis in SLE, and are also associated with an increase in inflammatory biomarkers of atherosclerosis such as piHDL, Lp(a) and OxPL/apoB100. High leptin levels may help to identify patients with SLE at risk of atherosclerosis.

Autoantibodies in systemic lupus erythematosus: comparison of historical and current assessment of seropositivity

Systemic lupus erythematosus (SLE) is characterized by multiple autoantibodies and complement activation. Recent studies have suggested that anti-nuclear antibody (ANA) positivity may disappear over time in some SLE patients. Anti-double-stranded DNA (dsDNA) antibody titers and complement levels may vary with time and immunosuppressive treatment, while the behavior of anti-extractable nuclear antigen (ENA) over time is less well understood. This study sought to determine the correlation between historical autoantibody tests and current testing in patients with SLE. Three hundred and two SLE patients from the ACR Reclassification of SLE (AROSE) database with both historical and current laboratory data were selected for analysis. The historical laboratory data were compared with the current autoantibody tests done at the reference laboratory and tested for agreement using percent agreement and Kappa statistic. Serologic tests included ANA, anti-dsDNA, anti-Smith, anti-ribonucleoprotein (RNP), anti-Ro, anti-La, rheumatoid factor (RF), C3 and C4. Among those historically negative for immunologic markers, a current assessment of the markers by the reference laboratory generally yielded a low percentage of additional positives (3-13%). However, 6/11 (55%) of those historically negative for ANA were positive by the reference laboratory, and the reference laboratory test also identified 20% more patients with anti-RNP and 18% more with RF. Among those historically positive for immunologic markers, the reference laboratory results were generally positive on the same laboratory test (range 57% to 97%). However, among those with a history of low C3 or C4, the current reference laboratory results indicated low C3 or C4 a low percentage of the time (18% and 39%, respectively). ANA positivity remained positive over time, in contrast to previous studies. Anti-Ro, La, RNP, Smith and anti-dsDNA antibodies had substantial agreement over time, while complement had less agreement. This variation could partially be explained by variability of the historical assays, which were done by local laboratories over varying periods of time. Variation in the results for complement, however, is more likely to be explained by response to treatment. These findings deserve consideration in the context of diagnosis and enrolment in clinical trials.

Current controversies in spondyloarthritis: SPARTAN

The Spondyloarthritis Research and Therapy Network (SPARTAN), founded in 2003 to promote research, education, and treatment of ankylosing spondylitis (AS) and related forms of spondyloarthritis (SpA), held its 7th Annual Research and Education Meeting in July 2009 in Houston, Texas. Current controversies in SpA discussed during the meeting included an update on the epidemiology of AS, axial SpA, and inflammatory back pain; the adequacy of the mSASS to assess radiographic involvement; the helpfulness of magnetic resonance imaging in assessing disease progression; the reliability of metrology in assessing damage; and whether biologic agents alter the course of AS. Presentations also were made on psoriasis in the SCID mouse model; the challenges and opportunities of SpA in China; a discussion of the special needs in managing SpA in Ibero-America, and the SPARK Survey in Europe and North America.

The lupus family registry and repository

The Lupus Family Registry and Repository (LFRR) was established with the goal of assembling and distributing materials and data from families with one or more living members diagnosed with SLE, in order to address SLE genetics. In the present article, we describe the problems and solutions of the registry design and biometric data gathering; the protocols implemented to guarantee data quality and protection of participant privacy and consent; and the establishment of a local and international network of collaborators. At the same time, we illustrate how the LFRR has enabled progress in lupus genetics research, answering old scientific questions while laying out new challenges in the elucidation of the biologic mechanisms that underlie disease pathogenesis. Trained staff ascertain SLE cases, unaffected family members and population-based controls, proceeding in compliance with the relevant laws and standards; participant consent and privacy are central to the LFRR's effort. Data, DNA, serum, plasma, peripheral blood and transformed B-cell lines are collected and stored, and subject to strict quality control and safety measures. Coded data and materials derived from the registry are available for approved scientific users. The LFRR has contributed to the discovery of most of the 37 genetic associations now known to contribute to lupus through 104 publications. The LFRR contains 2618 lupus cases from 1954 pedigrees that are being studied by 76 approved users and their collaborators. The registry includes difficult to obtain populations, such as multiplex pedigrees, minority patients and affected males, and constitutes the largest collection of lupus pedigrees in the world. The LFRR is a useful resource for the discovery and characterization of genetic associations in SLE.

Low physical activity is associated with proinflammatory high-density lipoprotein and increased subclinical atherosclerosis in women with systemic lupus erythematosus

OBJECTIVE

To investigate the association between physical activity, functional activity of high-density lipoprotein (HDL), and subclinical cardiovascular disease in patients with systemic lupus erythematosus (SLE).

METHODS

A total of 242 SLE patients (all women) participated in this cross-sectional study from February 2004 to February 2008. Carotid plaque and intima-media thickness (IMT), antioxidant function of HDL, and traditional cardiac risk factors were measured. Physical activity was assessed from self-reports by calculating the metabolic equivalents (METS) per week and by the physical function domain of the Medical Outcomes Study Short Form 36 (SF-36). Data were analyzed using bivariate and multivariate regression analyses.

RESULTS

Number of METS per week spent performing strenuous exercise was negatively correlated with IMT (r = -0.4, P = 0.002) and number of plaques (r = -0.30, P = 0.0001). Physical function as assessed by the SF-36 was also negatively correlated with IMT (r = -0.14, P = 0.03) and number of plaques (r = -0.14, P = 0.04). In multivariate analyses, number of strenuous exercise METS was significantly associated with IMT (t = -2.2, P = 0.028) and number of plaques (t = -2.5, P = 0.014) when controlling for markers of SLE disease activity and damage, but not after controlling for traditional cardiac risk factors. Low physical activity, defined as <225 total METS per week, was associated with the presence of proinflammatory HDL (P = 0.03).

CONCLUSION

Low physical activity is associated with increased subclinical atherosclerosis and proinflammatory HDL in patients with SLE. Increased strenuous exercise may reduce the risk of atherosclerosis in SLE.