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Loganathan A, Zanframundo G, Yoshida A, Faghihi-Kashani S, Bauer Ventura I, Dourado E, Bozan F, Sambataro G, Yamano Y, Bae SS, Lim D, Ceribelli A, Isailovic N, Selmi C, Fertig N, Bravi E, Kaneko Y, Saraiva AP, Jovani V, Bachiller-Corral J, Cifrian J, Mera-Varela A, Moghadam-Kia S, Wolff V, Campagne J, Meyer A, Giannini M, Triantafyllias K, Knitza J, Gupta L, Molad Y, Iannone F, Cavazzana I, Piga M, De Luca G, Tansley S, Bozzalla-Cassione E, Bonella F, Corte TJ, Doyle TJ, Fiorentino D, Gonzalez-Gay MA, Hudson M, Kuwana M, Lundberg IE, Mammen AL, McHugh NJ, Miller FW, Montecucco C, Oddis CV, Rojas-Serrano J, Schmidt J, Scirè CA, Selva-O'Callaghan A, Werth VP, Alpini C, Bozzini S, Cavagna L, Aggarwal R. Agreement between local and central anti-synthetase antibodies detection: results from the Classification Criteria of Anti-Synthetase Syndrome project biobank. Clin Exp Rheumatol 2024; 42:277-287. [PMID: 38488094 DOI: 10.55563/clinexprheumatol/s14zq8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/18/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES The CLASS (Classification Criteria of Anti-Synthetase Syndrome) project is a large international multicentre study that aims to create the first data-driven anti-synthetase syndrome (ASSD) classification criteria. Identifying anti-aminoacyl tRNA synthetase antibodies (anti-ARS) is crucial for diagnosis, and several commercial immunoassays are now available for this purpose. However, using these assays risks yielding false-positive or false-negative results, potentially leading to misdiagnosis. The established reference standard for detecting anti-ARS is immunoprecipitation (IP), typically employed in research rather than routine autoantibody testing. We gathered samples from participating centers and results from local anti-ARS testing. As an "ad-interim" study within the CLASS project, we aimed to assess how local immunoassays perform in real-world settings compared to our central definition of anti-ARS positivity. METHODS We collected 787 serum samples from participating centres for the CLASS project and their local anti-ARS test results. These samples underwent initial central testing using RNA-IP. Following this, the specificity of ARS was reconfirmed centrally through ELISA, line-blot assay (LIA), and, in cases of conflicting results, protein-IP. The sensitivity, specificity, positive likelihood ratio and positive and negative predictive values were evaluated. We also calculated the inter-rater agreement between central and local results using a weighted κ co-efficient. RESULTS Our analysis demonstrates that local, real-world detection of anti-Jo1 is reliable with high sensitivity and specificity with a very good level of agreement with our central definition of anti-Jo1 antibody positivity. However, the agreement between local immunoassay and central determination of anti-non-Jo1 antibodies varied, especially among results obtained using local LIA, ELISA and "other" methods. CONCLUSIONS Our study evaluates the performance of real-world identification of anti-synthetase antibodies in a large cohort of multi-national patients with ASSD and controls. Our analysis reinforces the reliability of real-world anti-Jo1 detection methods. In contrast, challenges persist for anti-non-Jo1 identification, particularly anti-PL7 and rarer antibodies such as anti-OJ/KS. Clinicians should exercise caution when interpreting anti-synthetase antibodies, especially when commercial immunoassays test positive for non-anti-Jo1 antibodies.
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Affiliation(s)
- Aravinthan Loganathan
- Royal National Hospital for Rheumatic Diseases, Bath; Department of Life Sciences, University of Bath, UK; and Arthritis Australia, Broadway, Glebe, NSW, Australia
| | - Giovanni Zanframundo
- Department of Internal Medicine and Therapeutics, Università di Pavia; and Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Akira Yoshida
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Sara Faghihi-Kashani
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Eduardo Dourado
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro; Aveiro Rheumatology Research Centre, Egas Moniz Health Alliance, Aveiro; and Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Portugal
| | - Francisca Bozan
- Hospital Clínico Universidad de Chile, Department of Medicine, Section of Rheumatology, Chile
| | - Gianluca Sambataro
- Regional Referral Center for Rare Lung Disease, Policlinico G. Rodolico-San Marco, University of Catania, Italy
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Japan
| | - Sharon Sangmee Bae
- Department of Medicine, Division of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, CA, USA
| | - Darosa Lim
- Department of Dermatology, Perelman School of Medicine & Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Angela Ceribelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele; and Rheumatology and Clinical Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Rozzano, Italy
| | - Natasa Isailovic
- Rheumatology and Clinical Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Rozzano, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele; and Rheumatology and Clinical Immunology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Rozzano, Italy
| | - Noreen Fertig
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elena Bravi
- Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Yuko Kaneko
- Keio University School of Medicine, Tokyo, Japan
| | | | - Vega Jovani
- Department of Rheumatology, Hospital General Universitario Dr. Balmis Alicante, ISABIAL, Alicante, Spain
| | | | - Jose Cifrian
- Hospital Universitario Marques de Valdecilla, IDIVAL, University of Cantabria, Santander, Spain
| | | | - Siamak Moghadam-Kia
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Alain Meyer
- Exploration Fonctionnelle Musculaire, Service de Physiologie, Service de Rhumatologie, Centre de Référence des Maladies Auto-Immunes Systémiques Rares RESO Hôpitaux Universitaires de Strasbourg, France
| | - Margherita Giannini
- Exploration Fonctionnelle Musculaire, Service de Physiologie, Service de Rhumatologie, Centre de Référence des Maladies Auto-Immunes Systémiques Rares RESO Hôpitaux Universitaires de Strasbourg, France
| | | | | | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, SGPGIMS, Lucknow, India
| | - Yair Molad
- Rabin Medical Center, Beilinson Hospital, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | | | - Matteo Piga
- University Clinic and AOU of Cagliari, Italy
| | - Giacomo De Luca
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Sarah Tansley
- Royal National Hospital for Rheumatic Diseases, Bath, and Department of Life Sciences, University of Bath, UK
| | - Emanuele Bozzalla-Cassione
- Department of Internal Medicine and Therapeutics, Università di Pavia, and Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Bonella
- Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Tamera J Corte
- University of Sydney, NSW, and Royal Prince Alfred Hospital, NSW, Australia
| | - Tracy J Doyle
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - David Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA, USA
| | - Miguel Angel Gonzalez-Gay
- Medicine and Psychiatry Department, University of Cantabria, and Division of Rheumatology, IIS-Fundacion Jiménez Díaz, Madrid, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | | | - Andrew L Mammen
- National Institute of Arthritis and Musculoskeletal and Skin Disorders, National Institutes of Health, Bethesda, MD, and Departments of Medicine and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Fredrick W Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Therapeutics, Università di Pavia; and Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chester V Oddis
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jorge Rojas-Serrano
- Interstitial Lung Disease and Rheumatology Units, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, México City, México
| | | | - Carlo Alberto Scirè
- IRCCS San Gerardo dei Tintori Foundation, Monza, and School of Medicine, University of Milano Bicocca, Milan, Italy
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Vall d'Hebron General Hospital, Universitat Autonoma de Barcelona, Spain
| | - Victoria P Werth
- Department of Dermatology, Perelman School of Medicine & Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Claudia Alpini
- Laboratory of Biochemical-Chemistry, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Sara Bozzini
- US Transplant Center, Laboratorio di Biologia Cellulare e Immunologia, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Lorenzo Cavagna
- Department of Internal Medicine and Therapeutics, Università di Pavia; and Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Rohit Aggarwal
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Keret S, Henig I, Zuckerman T, Kaly L, Shouval A, Awisat A, Rosner I, Rozenbaum M, Boulman N, Dortort Lazar A, Molad Y, Sabbah F, Naffaa ME, Hardak E, Slobodin G, Rimar D. Outcomes in progressive systemic sclerosis treated with autologous hematopoietic stem cell transplantation compared with combination therapy. Rheumatology (Oxford) 2023:kead457. [PMID: 37672021 DOI: 10.1093/rheumatology/kead457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/31/2023] [Accepted: 08/14/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES Autologous hematopoietic stem cell transplantation (AHSCT) has been shown to improve long-term survival for early diffuse progressive systemic sclerosis (SSc) compared with cyclophosphamide. Cyclophosphamide, however, does not provide a long-term benefit in SSc. The combination of mycophenolate mofetil (MMF) and rituximab is a potent alternative regimen. We aimed to retrospectively compare the outcomes of SSc patients who underwent AHSCT to patients who met the eligibility criteria for AHSCT but received upfront combination therapy with MMF and rituximab. METHODS Repeated assessments of modified Rodnan Skin Score (mRSS), forced vital capacity (FVC), and diffusing capacity (DLCO) values were conducted. Clinical improvement was defined as an mRSS decrease > 25% or an FVC increase > 10%. Event-free survival (EFS) was defined in the absence of persistent major organ failure or death. RESULTS Twenty-one SSc patients in the combination therapy group were compared with sixteen in the AHSCT group. Age, sex and disease duration were similar between the two groups. Clinical improvement at 12 months was seen in 18 (86%) patients in the combination group compared with 13 (81%) in the AHSCT group (p= 0.7). The hazard ratio for EFS at 24 months favored the combination group (HR = 0.09, P= 0.04). During follow-up, both groups exhibited a significant and comparable reduction in mRSS and an increase in FVC values at each time interval up to 24 months. CONCLUSION MMF and rituximab compared with AHSCT in SSc patients eligible for AHSCT resulted in similar skin and lung clinical improvement with a better safety profile at 24 months.
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Affiliation(s)
- Shiri Keret
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Israel Henig
- Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel
| | - Lisa Kaly
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Aniela Shouval
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Abid Awisat
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Itzhak Rosner
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Michael Rozenbaum
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Nina Boulman
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | | | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Petah Tikva, Israel
| | - Firas Sabbah
- Rheumatology Unit, Baruch Padeh Medical Center, Poriya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Mohammad E Naffaa
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Rheumatology Unit, Galilee Medical Center, Nahariya, Israel
| | - Emilia Hardak
- Pulmonary Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Doron Rimar
- Rheumatology Unit, Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
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Molad Y, Egbaria M, Tovar A, Dortort Lazar A, Pokroy Shapira E, Oren S, Edel Y, Kliminski V. Urine soluble triggering receptor expressed on myeloid cells-1 is a novel biomarker for active lupus nephritis: a case-control study. Clin Exp Rheumatol 2023; 41:1155-1162. [PMID: 36622114 DOI: 10.55563/clinexprheumatol/4lvaye] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 09/26/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To determine the value of plasma and urine sTREM-1 levels as a biomarker of lupus nephritis (LN) as well as extra-renal systemic lupus erythematosus (SLE). METHODS Consecutive adult patients with SLE attending a tertiary lupus clinic in 2016-2018 were prospectively divided into 3 groups according to SLEDAI-2K and renal-SLEDAI scores: active renal lupus (ARL), active non-renal lupus (ANL), and inactive lupus (IL). Blood and spot urine samples from each group and matched healthy subjects were analysed by means of ELISA for plasma and urine sTREM-1 levels. RESULTS The cohort included 59 patients (mean age 41.5+2.9 years, 85% female) with SLE: 15 ARL, 14 ANL, and 30 IL. The ARL group had higher scores on the SLEDAI-2K and renal-SLEDAI, and higher urine protein/creatinine ratio than the other patient groups (p=0.0001 for all). Plasma sTREM-1 level was highest in the ANL group (p=0.0085). Urine sTREM-1 level was higher in the whole SLE cohort than the healthy controls (p=0.0249), and higher in the ARL group than the others (p=0.0044). Neither plasma nor urine sTREM-1 level was associated with non-renal SLE features. On Spearman correlation analysis, urine sTREM-1 level, but not plasma sTREM-1 level, was correlated positively with renal-SLEDAI score (r=0.34, p=0.018), inversely with serum C3 and C4 levels (r=-0.42, p=0.0027 and r=-0.28, p=0.056, respectively), and positively with proteinuria (UPCR: r=0.32, p=0.0305). CONCLUSIONS Urine sTREM-1 might serve as a potential biomarker of active renal SLE.
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Affiliation(s)
- Yair Molad
- Institute of Rheumatology and Laboratory of Inflammation Research, Felsenstein Medical Research Center, Petah Tikva; Rabin Medical Center, Beilinson Hospital, Petah Tikva; and Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Mohamad Egbaria
- Rabin Medical Center, Beilinson Hospital, Petah Tikva, and Department of Medicine B, Ha'emek Medical Center, Faculty of Medicine, Israel Institute of Technology, Afula, Israel
| | - Ana Tovar
- Sackler Faculty of Medicine, Tel Aviv University, and Department of Pathology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Ariela Dortort Lazar
- Rabin Medical Center, Beilinson Hospital, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Elisheva Pokroy Shapira
- Rabin Medical Center, Beilinson Hospital, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shirly Oren
- Rabin Medical Center, Beilinson Hospital, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yonatan Edel
- Rabin Medical Center, Beilinson Hospital, Petah Tikva, and Department of Medicine B, Assuta Ashdod University Medical Center, Ben-Gurion University of the Negev, Ashdod, Israel
| | - Vitaly Kliminski
- Laboratory of Inflammation Research, Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Israel
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Kharouf F, Eviatar T, Braun M, Pokroy-Shapira E, Brodavka M, Zloof Y, Agmon-Levin N, Toledano K, Oren S, Lidar M, Zisman D, Tavor Y, Amit-Vazina M, Sabbah F, Breuer GS, Dagan A, Beshara-Garzuzi R, Markovits D, Elias M, Feld J, Tayer-Shifman O, Gazitt T, Reitblatt T, Rubin L, Haddad A, Giryes S, Paran D, Peleg H, Molad Y, Elkayam O, Mevorach D, Balbir-Gurman A, Braun-Moscovici Y. A deep look into the storm: Israeli multi-center experience of coronavirus disease 2019 (COVID-19) in patients with autoimmune inflammatory rheumatic diseases before and after vaccinations. Front Immunol 2023; 14:1064839. [PMID: 36993961 PMCID: PMC10040776 DOI: 10.3389/fimmu.2023.1064839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
ObjectiveWe aimed to characterize the course of COVID-19 in autoimmune inflammatory rheumatic disease (AIIRD) patients in Israel, taking into consideration several remarkable aspects, including the outcomes of the different outbreaks, the effect of vaccination campaigns, and AIIRD activity post-recovery.MethodsWe established a national registry of AIIRD patients diagnosed with COVID-19, including demographic data, AIIRD diagnosis, duration and systemic involvement, comorbidities, date of COVID-19 diagnosis, clinical course, and dates of vaccinations. COVID-19 was diagnosed by a positive SARS-CoV-2 polymerase chain reaction.ResultsIsrael experienced 4 outbreaks of COVID-19 until 30.11.2021. The first three outbreaks (1.3.2020 – 30.4.2021) comprised 298 AIIRD patients. 64.9% had a mild disease and 24.2% had a severe course; 161 (53.3%) patients were hospitalized, 27 (8.9%) died. The 4th outbreak (delta variant), starting 6 months after the beginning of the vaccination campaign comprised 110 patients. Despite similar demographic and clinical characteristics, a smaller proportion of AIIRD patients had negative outcomes as compared to the first 3 outbreaks, with regards to severity (16 patients,14.5%), hospitalization (29 patients, 26.4%) and death (7 patients, 6.4%). COVID-19 did not seem to influence the AIIRD activity 1-3 months post-recovery.ConclusionsCOVID-19 is more severe and has an increased mortality in active AIIRD patients with systemic involvement, older age and comorbidities. Vaccination with 3 doses of the mRNA vaccine against SARS-CoV-2 protected from severe COVID-19, hospitalization and death during the 4th outbreak. The pattern of spread of COVID-19 in AIIRD patients was similar to the general population.
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Affiliation(s)
- Fadi Kharouf
- The Department of Medicine, Rheumatology Unit and Rare Disease Research Center, Hadassah Medical Center, Jerusalem, Israel
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tali Eviatar
- Rheumatology Department, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Braun
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Elisheva Pokroy-Shapira
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Michal Brodavka
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Yair Zloof
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nancy Agmon-Levin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Clinical Immunology, Angioedema and Allergy Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Kochava Toledano
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
| | - Shirly Oren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Merav Lidar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Devy Zisman
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Yonit Tavor
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
| | - Mirit Amit-Vazina
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Service, Shamir Medical Center, Be’er Ya’akov, Israel
| | - Firas Sabbah
- Rheumatology Service, Baruch Padeh Medical Center, Tiberias, Israel
| | - Gabriel S. Breuer
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Rheumatology Unit, Shaare Tzedek Medical Center, Jerusalem, Israel
| | - Amir Dagan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Clinic, Assuta Ashdod Hospital, Ashdod, Israel
| | - Rima Beshara-Garzuzi
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Doron Markovits
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
| | - Muna Elias
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Joy Feld
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Oshrat Tayer-Shifman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
| | - Tal Gazitt
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | | | - Limor Rubin
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Allergy and Clinical Immunology Unit, Department of medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Amir Haddad
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Sami Giryes
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
| | - Daphna Paran
- Rheumatology Department, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Peleg
- The Department of Medicine, Rheumatology Unit and Rare Disease Research Center, Hadassah Medical Center, Jerusalem, Israel
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yair Molad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Ori Elkayam
- Rheumatology Department, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Mevorach
- The Department of Medicine, Rheumatology Unit and Rare Disease Research Center, Hadassah Medical Center, Jerusalem, Israel
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexandra Balbir-Gurman
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
| | - Yolanda Braun-Moscovici
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Israeli Institute of Technology-Technion, Haifa, Israel
- *Correspondence: Yolanda Braun-Moscovici,
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Nahum Y, Sagy I, Cohen Y, Pokroy-Shapira E, Abu-Shakra M, Molad Y. The Effect of Different Ethnic Origins in Israel on the Clinical Manifestations and Outcomes of Systemic Lupus Erythematous. Isr Med Assoc J 2023; 25:221-226. [PMID: 36946669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Epidemiological studies have shown a connection between ethnic origin and the incidence and outcome of systemic lupus erythematosus (SLE). OBJECTIVES To evaluate the SLE outcomes among Ashkenazi Jews, non-Ashkenazi Jews, and Arabs. METHODS We conducted a retrospective study of patients who were diagnosed with SLE and followed in lupus clinics at two large tertiary medical centers. The data were obtained from patient medical records. Patients were stratified into three ethnic origins: Ashkenazi Jews, non-Ashkenazi Jews, and Arabs. The primary outcomes were all-cause mortality, development of end-stage kidney disease (ESKD), and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2K ≤ 4 at last visit. RESULTS We included 570 patients in this study. The Arab group showed the highest number of SLE classification criteria at diagnosis and last encounters compared to non-Ashkenazi and Ashkenazi Jewish groups (6.0 vs. 5.0 and 4.0, respectively at diagnosis, P < 0.001; 8.0 vs. 7.0 and 6.0 at last visit, P = 0.01). In multivariate models, Arab patients had three times higher risk of all-cause mortality than Ashkenazi Jews (hazard ratio 2.99, 95% confidence interval [95%CI] 1.32-6.76, P = 0.009). ESKD was similar among the study groups. Low disease activity (SLEDAI 2K ≤ 4) at last visit was lower in the Arab group than the Ashkenazi Jews (odds ratio 0.50, 95%CI 0.28-0.87, P = 0.016), depicting a medium-to-high disease activity among the former. CONCLUSIONS Physicians should consider the influence of the ethnicity of the SLE patient when deciding on their care plan.
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Affiliation(s)
- Yehudit Nahum
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Iftach Sagy
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel, Rheumatic Diseases Unit, Ben Gurion University of the Negev, Beer Sheva, Israel, Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Yarden Cohen
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Elisheva Pokroy-Shapira
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mahmoud Abu-Shakra
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel, Rheumatic Diseases Unit, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Yair Molad
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sagy I, Finkel-Oron A, Naamany E, Barski L, Abu-Shakra M, Molad Y, Shiber S. Diagnostic utility of clinical characteristics, laboratory tests, and serum ferritin in diagnosis of adult-onset Still disease. Medicine (Baltimore) 2022; 101:e30152. [PMID: 36042585 PMCID: PMC9410682 DOI: 10.1097/md.0000000000030152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The diagnosis of adult-onset Still disease (AOSD) is challenging with ambiguous clinical presentation and no specific serological markers. We aim to evaluate the diagnostic utility of clinical, laboratory and serum ferritin features in established AOSD patients. We included all patients >18 years who were admitted to 2 tertiary medical centers (2003-2019) with serum ferritin above 1000 ng/mL. AOSD patients and non-AOSD controls were matched in 1:4 ratio for age and sex. The primary outcomes were sensitivity, specificity, positive/negative likelihood ratio and area under the curve (AUC) using clinical and laboratory characteristics based on the Yamaguchi classification criteria, in addition to serum ferritin. We identified 2658 patients with serum ferritin above 1000 ng/m, of whom 36 diagnosed with AOSD and 144 non-AOSD matched controls. Presence of arthralgia/arthritis showed the highest sensitivity (0.74), specificity (0.93), positive likelihood ratio (10.69), negative likelihood ratio (0.27) and AUC (0.83, 95% confidence interval 0.74-0.92) to the diagnosis of AOSD. On the other hand, serum ferritin showed variation and poorer results, depends on the chosen ferritin cutoff. Joint involvement showed the best diagnostic utility to establish the diagnosis of AOSD. Although clinicians use often elevated ferritin levels as an anchor to AOSD, the final diagnosis should be based on thorough clinical evaluation.
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Affiliation(s)
- Iftach Sagy
- Rheumatic Diseases Unit, Soroka University Medical Center, Beer Sheva, Israel
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alona Finkel-Oron
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eviatar Naamany
- Internal Medicine Division, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Barski
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Mahmoud Abu-Shakra
- Rheumatic Diseases Unit, Soroka University Medical Center, Beer Sheva, Israel
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachaf Shiber
- Institute of Rheumatology, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Internal Medicine Division, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Iftach Sagy, MD, PhD, Clinical Research Center, Soroka University Medical Center, POB 151, Beer-Sheva 84101, Israel (e-mail: )
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Sagy I, Cohen Y, Nahum Y, Pokroy-Shapira E, Abu-Shakra M, Molad Y. Lower socioeconomic status worsens outcome of patients with systemic lupus erythematosus independently of access to healthcare. Lupus 2022; 31:532-540. [PMID: 35341361 DOI: 10.1177/09612033221084518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Socioeconomic status (SES) has been found to be associated with worse outcomes of systemic lupus erythematosus (SLE). The impact of national health insurance on SLE outcomes has not been explored. METHODS A retrospective inception cohort of patients older than 18 years with SLE diagnosed and followed in lupus clinics of two large tertiary medical centers were included. Patients were stratified into three groups by SES: lower 25th quantile, middle 25th-75th quantile, and upper 75th quantile. Primary outcomes were all-cause mortality, development of end-stage kidney disease (ESKD), and score ≤ 4 on the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI 2K) at the last visit. RESULTS We identified 617 patients (548 females, 88.8%) with a median follow-up of 15 years (range, 8.0-23.0). Compared to the middle and upper SES groups, the lower SES group was characterized by younger age at disease onset (31.5 years vs. 34.3 and 37.4 years, respectively, p = 0.011) and higher rate of lupus nephritis (42.7% vs. 35.7% and 23.8%, respectively, p = 0.002). In multivariate models, patients in the middle and upper SES groups had a significantly lower risk of mortality (HR = 0.45; 95% CI, 0.24-0.82, p = 0.010) and ESKD (HR = 0.24; 95% CI, 0.08-0.73, p = 0.012), with no effect on the rate of SLEDAI 2K ≤ 4 (OR = 1.49; 95% CI, 0.92-2.40, p = 0.09). CONCLUSION Even within a health system that provides high and equal accessibility to medical care, low SES is associated with worse outcomes of SLE. Policymakers should focus on managing possible barriers that prevent patients of lower SES from obtaining optimal care.
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Affiliation(s)
- Iftach Sagy
- Rheumatic Diseases Unit, 26746Soroka University Medical Center, Beer Sheva, Israel.,Clinical Research Center, 26746Soroka University Medical Center, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yarden Cohen
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yehudit Nahum
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Elisheva Pokroy-Shapira
- Institute of Rheumatology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mahmoud Abu-Shakra
- Rheumatic Diseases Unit, 26746Soroka University Medical Center, Beer Sheva, Israel.,Clinical Research Center, 26746Soroka University Medical Center, Beer Sheva, Israel
| | - Yair Molad
- Institute of Rheumatology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Clowse MEB, Eudy AM, Balevic S, Sanders-Schmidler G, Kosinski A, Fischer-Betz R, Gladman DD, Molad Y, Nalli C, Mokbel A, Tincani A, Urowitz M, Bay C, van Noord M, Petri M. Hydroxychloroquine in the pregnancies of women with lupus: a meta-analysis of individual participant data. Lupus Sci Med 2022; 9:9/1/e000651. [PMID: 35318256 PMCID: PMC8935175 DOI: 10.1136/lupus-2021-000651] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/26/2022] [Indexed: 11/21/2022]
Abstract
Objective Multiple guidelines recommend continuing hydroxychloroquine (HCQ) for SLE during pregnancy based on observational data. The goal of this individual patient data meta-analysis was to identify the potential benefits and harms of HCQ use within lupus pregnancies. Methods Eligible studies included prospectively collected pregnancies in women with lupus. After a systematic literature search, seven datasets meeting inclusion criteria were obtained. Pregnancy outcomes and lupus activity were compared for pregnancies with a visit in the first trimester in women who did or did not take HCQ throughout pregnancy. Birth defects were not systematically collected. This analysis was conducted in each dataset, and results were aggregated to provide a pooled OR. Results Seven cohorts provided 938 pregnancies in 804 women. After selecting one pregnancy per patient with a first trimester visit, 668 pregnancies were included; 63% took HCQ throughout pregnancy. Compared with pregnancies without HCQ, those with HCQ had lower odds of highly active lupus, but did not have different odds of fetal loss, preterm delivery or pre-eclampsia. Among women with low lupus activity, HCQ reduced the odds of preterm delivery. Conclusions This large study of prospectively-collected lupus pregnancies demonstrates a decrease in lupus activity among woman who continue HCQ through pregnancy and no harm to pregnancy outcomes. Like all studies of HCQ in lupus pregnancy, this study is confounded by indication and non-adherence. As this study confirms the safety of HCQ and diminished SLE activity with use, it is consistent with current recommendations to continue HCQ throughout pregnancy.
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Affiliation(s)
| | - Amanda M Eudy
- Medicine, Duke University, Durham, North Carolina, USA
| | - Stephen Balevic
- Rheumatology and Clinical Immunology, Duke University, Durham, North Carolina, USA.,The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gillian Sanders-Schmidler
- Duke-Margolis Center for Health Policy, Duke Clinical Research Institute and Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Andrzej Kosinski
- Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | - Dafna D Gladman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yair Molad
- Rheumtology, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | | | - Megan van Noord
- Library, University of California Davis, Davis, California, USA
| | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
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9
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Meridor K, Sagy I, Molad Y. Anti-Ro/SS-A Antibody is Associated with Worse Pulmonary Outcome and Reduced Overall Survival in Systemic Sclerosis. Mod Rheumatol 2021; 32:1086-1093. [PMID: 34927207 DOI: 10.1093/mr/roab118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/30/2021] [Accepted: 11/19/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE We sought to determine the association of anti-Ro/SS-A antibody with organ involvement and disease outcome, in patients with systemic sclerosis (SSc). METHODS A retrospective, long-term study of a cohort of incident patients diagnosed with SSc, and continuously followed at our rheumatology clinic during 1990-2018. RESULTS Included were 105 patients with known anti-Ro/SS-A antibody status, 92.4% female, mean age at diagnosis 52.0±15.6 years, and median follow-up 10 years; 64% were diagnosed with limited cutaneous SSc, 18% with diffuse cutaneous SSc, and 18% had SSc siné scleroderma or undetermined disease type. Anti-Ro/SS-A antibody tested positive in 21% of patients. In univariate analysis, anti-Ro/SS-A antibody-positivity was significantly associated with SSc overlap with Sjogren's syndrome (p <0.001). Pulmonary function tests (PFT) deterioration at last encounter was significantly associated with anti-Ro/SS-A antibody-positivity. In multivariate regression for anti-Ro/SS-A antibody-positive SSc patients and disease outcome (adjusted for age>50 years, smoking, and baseline predicted forced vital capacity (pFVC) < 80%), positive anti-Ro/SS-A antibody was significantly associated with higher all-cause mortality rate (HR 5.17, CI 95% 1.18-22.67, p=0.029), and greater deterioration of pFVC defined as decrement of last available pFVC compared to first available pFVC of ≥10% (HR 3.65, CI 95% 1.07-12.38, p=0.038). CONCLUSIONS Anti-Ro/SS-A antibody is an independent risk factor for worse pulmonary outcome and higher all-cause mortality in patients with SSc, independent of SSc clinical and/or serological subtype.
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Affiliation(s)
- Katya Meridor
- Department of Internal Medicine B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Iftach Sagy
- Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel.,Ben-Gurion University of the Negev, Beer Sheva, Israel.,Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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10
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Nardi-Agmon I, Hamdan A, Eisen A, Orvin K, Porter A, Vaknin-Assa H, Itchaki G, Molad Y, Kornowski R, Itzhaki Ben Zadok O. Diffused coronary involvement in Takayasu arteritis with concomitant malignancy. Clin Rheumatol 2021; 41:921-928. [PMID: 34839417 DOI: 10.1007/s10067-021-06000-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/10/2021] [Accepted: 11/21/2021] [Indexed: 01/17/2023]
Abstract
Large vessel vasculitis (LVV) is composed of conditions in which inflammation of blood vessel walls affects mainly large arteries, such as the aorta and its main branches, and in some cases the coronary arteries. Coronary artery involvement in systemic vasculitis is associated with significant morbidity and mortality. We present a case of a young patient diagnosed with extensive coronary disease diagnosed as Takayasu arteritis, when whom a concomitant diagnosis of Hodgkin's lymphoma was made. The literature review revealed ten cases of malignancies associated with Takayasu arteritis. We discuss the complexity of the management of concurrent hematological malignancy with TAK and extensive coronary arteritis. This complicated and cross-disciplinary case also represents the pivotal importance of multi-disciplinary team decision in order to achieve the best clinical outcome of both disorders.
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Affiliation(s)
- Inbar Nardi-Agmon
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Ashraf Hamdan
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alon Eisen
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Katia Orvin
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avital Porter
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hana Vaknin-Assa
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gilad Itchaki
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Hematology Division, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
| | - Yair Molad
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Rheumatology Division, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
| | - Ran Kornowski
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Osnat Itzhaki Ben Zadok
- Cardiology Division, Rabin Medical Center - Beilinson Hospital, 39 Zabotinski st., 4941492, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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11
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Affiliation(s)
- Amir Sharabi
- Rheumatology Institute, Rabin Medical Center, Beilinson Campus, Petach-Tikva Israel, affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Israel; Department of Microbiology and Immunology, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
| | - Shachaf Shiber
- Rheumatology Institute, Rabin Medical Center, Beilinson Campus, Petach-Tikva Israel, affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Yair Molad
- Rheumatology Institute, Rabin Medical Center, Beilinson Campus, Petach-Tikva Israel, affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Israel
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12
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Ghantous N, Hershkovic S, Poran I, Benninger F, Molad Y, Eliakim-Raz N. [NEUROLOGIC COMPLICATIONS AROUND THE DIAGNOSIS OF KIKUCHI-FUJIMOTO DISEASE: A RARE PRESENTATION OF THE DISEASE OR A HINT OF AN ADDITIONAL DIAGNOSIS?]. Harefuah 2021; 160:307-310. [PMID: 34028223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Neurologic symptoms are an extremely rare presentation of Kikuchi-Fujimoto disease. We report a case of a young female patient diagnosed with Kikuchi-Fujimoto disease, presenting with neurologic symptoms compatible with aseptic meningitis, along with radiographic findings which improved with steroidal treatment. Despite the rarity of these findings, they were reported as part of the disease manifestation, however, since Kikuchi-Fujimoto disease is associated with other diseases, such as systemic lupus erythematosus (SLE), other diagnoses cannot be ruled out.
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Affiliation(s)
- Nassem Ghantous
- Department of Medicine E, Rabin Medical Center- Beilinson, Petah Tikva, Israel
| | - Shimrit Hershkovic
- Department of Medicine E, Rabin Medical Center- Beilinson, Petah Tikva, Israel
| | - Itamar Poran
- Department of Medicine E, Rabin Medical Center- Beilinson, Petah Tikva, Israel
| | - Felix Benninger
- Department of Neurology, Rabin Medical Center- Beilinson, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Molad
- Department of Rheumatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center- Beilinson, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
BACKGROUND Rheumatic diseases have many hematological manifestations. Blood dyscrasias and other hematological abnormalities are sometimes the first sign of rheumatic disease. In addition, novel antirheumatic biological agents may cause cytopenias. SUMMARY The aim of this review was to discuss cytopenias caused by systemic lupus erythematosus and antirheumatic drugs, Felty's syndrome in rheumatoid arthritis, and autoimmune hemolytic anemia, thrombosis, and thrombotic microangiopathies related to rheumatological conditions such as catastrophic antiphospholipid syndrome and scleroderma renal crisis. Key Message: The differential diagnosis of various hematological disorders should include rheumatic autoimmune diseases among other causes of blood cell and hemostasis abnormalities. It is crucial that hematologists be aware of these presentations so that they are diagnosed and treated in a timely manner.
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Affiliation(s)
- Alina Klein
- Department of Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel,
| | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Langevitz P, Lidar M, Rosner I, Feld J, Tishler M, Amital H, Aamar S, Elkayam O, Balbir-Gurman A, Abu-Shakra M, Mevorach D, Kimhi O, Molad Y, Kuperman A, Ehrlich S. A Study of the Efficacy and Safety of Subcutaneous Injections of Tocilizumab in Adults with Rheumatoid Arthritis. Isr Med Assoc J 2020; 22:557-563. [PMID: 33236554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Tocilizumab is an interleukin 6 (IL-6) receptor antagonist used treat moderate to severe active rheumatoid arthritis (RA). Both intravenous (IV) and subcutaneous (SC) routes are approved for the treatment of adults with RA. OBJECTIVES To evaluate SC tocilizumab in a real-life clinical setting. METHODS Our study was a multi-center, open-label, single-arm study. Participants were adults with a diagnosis of active RA, previously treated with disease-modifying antirheumatic drugs (DMARDs), with or without biologic agents. Participants received a weekly SC injection of tocilizumab 162 mg as monotherapy or in combination with methotrexate or DMARDs for 24 weeks. Efficacy, safety, and immunogenicity were assessed. RESULTS Treatment of 100 patients over 24 weeks resulted in improvement in all efficacy parameters assessed: Clinical Disease Activity Index, Disease Activity Score using 28 joint counts and erythrocyte sedimentation rate, American College of Rheumatology response scores, Simplified Disease Activity Index, tender and swollen joint counts, and patient-reported outcomes including fatigue, global assessment of disease activity, pain, and Health Assessment Quality of Life Disease Index. Improvement was achieved as early as the second week of treatment. There were 473 adverse events (AEs)/100 patient-years (PY) and 16.66 serious AEs/100 PY. The most common AEs were neutropenia (12%), leukopenia (11%), and increased hepatic enzymes (11%). Of a total of 42 PY, the rates of serious infections and AEs leading to discontinuation were 4.8, and 11.9 events/100 PY, respectively. CONCLUSIONS The safety, tolerability, and efficacy profile of tocilizumab SC were comparable to those reported in other studies evaluating the IV and SC routes of administration.
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Affiliation(s)
- Pnina Langevitz
- Department of Rheumatology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Merav Lidar
- Department of Rheumatology, Sheba Medical Center, Tel Hashomer, Israel
| | - Itzhak Rosner
- Department of Rheumatology, Bnai Zion Medical Center, Haifa, Israel
| | - Joy Feld
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Moshe Tishler
- Department of Internal Medicine B, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Howard Amital
- Department of Internal Medicine B, Sheba Medical Center, Tel Hashomer, Israel
| | - Suhail Aamar
- Rheumatology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Mahmoud Abu-Shakra
- Rheumatology Disease Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Dror Mevorach
- Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Oded Kimhi
- Department of Internal Medicine A, Meir Medical Center, Kfar Saba, Israel
| | - Yair Molad
- Rheumatology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ana Kuperman
- Rheumatology Clinic, Rabin Medical Center (Hasharon Campus), Petah Tikva, Israel
| | - Sharon Ehrlich
- Roche Pharmaceuticals (Israel) Ltd., Hod HaSharon, Israel
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15
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Tiosano S, Yavne Y, Watad A, Langevitz P, Lidar M, Feld J, Tishler M, Aamar S, Elkayam O, Balbir-Gurman A, Molad Y, Ehrlich S, Abu-Shakra M, Amital D, Amital H. The impact of tocilizumab on anxiety and depression in patients with rheumatoid arthritis. Eur J Clin Invest 2020; 50:e13268. [PMID: 32478417 DOI: 10.1111/eci.13268] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mood disorders, such as anxiety and depression, are extremely prevalent among patients with rheumatoid arthritis (RA). In this study, we assessed the impact of treatment with tocilizumab (TCZ), an IL-6 antagonist, upon anxiety and depressive symptoms in a cohort of RA patients. MATERIALS AND METHODS Study participants were adults diagnosed with RA who received a weekly subcutaneous injection of tocilizumab for 24 weeks. We used the Hamilton Depression (HDRS) and Anxiety (HAMA) scores in order to assess the severity of depression and anxiety, respectively. RA disease activity indices and depression and anxiety levels were assessed at baseline, 4 weeks and study completion. RESULTS Ultimately, 91 patients were included in the study. The mean age was 54 years, and the majority were female (79%). The mean score in all disease activity indices as well as depression and anxiety levels decreased dramatically from baseline to study completion. Sixty patients (66%) demonstrated a significant decrease in anxiety and/or depression levels. When logistic regression was performed, an HDRS score indicative of depression at study baseline demonstrated an independent association with a significant psychiatric response whilst older age and increased baseline weight were negatively associated. HAMA and HDRA scores correlated with the following RA disease activity parameters, respectively; HAQ-DI (r = .4, .42), DAS28 (r = .29, .32) and CDAI (0.28 and 0.33), all of them were statistically significant (P < .01). CONCLUSIONS This study has demonstrated a favourable impact of TCZ therapy on parameters reflecting depression and anxiety severity in patients with RA.
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Affiliation(s)
- Shmuel Tiosano
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yarden Yavne
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Pnina Langevitz
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Rheumatology Disease Unit, Sheba Medical Center, Tel-Hashomer, Israel
| | - Merav Lidar
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Rheumatology Disease Unit, Sheba Medical Center, Tel-Hashomer, Israel
| | - Joy Feld
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
| | - Moshe Tishler
- Internal Department B, Assaf Harofeh Medical Center, Zrifin, Israel
| | - Suhail Aamar
- Rheumatology Unit, Hadassah Mount Scopus Medical Center, Jeursalem, Israel
| | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Ehrlich
- Roche Pharmaceuticals (Israel) Ltd., Hod HaSharon, Israel
| | - Mahmoud Abu-Shakra
- Soroka University Medical Center Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Daniela Amital
- Ness Ziona Beer-Yaacov Mental Health Center, Beer Yaakov, Israel
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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Edel Y, Avni T, Shepshelovich D, Reich S, Rozen-Zvi B, Elbaz M, Leibovici L, Molad Y, Gafter-Gvili A. The safety of pulse corticosteroid therapy- Systematic review and meta-analysis. Semin Arthritis Rheum 2020; 50:534-545. [PMID: 31812351 DOI: 10.1016/j.semarthrit.2019.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/05/2019] [Accepted: 11/08/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety. PATIENTS AND METHODS All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality. RESULTS A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids. CONCLUSION Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.
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Affiliation(s)
- Yonatan Edel
- Rheumatology unit Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Department of Medicine C, Beilinson Hospital, Rabin Medical Center, Petah Tikva 49100, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Tomer Avni
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Daniel Shepshelovich
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shelley Reich
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Benaya Rozen-Zvi
- Nephrology unit Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Michal Elbaz
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Leonard Leibovici
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yair Molad
- Rheumatology unit Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Anat Gafter-Gvili
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
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17
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Edel Y, Sagy I, Pokroy-Shapira E, Oren S, Dortort Lazar A, Egbaria M, Shiber S, Tal BS, Molad Y. A Cross-sectional Survey on the Preference of Patients with Rheumatoid Arthritis for Route of Administration of Disease-Modifying Anti-Rheumatic Drugs: Oral Target-Specific Versus Parenteral Biologic. Isr Med Assoc J 2020; 22:154-159. [PMID: 32147979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Guidelines recommend initiation of parenteral biologic or oral target-specific disease-modifying anti-rheumatic drugs (bDMARDs/tsDMARDs) in rheumatoid arthritis (RA) patients who do not adequately respond to conventional DMARDs. OBJECTIVES To compare the preferred route of administration of bDMARDs or tsDMARDs in RA patients who were previously treated with at least one type. METHODS A cross-sectional survey was conducted of consecutive RA patients previously prescribed bDMARDs or tsDMARDs. We analyzed the factors associated with patients' preferred route of administration. RESULTS The cohort included 95 patients, mostly female (72.6%), seropositive (81.05%), mean age 63.4 ± 11.9 years. The oral route was preferred by 39 patients (41%) and 56 (59%) preferred the parenteral route. Most patients (65.9%) preferred to continue with their current route (P < 0.001). Switching from a current route was less common with patients who were currently using the oral route (13.3% vs. 38.2%, P = 0.04). Many patients (53.8%) who preferred the oral route had never experienced it before, while this was rare (3.6%) regarding the parenteral route (P = 0.0001). Employment status was associated with preference of the subcutaneous route over the intravenous route of bDMARDs (P = 0.01). Of the 21 patients who had previously experienced both parenteral and oral treatment, 16 (76.2%) preferred the oral route. CONCLUSIONS RA patients preferred to continue treatment with an administration route they have already experienced. However, when choosing an unexperienced route, significantly more patients preferred the oral route. Our results strengthen the understanding of patient preferences, which could improve drug adherence, compliance, and disease outcome.
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Affiliation(s)
- Yonatan Edel
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iftach Sagy
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Elisheva Pokroy-Shapira
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shirly Oren
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariela Dortort Lazar
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohammad Egbaria
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
| | - Shachaf Shiber
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bat Sheva Tal
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
| | - Yair Molad
- Department of Rheumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Edel Y, Mamet R, Snast I, Kaftory R, Mazor S, Hodak E, Lapidoth M, Elis A, Molad Y, Levi A. Epidemiology of cutaneous porphyria in Israel: a nationwide cohort study. J Eur Acad Dermatol Venereol 2019; 34:184-187. [PMID: 31264284 DOI: 10.1111/jdv.15769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/13/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND From a dermatologist's perspective, there are four major types of cutaneous porphyrias (CPs): porphyria cutanea tarda (PCT), erythropoietic protoporphyria (EPP), variegate porphyria (VP) and hereditary coproporphyria (HCP). Scarce data are available regarding the epidemiology of CPs. OBJECTIVES To describe the epidemiology of CPs in Israel, including distribution, incidence and prevalence rates of major types. METHODS This retrospective study includes all patients who were diagnosed with CPs between the years 1988-2018. It is based on data from Israel's National Service for the Biochemical Diagnoses of Porphyrias, and Israeli patients' nationwide electronic medical charts. Incidence and prevalence rates were calculated. RESULTS Of 173 patients with CPs diagnosed during a 30-year period, 65 (38%) had VP, 62 (36%) had PCT, 31 (18%) had HCP and 15 (9%) had EPP; with incidence rates of 0.29, 0.30, 0.17, 0.07, and prevalence rates of 6.3, 4.8, 2.9, 1.6, respectively, per million population. Characteristics of patients with PCT differed from those with other CPs with regard to lack of family history, older mean age at diagnosis [51 vs. 36 (VP), 35 (HCP) and 25 (EPP) years] and male predominance (81% vs. similar distribution). All patients with PCT were diagnosed at adulthood, while 20%, 19% and 15% of patients with VP, HCP and EPP, respectively, were diagnosed during childhood or adolescence. CONCLUSIONS Variegate porphyria and PCT were found to be the most prevalent in Israel; however, CPs might be underdiagnosed, thus dermatologists' awareness of these rare disorders is highly important.
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Affiliation(s)
- Y Edel
- National Service for the Biochemical Diagnoses of Porphyrias, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Mamet
- National Service for the Biochemical Diagnoses of Porphyrias, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - I Snast
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
| | - R Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mazor
- Department of Community Dentistry, School of Dental Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - E Hodak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
| | - M Lapidoth
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
| | - A Elis
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department "C" of internal, Belinson Hospital, Petah Tikva, Israel
| | - Y Molad
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - A Levi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
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19
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Jaffe DH, Klein AB, Benis A, Flores NM, Gabay H, Morlock R, Teltsch DY, Chapnick J, Molad Y, Giveon SM, Feldman B, Leventer-Roberts M. Incident gout and chronic Kidney Disease: healthcare utilization and survival. BMC Rheumatol 2019; 3:11. [PMID: 30937425 PMCID: PMC6425669 DOI: 10.1186/s41927-019-0060-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background Uncontrolled gout can cause significant joint and organ damage and has been associated with impairments in quality of life and high economic cost. Gout has also been associated with other comorbid diseases, such as chronic kidney disease. The current study explored if healthcare resource utilization (HRU) and survival differs between patients with incident gout in the presence or absence of chronic kidney disease (CKD). Methods Clalit Health Services (CHS) data were used to conduct a retrospective population-based cohort study of incident gout between 1/1/2006–31/12/2009. Incident cases of gout were identified and stratified by CKD status and by age group (< 55 and 55+ years). CKD status was defined as a pre-existing diagnosis of chronic kidney disease, chronic renal failure, kidney transplantation, or dialysis at index date. Demographic and clinical characteristics, as well as healthcare resource use, were reported. Results A total of 12,940 incident adult gout patients, with (n = 8286) and without (n = 4654) CKD, were followed for 55,206 person-years. Higher rates of HRU were observed for gout patients with CKD than without. Total annual hospital admissions for patients with gout and CKD were at least 3 times higher for adults < 55 (mean = 0.51 vs 0.13) and approximately 1.5 times higher for adults 55+ (mean = 0.46 vs 0.29) without CKD. Healthcare utilization rates from year 1 to year 5 remained similar for gout patients < 55 years irrespective of CKD status, however varied according to healthcare utilization by CKD status for gout patients 55+ years. The 5-year all-cause mortality was higher among those with CKD compared to those without CKD for both age groups (HR< 55 years = 1.65; 95% CI 1.01–2.71; HR55+ years = 1.50; 95% CI 1.37–1.65). Conclusions The current study suggests important differences exist in patient characteristics and outcomes among patients with gout and CKD. Healthcare utilization differed between sub-populations, age and comorbidities, over the study period and the 5-year mortality risk was higher for gout patients with CKD, regardless of age. Future work should explore factors associated with these outcomes and barriers to gout control in order to enhance patient management among this high-risk subgroup.
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Affiliation(s)
- Dena H Jaffe
- Kantar Health, Ariel Sharon St 4, 52511 Ramat-Gan, Israel
| | - Alyssa B Klein
- 2AstraZeneca, Medical Evidence and Observational Research Centre, 200 Orchard Ridge Drive, Gaithersburg, MD USA
| | - Arriel Benis
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
| | | | - Hagit Gabay
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
| | | | | | | | - Yair Molad
- 8Beilinson Hospital, Rabin Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Shmuel M Giveon
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
| | - Becca Feldman
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
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20
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Edel Y, Kliminski V, Pokroy-Shapira E, Oren S, Dortort Lazar A, Pri-Paz Basson Y, Egbaria M, Molad Y. Elevated plasma level of soluble triggering receptor expressed on myeloid cells-1 is associated with inflammation activity and is a potential biomarker of thrombosis in primary antiphospholipid syndrome. Arthritis Res Ther 2019; 21:10. [PMID: 30616644 PMCID: PMC6323669 DOI: 10.1186/s13075-018-1779-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 11/27/2018] [Indexed: 01/28/2023] Open
Abstract
Background Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is an innate-immune receptor found in blood. Its presence reflects innate immune cell activation. We sought to investigate plasma sTREM-1 levels in patients with primary antiphospholipid syndrome (PAPS). Methods A cross-sectional, case-control design was used. Plasma sTREM-1 levels were analyzed by enzyme-linked immunosorbent assay (ELISA) in consecutive patients diagnosed with PAPS or asymptomatic antiphospholipid antibody (APLA) carriers and controls. Results The study cohort included 33 patients with PAPS, 10 asymptomatic APLA carriers, and 73 controls. Mean plasma sTREM-1 levels were significantly higher in patients with PAPS (299.2 ± 146.7 pg/ml) and thrombotic PAPS-ever (current and past thrombotic event) (327.2 ± 151.3 pg/ml) compared with controls (230.2 ± 85.5 pg/ml; p = 0.006 and p = 0.003, respectively), patients with thrombotic PAPS compared with patients with past obstetric APS (195.12 ± 58.52 pg/ml, p = 0.01) and APLA carriers (215.8 ± 51.6 pg/ml, p = 0.02), patients with current thrombotic PAPS (429.5 ± 227.5 pg/ml) compared with patients with past thrombotic PAPS (289.5 ± 94.65 pg/ml, p = 0.01), and patients with PAPS who had ever had a stroke or venous thromboembolic event compared with patients who had not (p = 0.007 and p = 0.02, respectively). On receiver operator characteristic curve analysis, plasma sTREM-1 levels differentiated patients with current thrombotic PAPS from asymptomatic APLA carriers and controls, with an area under the curve of 0.7292 (p = 0.0014) and 0.88 (p < 0.0001), respectively. Multivariate regression analysis to identify sTREM-1 predictors (thrombotic PAPS-ever, age, and sex) yielded an independent association of sTREM-1 levels with thrombotic PAPS (p < 0.0001). Conclusions Plasma sTREM-1 levels are significantly elevated in patients with thrombotic PAPS. Levels of sTREM-1 might serve as a biomarker for thrombosis in patients with PAPS.
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Affiliation(s)
- Yonatan Edel
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vitaly Kliminski
- Laboratory of Inflammation Research, Felsenstein Medical Research Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elisheva Pokroy-Shapira
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shirly Oren
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel
| | - Ariela Dortort Lazar
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Pri-Paz Basson
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel
| | - Mohammad Egbaria
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel
| | - Yair Molad
- Rheumatology Unit, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel. .,Laboratory of Inflammation Research, Felsenstein Medical Research Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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21
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Abu-Shakra M, Zisman D, Balbir-Gurman A, Amital H, Levy Y, Langevitz P, Tishler M, Molad Y, Aamar S, Roser I, Avshovich N, Paran D, Reitblat T, Mader R, Savin H, Friedman J, Lieberman N, Ehrlich S. Effect of Tocilizumab on Fatigue and Bone Mineral Density in Patients with Rheumatoid Arthritis. Isr Med Assoc J 2018; 20:239-244. [PMID: 29629732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Chronic fatigue is common among patients with rheumatoid arthritis (RA), affecting quality of life. Osteoporosis is a prevalent co-morbidity in RA patients. OBJECTIVES To assess the effect of long-term treatment with tocilizumab on fatigue and bone mineral density (BMD) in RA patients with inadequate response to synthetic or biologic disease-modifying anti-rheumatic drugs. METHODS In this multicenter, open-label, non-controlled, single-arm study, patients ≥ 18 years of age received intravenous tocilizumab 8 mg/kg every 4 weeks for 96 weeks. The primary outcome was the change in Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score from baseline to weeks 24, 48, 72, and 96. BMD was assessed before and 96 weeks after treatment. RESULTS The study comprised 145 patients (mean age 53.4 ± 13.4 years, 83.4% women). Of these, 88 (60.7%) completed the 2 year treatment period. The mean FACIT-Fatigue score improved consistently starting from week 4 and showed a statistically significant increase of 5.0 ± 9.7, 6.8 ± 10.5, 7.3 ± 10.9, and 7.3 ± 10.4 from baseline to weeks 24, 48, 72, and 96, respectively (P < 0.0001). Mean BMD of femoral neck and total spine remained stable. Disease activity, acute phase reactants, and composite efficacy measures decreased during the study, while hemoglobin levels increased. Adverse events and serious adverse events were as expected for the known and previously described data. CONCLUSIONS Tocilizumab therapy for 2 years significantly and clinically decreased fatigue. BMD remained stable and no new safety issue was reported.
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Affiliation(s)
- Mahmoud Abu-Shakra
- Rheumatic Diseases Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Devy Zisman
- Rheumatology Unit, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Alexandra Balbir-Gurman
- Rheumatology Unit, Rambam Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Howard Amital
- Department of Medicine 'B' and Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Levy
- Department of Internal Medicine E, 6Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pnina Langevitz
- Department of Rheumatology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Tishler
- Department of Internal Medicine B; Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Molad
- Rheumatology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suhail Aamar
- Rheumatology Service, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Itzhak Roser
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nina Avshovich
- Department of Internal Medicine D, Hillel Yaffe Medical Center, Hadera, Israel
| | - Daphna Paran
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tatiana Reitblat
- Rheumatology Unit, Barzilai Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Reuven Mader
- Rheumatology Unit, Emek Medical Center, Afula, Israel Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hillel Savin
- Department of Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
| | | | | | - Sharon Ehrlich
- Roche Pharmaceuticals (Israel) Ltd, Hod Hasharon, Israel
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22
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Molad Y. Response to the letter to the editor by Gkougkourelas et al - EJCI-2017-0361. Eur J Clin Invest 2017; 47. [PMID: 29047115 DOI: 10.1111/eci.12850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 10/15/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Yair Molad
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, The Laboratory of Inflammation Research, Felsenstein Medical Research Center, Petach Tikva, Israel
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Pokroy-Shapira E, Molad Y. [IgG4-RELATED DISEASE]. Harefuah 2017; 156:441-445. [PMID: 28786269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
IgG4-related disease is a syndrome of unknown etiology, which can affect any organ. It is characterized by lymphoplasmacytic infiltration of the affected organs that is rich in IgG4-positive plasma cells, fibrosis, and sometimes increased blood levels of IgG4. Treatment is determined according to the organs involved and the severity of involvement. Corticosteroids are considered to be the first line of treatment. In steroid-resistant or recurrent disease, immunosuppressive drugs or rituximab are used, although their efficacy has not been proven in clinical trials. This review describes the current understanding of the pathogenesis, clinical features, diagnosis and treatment of IgG4-related disease.
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Affiliation(s)
| | - Yair Molad
- Rheumatology Unit, Rabin Medical Center, Beilinson Campus, Petah Tikva
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Furer V, Zisman D, Pokroy-Shapira E, Molad Y, Elkayam O, Paran D. Authors’ reply. Scand J Rheumatol Suppl 2017; 46:251-252. [DOI: 10.1080/03009742.2016.1264628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Zisman
- Rheumatology Unit Carmel Medical Center, Rappoport Faculty of Medicine, Haifa, Israel
| | - E Pokroy-Shapira
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Y Molad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Paran
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sherman S, Gal N, Didkovsky E, Molad Y, Pavlovsky L, Hodak E. Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss) Relapsing as Bullous Eruption. Acta Derm Venereol 2017; 97:406-407. [PMID: 27868151 DOI: 10.2340/00015555-2570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shany Sherman
- Laboratory for Molecular Dermatology, Felsenstein Medical Research Center, Tel Aviv University, Petach Tikva, Israel. ,
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Molad Y, Borkowski T, Monselise A, Ben-Haroush A, Sulkes J, Hod M, Feldberg D, Bar J. Maternal and fetal outcome of lupus pregnancy: a prospective study of 29 pregnancies. Lupus 2016; 14:145-51. [PMID: 15751819 DOI: 10.1191/0961203305lu2072oa] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to analyse pregestational and pregnancy risk factors for adverse fetal and maternal outcome in lupus pregnancy. Twenty women with systemic lupus erythematosus (SLE) (29 pregnancies) were prospectively evaluated. Mean patient age was 29.5 + 4.7 years, and mean disease duration, 6.3 + 6.5 years. Twenty-two pregnancies (75.9%) ended in live births; preterm delivery occurred in 17.4%, intrauterine growth restriction in 50%, preeclampsia in 3.7%, and gestational hypertension in 8%. Six pregnancies (20.7%) ended in spontaneous abortions. Adverse live-birth outcome was significantly associated with low pregestational serum albumin level, elevated gestational anti-dsDNA antibody, and diabetes mellitus. Spontaneous abortion was directly associated with low levels of pregestational serum albumin, positive anticardiolipin IgA, anti-β2-glycoprotein I IgM, and anti-La antibodies, and inversely associated with number of patients’ children. Postgestational lupus flare-up was noted in six pregnancies. Risk factors included high pregestational SLE Disease Activity Index (SLEDAI), lower serum albumin, elevated serum antibody to dsDNA, proteinuria, and use of prednisone and hydroxychloroquine. We conclude that despite high rate of obstetrical complications and postpartum lupus flare-up, pregnancy poses low risk for the majority of women with SLE.
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Affiliation(s)
- Y Molad
- Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel.
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Ofer-Shiber S, Molad Y. Elevated C-Reactive Protein Level Predicts Earlier Treatment with Tumor Necrosis Factor-Alpha Inhibitors in Psoriatic Arthritis. Isr Med Assoc J 2016; 18:279-282. [PMID: 27430084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Tumor necrosis factor-alpha (TNFα) inhibitors are indicated for patients with psoriatic arthritis (PsA) in whom conventional disease-modifying anti-rheumatic drugs (DMARDs) are insufficient to achieve disease remission. OBJECTIVES To determine the value of acute-phase reactant levels at diagnosis of psoriatic arthritis in predicting the need for biologic treatment with TNFα inhibitors. METHODS We conducted a longitudinal observational study of an inception cohort of 71 consecutive patients diagnosed with psoriatic arthritis. C-reactive protein (CRP) was assayed for all patients at their first visit. RESULTS All patients were treated with one or more DMARDs, mainly methotrexate (81.6%). Thirty-seven patients (52.11%) had an inadequate response and received at least one TNF inhibitor. CRP level at diagnosis was positively correlated with need for a TNF inhibitor (P = 0.009, HR 1.8, 95% CI 1.27-1.85). Patients with CRP > 0.9 mg/dl at diagnosis started biologic treatment significantly earlier than patients with a lower level (P = 0.003, HR 2.62, 95% CI 0.393-2.5). CONCLUSIONS In patients with psoriatic arthritis, CRP ≥ 0.9 mg/dl at diagnosis significantly predicts an earlier need for a TNF inhibitor to achieve disease control.
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Furer V, Zisman D, Pokroy-Shapira E, Molad Y, Elkayam O, Paran D. Systemic lupus erythematosus exacerbation following cessation of belimumab treatment. Scand J Rheumatol 2015; 45:103-6. [PMID: 26515057 DOI: 10.3109/03009742.2015.1074277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Belimumab has recently been approved for the treatment of systemic lupus erythematosus (SLE) refractory to standard therapy. Following one case of an SLE flare after cessation of belimumab, we hypothesized that this might lead to a rebound phenomenon and possible exacerbation of SLE. METHOD Members of the Israeli Society of Rheumatology were contacted by e-mail and asked to report cases of an SLE flare following cessation of belimumab treatment. RESULTS Three cases of SLE patients who experienced a severe SLE flare following cessation of belimumab therapy were reported. In all cases, belimumab was given as treatment for active mucocutaneous manifestations and/or polyarthritis with improvement in all three patients, one of whom achieved disease remission. In all three cases, patients experienced a severe flare in previously uninvolved major organ systems, including one case of class IV lupus nephritis accompanied by a new-onset severe headache with elevated cerebrospinal fluid (CSF) protein and white matter lesions on brain magnetic resonance imaging (MRI), one case of severe pneumonitis and haemolytic anaemia, and one case of a systemic flare, fatigue, arthritis, and severe abdominal pain. CONCLUSIONS Belimumab therapy has been shown to be beneficial in the management of active SLE, mostly in patients with mucocutaneous and musculoskeletal manifestations. We suggest a possible rebound effect following cessation of belimumab that could be due to an increase in B-cell activating factor (BAFF) levels and lead to a disease flare. Future assessment of BAFF levels in patients stopping belimumab therapy and clinical correlation may support this hypothesis. Further studies are needed to confirm this observation.
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Affiliation(s)
- V Furer
- a Department of Rheumatology , Tel Aviv Sourasky Medical Centre , Tel Aviv , Israel
| | - D Zisman
- b Rheumatology Unit, Carmel Medical Centre, Rappoport Faculty of Medicine , Technion , Haifa , Israel
| | - E Pokroy-Shapira
- c Rheumatology Unit, Rabin Medical Centre , Beilinson Hospital , Petach Tikva , Israel
| | - Y Molad
- c Rheumatology Unit, Rabin Medical Centre , Beilinson Hospital , Petach Tikva , Israel.,d Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - O Elkayam
- a Department of Rheumatology , Tel Aviv Sourasky Medical Centre , Tel Aviv , Israel.,d Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - D Paran
- a Department of Rheumatology , Tel Aviv Sourasky Medical Centre , Tel Aviv , Israel.,d Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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Fattal I, Shental N, Ben-Dor S, Molad Y, Gabrielli A, Pokroy-Shapira E, Oren S, Livneh A, Langevitz P, Zandman-Goddard G, Sarig O, Margalit R, Gafter U, Domany E, Cohen IR. Guanine polynucleotides are self-antigens for human natural autoantibodies and are significantly reduced in the human genome. Immunology 2015; 146:401-10. [PMID: 26227667 DOI: 10.1111/imm.12514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/16/2015] [Accepted: 07/21/2015] [Indexed: 11/28/2022] Open
Abstract
In the course of investigating anti-DNA autoantibodies, we examined IgM and IgG antibodies to poly-G and other oligonucleotides in the sera of healthy persons and those diagnosed with systemic lupus erythematosus (SLE), scleroderma (SSc), or pemphigus vulgaris (PV); we used an antigen microarray and informatic analysis. We now report that all of the 135 humans studied, irrespective of health or autoimmune disease, manifested relatively high amounts of IgG antibodies binding to the 20-mer G oligonucleotide (G20); no participants entirely lacked this reactivity. IgG antibodies to homo-nucleotides A20, C20 or T20 were present only in the sera of SLE patients who were positive for antibodies to dsDNA. The prevalence of anti-G20 antibodies led us to survey human, mouse and Drosophila melanogaster (fruit fly) genomes for runs of T20 and G20 or more: runs of T20 appear > 170,000 times compared with only 93 runs of G20 or more in the human genome; of these runs, 40 were close to brain-associated genes. Mouse and fruit fly genomes showed significantly lower T20/G20 ratios than did human genomes. Moreover, sera from both healthy and SLE mice contained relatively little or no anti-G20 antibodies; so natural anti-G20 antibodies appear to be characteristic of humans. These unexpected observations invite investigation of the immune functions of anti-G20 antibodies in human health and disease and of runs of G20 in the human genome.
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Affiliation(s)
- Ittai Fattal
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel.,Department of Physics of Complex Systems, The Weizmann Institute of Science, Rehovot, Israel.,Department of Nephrology, Rabin Medical Centre, Petach Tikva, Israel
| | - Noam Shental
- Department of Computer Science, The Open University of Israel, Raanana, Israel
| | - Shifra Ben-Dor
- Bioinformatics and Biological Computing Unit, The Weizmann Institute of Science, Rehovot, Israel
| | - Yair Molad
- The Rheumatology Unit, Rabin Medical Centre, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Armando Gabrielli
- Istituto di, Dipartimento di Scienze Cliniche e Molecolari- Clinica Medica, Università Politecnica delle Marche, Ancona, Italy
| | - Elisheva Pokroy-Shapira
- The Rheumatology Unit, Rabin Medical Centre, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shirly Oren
- The Rheumatology Unit, Rabin Medical Centre, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Livneh
- Department of Medicine F, Sheba Medical Centre, Tel Hashomer, Israel
| | - Pnina Langevitz
- The Rheumatology Unit, Sheba Medical Centre, Tel Hashomer, Israel
| | | | - Ofer Sarig
- Department of Dermatology, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Raanan Margalit
- Science in Action Ltd, Weizmann Science Park, Ness-Ziona, Israel
| | - Uzi Gafter
- Department of Nephrology, Rabin Medical Centre, Petach Tikva, Israel
| | - Eytan Domany
- Department of Physics of Complex Systems, The Weizmann Institute of Science, Rehovot, Israel
| | - Irun R Cohen
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel
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Atzmony L, Feuerman H, Molad Y, Didkovsky Y, Hodak E. Cutaneous Polyarteritis Nodosa Associated with Destructive Arthritis. Isr Med Assoc J 2015; 17:587-588. [PMID: 26625555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Molad Y, Ofer-Shiber S, Pokroy-Shapira E, Oren S, Shay-Aharoni H, Babai I. Soluble triggering receptor expressed on myeloid cells-1 is a biomarker of anti-CCP-positive, early rheumatoid arthritis. Eur J Clin Invest 2015; 45:557-64. [PMID: 25832796 DOI: 10.1111/eci.12442] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 03/25/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To assess serum soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) levels in disease-modifying antirheumatic drug (DMARD)-naïve early rheumatoid arthritis (ERA), to investigate the association of sTREM-1 levels with Disease Activity Score in 28 joints (DAS28) and seropositivity for anti-cyclic citrullinated peptide (CCP) antibody and to determine the predictive value of sTREM-1 with respect to clinical response to DMARD therapy. METHODS Twenty-two consecutive patients with DMARD-naïve ERA were prospectively evaluated for serum sTREM-1 by means of ELISA at diagnosis and at the following clinic visit after prednisone and/or DMARD has been administered, and related to DAS28 and serum level of anti-CCP antibody. We compared the sTREM-1 level to that of 31 patients with established RA as well as to 24 controls. RESULTS Serum sTREM-1 level was significantly higher in the DMARD-naïve ERA group (212.9 ± 388.9 ρg/mL) compared to established RA group (1478.0 ± 280.0 ρg/mL, P = 0.001) and normal control (34.4 ± 7.4 ρg/mL, P < 0.001). In the ERA group, elevated basal sTREM-1 level correlated with higher DAS28-CRP score (P = 0.001, HR 3.23, 95% CI 1.4-8.12), DAS28-ESR (P = 0.04, HR 2.34 95% CI 0.1-8.12), as well as predicted higher DAS28 score at the following encounter after DMARD treatment was administered (P = 0.001, HR 3.2 95% CI 1.1-7.2). Higher serum level of sTREM-1 correlated with higher titres of anti-CCP antibody (P < 0.001). CONCLUSIONS Our results suggest that serum sTREM-1 may provide a novel biomarker for DMARD-naïve ERA as well as for seropositivity for anti-CCP antibody and RA activity.
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Affiliation(s)
- Yair Molad
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Laboratory of Inflammation Research, Felsenstein Medical Research Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachaf Ofer-Shiber
- Department of Internal Medicine H, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | | | - Shirly Oren
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Hagit Shay-Aharoni
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Ilan Babai
- Laboratory of Clinical Immunology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
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Ofer-Shiber S, Molad Y. Association of the Charlson comorbidity index with renal outcome and all-cause mortality in antineutrophil cytoplasmatic antibody-associated vasculitis. Medicine (Baltimore) 2014; 93:e152. [PMID: 25437028 PMCID: PMC4616372 DOI: 10.1097/md.0000000000000152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study is to determine the effect of comorbidity assessed by the Charlson comorbidity index (CCI) at the time of diagnosis on the outcome of antineutrophil cytoplasmatic antibody (ANCA) associated vasculitis (AAV).This is a longitudinal observational study of 30 consecutive patients with AAV who were diagnosed and followed from January 1996 to December 2011. The degree of comorbidity at diagnosis and last visit was scored according to the age-adjusted Charlson comorbidity index (CCI (a)). The post hoc analysis of increment in CCI during the study period and its predictive value for patient and renal survival were analyzed.Thirty patients with AAV were included in this study. A higher CCI (a) at diagnosis was positively correlated with higher activity score of AAV (P = 0.016), a CCI (a) >5, and with an increased risk for mortality (odds ratio 12; confidence interval 1.8-79.68, P = 0.014). The mean increment (Δ) of CCI (a) during the study period was 1.26 ± 2.03 (6-5). Correlation was found between lower Δ CCI (a) and chronic kidney disease (P = 0.036) and mortality (P = 0.002).Comorbidity at the time of diagnosis of AAV is associated with reduced patient and renal survival. We suggest including the CCI score in the assessment of patients with AAV at diagnosis and at disease relapse.
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Affiliation(s)
- Shachaf Ofer-Shiber
- From the Department of Internal Medicine (SO-S); Rheumatology Unit, Beilinson Hospital, Rabin Medical Center (YM); and Sackler Faculty of Medicine, Tel Aviv University (SO-S, YM), Tel Aviv, Israel
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Bloch O, Amit-Vazina M, Yona E, Molad Y, Rapoport MJ. Increased ERK and JNK activation and decreased ERK/JNK ratio are associated with long-term organ damage in patients with systemic lupus erythematosus. Rheumatology (Oxford) 2014; 53:1034-42. [PMID: 24501249 DOI: 10.1093/rheumatology/ket482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The activities of two mitogen-activated protein kinases (MAPKs), extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase (JNK), correlate with disease severity in SLE patients. Whether they are also associated with long-term organ damage is unknown. The aim of the present work was to determine whether impaired expression and activity of ERK and JNK correlate with long-term damage in SLE. METHODS The expression of ERK and JNK and their phosphorylated active forms was determined by western blot analysis four times during the first year of follow-up in peripheral blood mononuclear cells from 36 SLE patients. A correlation analysis was performed between ERK and JNK expression and longterm organ damage estimated by the SLICC/ARC Damage Index (SDI) 4 years later. RESULTS Mean levels of ERK and JNK activities during the first year correlated with long-term organ damage severity (r = 0.38 and r = 0.35, respectively; P = 0.05). Overall JNK expression increased with the severity of chronic damage (P = 0.01; P = 0.05 for SDI score 2 and 3, respectively). In contrast, overall ERK expression significantly decreased in patients with maximal organ damage (SDI score 3) compared with patients with an SDI score of 2 (P = 0.03). The ERK/JNK ratio decreased by approximately 40% and 30% in patients with an SDI score of 3 as compared with patients without organ damage and healthy controls, respectively. CONCLUSION These results demonstrate that early activation of ERK and JNK along with decreased overall ERK expression and reduced ERK/JNK ratio may predict the severity of long-term organ damage in SLE patients.
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Fattal I, Rimer J, Shental N, Molad Y, Gabrielli A, Livneh A, Sarig O, Goldberg I, Gafter U, Domany E, Cohen IR. Pemphigus vulgaris is characterized by low IgG reactivities to specific self-antigens along with high IgG reactivity to desmoglein 3. Immunology 2014; 143:374-80. [PMID: 24820664 DOI: 10.1111/imm.12316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 04/14/2014] [Accepted: 05/01/2014] [Indexed: 11/28/2022] Open
Abstract
Pemphigus vulgaris (PV) is an autoimmune skin disease, which has been characterized by IgG autoantibodies to desmoglein 3. Here we studied the antibody signatures of PV patients compared with healthy subjects and with patients with two other autoimmune diseases with skin manifestations (systemic lupus erythematosus and scleroderma), using an antigen microarray and informatics analysis. We now report a previously unobserved phenomenon--patients with PV, compared with the healthy subjects and the two other diseases, show a significant decrease in IgG autoantibodies to a specific set of self-antigens. This novel finding demonstrates that an autoimmune disease may be associated with a loss of specific, healthy IgG autoantibodies and not only with a gain of specific, pathogenic IgG autoantibodies.
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Affiliation(s)
- Ittai Fattal
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel; Department of Physics of Complex Systems, The Weizmann Institute of Science, Rehovot, Israel; Department of Nephrology, Rabin Medical Centre, Petach Tikva, Israel
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Blickstein D, Dardik R, Rosenthal E, Lahav J, Molad Y, Inbal A. Acquired thrombasthenia due to inhibitory effect of glycoprotein IIbIIIa autoantibodies. Isr Med Assoc J 2014; 16:307-310. [PMID: 24979837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND A 75 year old patient presenting with mucocutaneous bleeding was diagnosed with acquired thrombasthenia. The diagnosis was based on lack of platelet aggregation with adenosine diphosphate (ADP), arachidonic acid and collagen, and normal aggregation induced by ristocetin. OBJECTIVE To study the mechanism of platelet function inhibition in a patient with acquired thrombasthenia. METHODS Aggregation assays of platelets from the patient and healthy controls were performed. In addition, anti-glycoprotein (GP) IIbIIIa antibodies bindingto normal in the presence or absence of the patient's serum was by flow cytometry. RESULTS Aggregation of normal platelets in the presence of patient's plasma was inhibited four- and 2.5-fold in the presence of ADP and arachidonic acid respectively, while collagen-induced aggregation was completely abolished. Ristocetin-induced aggregation was normal. The patient's serum inhibited binding of commercial anti-glycoprotein IIbIIIa antibodies to normal platelets twofold by flow cytometry. Treatment with anti-CD20 monoclonal antibody (rituximab) normalized the patient's platelet aggregation. CONCLUSIONS These results suggest that the patient developed inhibitory anti-GPIIbIIIa autoantibodies that caused acquired thrombasthenia.
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Fattal I, Shental N, Molad Y, Gabrielli A, Pokroy-Shapira E, Oren S, Livneh A, Langevitz P, Pauzner R, Sarig O, Gafter U, Domany E, Cohen IR. Epstein-Barr virus antibodies mark systemic lupus erythematosus and scleroderma patients negative for anti-DNA. Immunology 2014; 141:276-85. [PMID: 24164500 DOI: 10.1111/imm.12200] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 10/20/2013] [Accepted: 10/21/2013] [Indexed: 01/01/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that can attack many different body organs; the triggering event is unknown. SLE has been associated with more than 100 different autoantibody reactivities - anti-dsDNA is prominent. Nevertheless, autoantibodies to dsDNA occur in only two-thirds of SLE patients. We previously reported the use of an antigen microarray to characterize SLE serology. We now report the results of an expanded study of serology in SLE patients and scleroderma (SSc) patients compared with healthy controls. The analysis validated and extended previous findings: two-thirds of SLE patients reacted to a large spectrum of self-molecules that overlapped with their reactivity to dsDNA; moreover, some SLE patients manifested a deficiency of natural IgM autoantibodies. Most significant was the finding that many SLE patients who were negative for autoantibodies to dsDNA manifested abnormal antibody responses to Epstein-Barr virus (EBV): these subjects made IgG antibodies to EBV antigens to which healthy subjects did not respond or they failed to make antibodies to EBV antigens to which healthy subjects did respond. This observation suggests that SLE may be associated with a defective immune response to EBV. The SSc patients shared many of these serological abnormalities with SLE patients, but differed from them in increased IgG autoantibodies to topoisomerase and centromere B; 84% of SLE patients and 58% of SSc patients could be detected by their abnormal antibodies to EBV. Hence an aberrant immune response to a ubiquitous viral infection such as EBV might set the stage for an autoimmune disease.
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Affiliation(s)
- Ittai Fattal
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel; Department of Physics of Complex Systems, The Weizmann Institute of Science, Rehovot, Israel; Department of Nephrology, Rabin Medical Centre, Petach Tikva, Israel
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Molad Y, Tovar A, Ofer-Shiber S. Association of low serum complement C3 with reduced patient and renal survival in antimyeloperoxidase-associated small-vessel vasculitis. Nephron Clin Pract 2014; 126:67-74. [PMID: 24577364 DOI: 10.1159/000357154] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 10/29/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study aimed to determine the value of hypocomplementemia in predicting the renal and patient survival of patients with antineutrophil cytoplasmatic antibody-associated vasculitis (AAV). METHODS A retrospective analysis of 30 consecutive patients who were diagnosed with AAV and followed at our hospital from 1996 to 2011 was performed. Renal outcome was determined by the Modification of Diet in Renal Disease equation. Disease outcome measures included patient survival and accrual of chronic kidney disease (CKD) defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) from the date of diagnosis. Logistic regression analysis was used to identify predictors of survival. RESULTS At presentation, 6 (20%) patients had a low C3 level, which was significantly associated with older age (p = 0.009), higher C-reactive protein (p = 0.02), a lower eGFR (p = 0.03), and anti-MPO antibody positivity (p = 0.03). A low C3 level at presentation was significantly associated with a reduced eGFR at the last study visit (p = 0.015, OR = 11; 95% CI 1.27-95.15). During a mean follow-up of 9.0 ± 6.2 years, 8 (26.6%) patients had accrued CKD that was significantly associated with low C3 levels at presentation (p = 0.002, OR = 22; 95% CI 2.36-204.7). Mortality was significantly associated with low serum C3 levels at presentation (p = 0.02). CONCLUSION We found that a low serum C3 level at the time of diagnosis was significantly associated with reduced renal and patient survival in patients with anti-MPO AAV. Our results suggest a role for complement activation in the pathogenesis of AAV.
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Affiliation(s)
- Yair Molad
- Rheumatology Unit, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
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Pokroy-Shapira E, Gelernter I, Molad Y. Evolution of chronic kidney disease in patients with systemic lupus erythematosus over a long-period follow-up: a single-center inception cohort study. Clin Rheumatol 2014; 33:649-57. [PMID: 24535410 DOI: 10.1007/s10067-014-2527-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/15/2013] [Accepted: 02/05/2014] [Indexed: 12/15/2022]
Abstract
The objective is to investigate the accrual rate and risk factors of chronic kidney disease (CKD) in an inception cohort of patients with systemic lupus erythematosus (SLE) followed at a single tertiary center. A prospectively collected database of 256 consecutive patients with SLE followed over a 25-year period was systematically interrogated for demographic, disease manifestations, co-morbidities, and outcome. Standardized SLE activity and damage scores were determined for the first and last study visits, and estimated glomerular filtration rate (eGFR; MDRD formula) was calculated at the time of diagnosis and at each year of the follow-up. CKD was defined as eGFR <60 ml/min/1.73 m(2). Results were analyzed with univariate and multivariate models and Kaplan-Meier curves, as appropriate. The cohort was predominantly female (90 %) and Jewish (91.1 %). Mean age at diagnosis was 38 ± 15.5 years, mean SLE activity score 6.4 ± 3.8, mean disease duration 8.8 ± 6.6 years, and mean damage score 0.2 ± 0.6. Seventy-five patients (30.8 %) were diagnosed with American College of Rheumatology (ACR)-defined lupus renal disease during the study period. There was a progressive decrease in eGFR over time. The prevalence of CKD was 46.7 % in patients with ACR-defined renal lupus disease and 16.4 % in those without. The hazards ratio for CKD was significantly higher in patients with lupus nephritis (LN) than without (p < 0.001). Earlier CKD was positively associated with hypertension (p = 0.01), older age at diagnosis (p = 0.01), and LN (p < 0.001), and negatively associated with hydroxychloroquine treatment (p < 0.001). The prevalence of CKD increases cumulatively in patients with SLE, also in those without overt lupus renal disease. Lupus renal disease poses a significant hazard for earlier development of CKD, and hypertension is a major risk factor for patients with and without nephritis. Antimalarial treatment is associated with renal preservation only in patients with lupus nephritis.
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Affiliation(s)
- Elisheva Pokroy-Shapira
- Lupus Clinic, Rheumatology Unit, Beilinson Hospital, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel
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Abstract
Connective tissue disorders are systemic, autoimmune, multiorgan diseases in which the central and peripheral nervous systems are frequently involved. The objective of this chapter is to describe the neurological manifestations of three of the most common systemic autoimmune disorders: systemic lupus erythematosus (SLE), scleroderma, and Sjögren's syndrome (SS). In SLE the neuropsychiatric manifestations involve mainly the central nervous system (CNS), including cognitive dysfunction, headache, psychosis and mood changes, seizures, cerebrovascular disease, and myelopathy. Peripheral nervous system (PNS) manifestations are less common and include polyneuropathies as well as mononeuropathies and acute inflammatory demyelinating polyneuropathy. Antiphospholipid syndrome (APLS) is relatively common and should be searched for whenever focal neurological symptoms occur. In scleroderma the PNS is more commonly involved; symptoms include polyneuropathies, entrapment neuropathies, and mononeuropathies (mostly cranial neuropathies or mononeuritis multiplex). Additionally autonomic involvement occurs and myopathies are relatively common. In SS the PNS is similarly involved with several types of polyneuropathies, mononeuropathies, and autonomic dysfunction. Also common are myelopathies and aseptic meningitides. These and other, less common manifestations, as well as the diagnostic procedures and the therapeutic approaches, will be dealt with in this chapter.
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Affiliation(s)
- Jonathan Y Streifler
- Department of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv and Neurology Unit, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Israel.
| | - Yair Molad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv and Rheumatology Unit, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
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Ling E, Ofer-Shiber S, Goren O, Molad Y. Outcome of patients with rheumatoid arthritis: cross-sectional study of a single-center real-world inception cohort. Isr Med Assoc J 2013; 15:758-762. [PMID: 24449980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Tight control of disease activity is the recommended target of therapy for rheumatoid arthritis (RA). OBJECTIVES To determine the outcome of RA with respect to disease activity and the rate of remission, as measured by the DAS-28, in a real-world inception cohort. METHODS We conducted an observational cross-sectional study of a single-center real-world inception cohort of 101 consecutive patients being treated for RA in 2009-2010 in a rheumatology outpatient clinic. Patients were managed at the discretion of the attending rheumatologist with the goal of achieving remission. DAS-28 scores were calculated and analyzed by clinical and treatment variables derived from the medical files. RESULTS Mean patient age was 58.6 +/- 13.4 years and mean duration of disease 10.7 +/- 7.9years. Disease remission (DAS-28 < 2.6) was achieved in 26.7% of patients and low disease activity (> 2 .6 DAS-28 < 3.2) in 17%. Monotherapy with a conventional disease-modifying anti-rheumatic drug (C-DMARD, 21% of patients at last follow-up) was associated with a significantly lower mean DAS-28 score and C-reactive protein level than combined C-DMARD treatment (79% of patients), and with shorter disease duration than combined treatment with C-DMARDs or C-DMARD(s)+biological DMARD (40% of patients). Rheumatoid factor and anti-cyclic citrullinated peptide positivity had no effect on DAS-28 scores. Time from diagnosis was inversely correlated with DAS-28 scores. CONCLUSIONS The achievement of low disease activity and remission in a significant portion of our inception cohort of patients with RA suggests that the treat-to-target strategy is feasible and effective in routine clinical practice.
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Affiliation(s)
- Eduard Ling
- Rheumatology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
| | - Shachaf Ofer-Shiber
- Department of Internal Medicine H, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
| | - Or Goren
- Anesthesiology and Intensive Care Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yair Molad
- Rheumatology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
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Briassouli P, Halushka MK, Reed JH, Molad Y, Fox-Talbot K, Buyon L, Guzman E, Ludomirsky A, Clancy RM, Buyon JP. A central role of plasmin in cardiac injury initiated by fetal exposure to maternal anti-Ro autoantibodies. Rheumatology (Oxford) 2013; 52:1448-53. [PMID: 23598443 DOI: 10.1093/rheumatology/ket156] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Cardiac neonatal lupus (cardiac-NL), initiated by surface binding of anti-Ro60 autoantibodies to apoptotic cardiocytes during development, activates the urokinase plasminogen activator/urokinase plasminogen activator receptor (uPA/uPAR) system. Subsequent accumulation of apoptotic cells and plasmin generation facilitates increased binding of anti-Ro60 by disrupting and cleaving circulating β2-glycoprotein I (β2GPI) thereby eliminating its protective effect. The association of soluble levels of components of the uPA/uPAR system with cardiac-NL was examined. METHODS Levels of the uPA/uPAR system were assessed by ELISA in cord blood and immunohistological evaluation of autopsies. RESULTS uPA, uPAR and plasminogen levels were each significantly higher in cord blood from cardiac-NL (n = 35) compared with non-cardiac-NL (n = 26) anti-Ro-exposed neonates: 3.3 ± 0.1 vs 1.9 ± 0.05 ng/ml (P < 0.0001), 6.6 ± 0.3 vs 2.1 ± 0.2 ng/ml (P < 0.0001) and 435 ± 34 vs 220 ± 19 ng/ml (P < 0.0001), respectively. In three twin pairs discordant for cardiac-NL, the twin with cardiac-NL had higher levels of uPA, uPAR and plasminogen than the unaffected twin (3.1 ± 0.1 vs 1.9 ± 0.05 ng/ml; P = 0.0086, 6.2 ± 1.4 vs 2.2 ± 0.7 ng/ml; P = 0.147 and 412 ± 61 vs 260 ± 27 ng/ml; P = 0.152, respectively). Immunohistological evaluation of three hearts from fetuses dying with cardiac-NL revealed macrophages and giant cells expressing uPA and plasminogen in the septal region. CONCLUSION Increased soluble uPA, uPAR and plasminogen in cord blood and expression in affected tissue of fetuses with cardiac-NL supports the hypothesis that fetal cardiac injury is in part mediated by plasmin generation initiated by anti-Ro binding to the apoptotic cardiocyte.
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Affiliation(s)
- Paraskevi Briassouli
- Department of Rheumatology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA.
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Abstract
CpG-oligonucleotide (ODN)-induced TLR9 activation exerts anti-inflammatory effects. TREM-1 is a DAP12-associated receptor, which is up-regulated in response to LPS-mediated TLR4 activation, and plays an essential role in innate immune response by augmenting the production of pro-inflammatory chemokines and cytokines. TREM-1 up-regulation resulted in a grave outcome in animal models, and in patients with sepsis and rheumatoid arthritis, while its soluble form (sTREM-1) exerted anti-inflammatory effects. We hypothesized that CpG-ODN regulates membrane TREM-1 expression and sTREM-1 shedding. The effect of CpG-ODN-induced TLR9 activation on TREM-1 expression and shedding was studied in mouse peritoneal macrophages and the mouse macrophage cell line RAW 264.7. While TREM-1 expression was not altered by CpG-ODN alone, stimulation with both LPS and CpG-ODN significantly abrogated TREM-1 LPS-induced up-regulation. Moreover, CpG-ODN-induced TLR9 activation either alone or in combination with LPS resulted in a significant increase of supernatant sTREM-1. The release of sTREM-1 was correlated positively with MMP-9 activity and was inhibited by chloroquine. These results suggest (i) a novel CpG-ODN-induced TLR9 pathway for the regulation of macrophage TREM-1 expression and MMP-9-mediated TREM-1 shedding; and (ii) a novel mechanism for an anti-inflammatory effect of CpG-ODN through abrogation of LPS-induced membrane TREM-1 up-regulation and increased MMP-9-mediated TREM-1 shedding.
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Affiliation(s)
- Yair Molad
- 1Laboratory of Inflammation Research, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
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Abstract
A case is presented of Capnocytophaga bacteraemia, in a juvenile chronic arthritis (JCA) patient receiving steroids, methotrexate and rituximab. This Gram-negative bacillus commonly found in dog saliva has been described to cause illness in immune compromised hosts such as oncology patients, those receiving cytotoxic or biological drugs, alcoholics or postsplenectomy. To the best of our knowledge, this is the first report of Capnocytophaga bacteraemia following rituximab treatment.
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Rapoport MJ, Bloch O, Amit-Vasina M, Yona E, Molad Y. Constitutive abnormal expression of RasGRP-1 isoforms and low expression of PARP-1 in patients with systemic lupus erythematosus. Lupus 2011; 20:1501-9. [PMID: 21976405 DOI: 10.1177/0961203311418790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Defective expression of Ras guanil releasing protein-1 (RasGRP-1) and increased apoptosis have been reported in lymphocytes from SLE patients. Whether these aberrations are correlated and linked to disease activity has not been elucidated. METHODS Expression of normal 90 kDa RasGRP-1, its most prevalent 86 kDa isoform and full PARP-1 116 kDa and its cleavage fragment 84 kDa were determined in whole protein lysates of peripheral blood mononuclear cells (PBMC) in correlation with mitogen activated protein kinase (MAPK) activity and SLE clinical status in a large group of SLE patients during 1 year follow-up. RESULTS Expression of normal 90 kDa RasGRP-1 was comparable in patients and controls. However, SLE patients demonstrated a constitutively increased 86 kDa/90 kDA ratio (p < 0.01) and decreased full poly (ADP-ribose) polymerase protein-1 (PARP-1) expression (p < 0.002) compared with controls who were disease-independent. A remission in disease activity was associated with decreased RasGRP-1 expression. Expression of 84 kDa PARP-1 cleavage fragment was found in 15% of patients but in none of the controls. In addition, expression of PARP-1 correlated positively with normal 90 kDa RasGRP-1 expression and negatively with the RasGRP-1 86 kDa/90 kDA ratio. CONCLUSIONS These data suggest that constitutive aberrant expression of PARP-1 and RasGRP-1 ratio may act in concert to impair survival of lymphocytes in SLE patients.
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Oron G, Ben-Haroush A, Goldfarb R, Molad Y, Hod M, Bar J. Contribution of the addition of anti-β2-glycoprotein to the classification of antiphospholipid syndrome in predicting adverse pregnancy outcome. J Matern Fetal Neonatal Med 2010; 24:606-9. [DOI: 10.3109/14767058.2010.511339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Molad Y, Amit-Vasina M, Bloch O, Yona E, Rapoport MJ. Increased ERK and JNK activities correlate with disease activity in patients with systemic lupus erythematosus. Ann Rheum Dis 2010; 69:175-80. [PMID: 19158114 DOI: 10.1136/ard.2008.102780] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Aberrant signalling along the p21ras/MAP kinase pathway has been demonstrated in systemic lupus erythematosus (SLE). OBJECTIVE To determine whether expression and activity of the MAP kinases ERK and JNK reflect disease activity in patients with SLE. METHODS Blood samples of 42 outpatients with SLE were prospectively collected during four consecutive visits. The control group included 20 healthy subjects. Disease activity was assessed using the SLE Disease Activity Index (SLEDAI). Expression of total ERK and JNK kinases and their active forms (pERK and pJNK) was determined in whole protein lysates of peripheral blood mononuclear cells. RESULTS The mean levels of the active kinases pERK and pJNK were significantly increased in patients with active disease (SLEDAI 4-20) as compared with patients with inactive disease (SLEDAI 0-3), p = 0.04, as well as with healthy controls, p = 0.03 and p = 0.003 for pERK and pJNK, respectively. The percentage of activated forms of ERK and JNK of the total expression of these MAP kinases was also gradually increased, reaching 50% for pERK and >40% for pJNK in patients with SLE with moderate-to-severe disease (SLEDAI 7-20), p = 0.005, p = 0.005 and p = 0.02, p = 0.05 as compared with controls and inactive patients, respectively. A decrease of more than three SLEDAI points was associated with a significant reduction in the expression of both total and activated forms of ERK and JNK, p = 0.03, p = 0.01, respectively. CONCLUSIONS The results show that ERK and JNK activity reflects disease activity in patients with SLE. These MAP kinases may serve as additional tools for the evaluation of disease activity and management of these patients.
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Affiliation(s)
- Y Molad
- Rheumatology Unit, Beilinson Hospital, Rabin Medical Centre, Petah Tikva, Israel
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Melamed N, Molad Y. Spontaneous retroperitoneal bleeding from renal microaneurysms and pancreatic pseudocyst in a patient with systemic lupus erythematosus. Scand J Rheumatol 2009; 35:481-4. [PMID: 17343259 DOI: 10.1080/03009740600844464] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Visceral vasculitis and pancreatic pseudocyst are rare manifestations of systemic lupus erythematosus (SLE). We describe a patient with SLE who presented with spontaneous bilateral perinephric and retroperitoneal haematoma secondary to polyarteritis nodosa (PAN)-like vasculitis of the renal arteries, which subsequently evolved into systemic vasculitis with pancreatic pseudocyst formation.
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Affiliation(s)
- N Melamed
- Rheumatology Unit, Rabin Medical Centre, Beilinson Campus, Petah Tiqva, Israel.
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Sthoeger ZM, Sharabi A, Molad Y, Asher I, Zinger H, Dayan M, Mozes E. Treatment of lupus patients with a tolerogenic peptide, hCDR1 (Edratide): immunomodulation of gene expression. J Autoimmun 2009; 33:77-82. [PMID: 19346102 DOI: 10.1016/j.jaut.2009.03.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 03/03/2009] [Accepted: 03/05/2009] [Indexed: 01/08/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by dysregulation of cytokines, apoptosis, and B- and T-cell functions. The tolerogenic peptide, hCDR1 (Edratide), ameliorated the clinical manifestations of murine lupus via down-regulation of pro-inflammatory cytokines and apoptosis, up-regulation of the immunosuppressive cytokine TGF-beta, and the induction of regulatory T-cells. In the present study, gene expression was determined in peripheral blood mononuclear cells of 9 lupus patients that were treated for 26 weeks with either hCDR1 (five patients), or placebo (four patients). Disease activity was assessed by SLEDAI-2K and the BILAG scores. Treatment with hCDR1 significantly down-regulated the mRNA expression of the pathogenic cytokines IL-1beta, TNF-alpha, IFN-gamma, and IL-10, of BLyS (B-lymphocyte stimulator) and of the pro-apoptotic molecules caspase-3 and caspase-8. In contrast, the treatment up-regulated in vivo gene expression of both TGF-beta and FoxP3. Furthermore, hCDR1 treatment resulted in a significant decrease in SLEDAI-2K (from 8.0+/-2.45 to 4.4+/-1.67; P=0.02) and BILAG (from 8.2+/-2.7 to 3.6+/-2.9; P=0.03) scores. Thus, the tolerogenic peptide hCDR1, immunomodulates, in vivo, the expression of genes that play a role in SLE, consequently restoring the global immune dysregulation of lupus patients. Hence, hCDR1 has a potential role as a novel disease-specific treatment for lupus patients.
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Grossman A, Gafter-Gvili A, Green H, Ben Aharon I, Stemmer SM, Molad Y, Krause I. Severe digital ischemia–a presenting symptom of malignancy–associated antiphospholipid syndrome. Lupus 2008; 17:206-9. [DOI: 10.1177/0961203307086235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The association of the antiphospholipid syndrome with malignancy has been extensively reported. Raynaud’s phenomenon has also been reported to be associated with various malignancies. In this report, we describe two patients who presented with severe digital ischemia mimicking Raynaud’s phenomenon. The patients were found to have antiphospholipid syndrome, and upon extensive evaluation, a diagnosis of a malignancy was made. This report highlights the importance of malignancy workup in patients with severe digital ischemia associated with antiphospholipid syndrome.
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Affiliation(s)
- A Grossman
- Department of Internal Medicine E, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - A Gafter-Gvili
- Department of Internal Medicine E, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - H Green
- Department of Internal Medicine E, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - I Ben Aharon
- Davidoff Comprehensive Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Faculty of Medicine School, Tel Aviv University, Tel Aviv, Israel
| | - SM Stemmer
- Davidoff Comprehensive Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Faculty of Medicine School, Tel Aviv University, Tel Aviv, Israel
| | - Y Molad
- Unit of Rheumatology, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - I Krause
- Department of Internal Medicine E, Rabin Medical Center, Beilinson Campus, Petach Tikva Israel. Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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van der Heijde D, Klareskog L, Landewé R, Bruyn GAW, Cantagrel A, Durez P, Herrero-Beaumont G, Molad Y, Codreanu C, Valentini G, Zahora R, Pedersen R, MacPeek D, Wajdula J, Fatenejad S. Disease remission and sustained halting of radiographic progression with combination etanercept and methotrexate in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 56:3928-39. [PMID: 18050208 DOI: 10.1002/art.23141] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes (TEMPO) is a 3-year, double-blind, multicenter study evaluating the efficacy and safety of etanercept, methotrexate, and the combination of etanercept plus methotrexate in patients with active rheumatoid arthritis (RA). The results after 1 and 2 years of the study have been previously reported. Here we provide the 3-year clinical and radiographic outcomes and safety of etanercept, methotrexate, and the combination in patients with RA. METHODS In this randomized, double-blind, multicenter TEMPO study, 682 patients received etanercept 25 mg twice weekly, methotrexate < or =20 mg weekly, or the combination. Key efficacy assessments included the Disease Activity Score (DAS) and the DAS in 28 joints. RESULTS Combination therapy resulted in significantly greater improvement in the DAS and in more patients with disease in remission than either monotherapy. This finding was confirmed by longitudinal analysis; patients receiving combination therapy were more than twice as likely to have disease in remission than those receiving either monotherapy. Independent predictors of remission included male sex, lower disease activity, lower level of joint destruction, and/or better physical function. Combination and etanercept therapy both resulted in significantly less radiographic progression than did methotrexate (P < 0.05). Etanercept and combination treatment were well tolerated, with no new safety findings. CONCLUSION Etanercept plus methotrexate showed sustained efficacy through 3 years and remained more effective than either monotherapy, even after adjustment for patient withdrawal. Combination therapy for 3 years led to disease remission and inhibition of radiographic progression, 2 key goals for treatment of patients with RA.
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Affiliation(s)
- D van der Heijde
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
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