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Chakravarty EF, Utset T, Kamen DL, Contreras G, McCune WJ, Aranow C, Kalunian K, Massarotti E, Clowse MEB, Rovin BH, Lim SS, Majithia V, Dall'Era M, Looney RJ, Erkan D, Saxena A, Olsen NJ, Ko K, Guthridge JM, Goldmuntz E, Springer J, D'Aveta C, Keyes-Elstein L, Barry B, Pinckney A, McNamara J, James JA. Mycophenolate mofetil withdrawal in patients with systemic lupus erythematosus: a multicentre, open-label, randomised controlled trial. Lancet Rheumatol 2024; 6:e168-e177. [PMID: 38301682 PMCID: PMC10922882 DOI: 10.1016/s2665-9913(23)00320-x] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Mycophenolate mofetil is an immunosuppressant commonly used to treat systemic lupus erythematosus (SLE) and lupus nephritis. It is a known teratogen associated with significant toxicities, including an increased risk of infections and malignancies. Mycophenolate mofetil withdrawal is desirable once disease quiescence is reached, but the timing of when to do so and whether it provides a benefit has not been well-studied. We aimed to determine the effects of mycophenolate mofetil withdrawal on the risk of clinically significant disease reactivation in patients with quiescent SLE on long-term mycophenolate mofetil therapy. METHODS This multicenter, open-label, randomised trial was conducted in 19 centres in the USA. Eligible patients were aged between 18 and 70 years old, met the American College of Rheumatology (ACR) 1997 SLE criteria, and had a clinical SLEDAI score of less than 4 at screening. Mycophenolate mofetil therapy was required to be stable or decreasing for 2 years or more if initiated for renal indications, or for 1 year or more for non-renal indications. Participants were randomly allocated in a 1:1 ratio to a withdrawal group, who tapered off mycophenolate mofetil over 12 weeks, or a maintenance group who maintained their baseline dose (1-3g per day) for 60 weeks. Adaptive random allocation ensured groups were balanced for study site, renal versus non-renal disease, and baseline mycophenolate mofetil dose (≥2 g per day vs <2 g per day). Clinically significant disease reactivation by week 60 following random allocation, requiring increased doses or new immunosuppressive therapy was the primary endpoint, in the modified intention-to-treat population (all randomly allocated participants who began study-provided mycophenolate mofetil). Non-inferiority was evaluated using an estimation-based approach. The trial was registered at ClinicalTrials.gov (NCT01946880) and is completed. FINDINGS Between Nov 6, 2013, and April 27, 2018, 123 participants were screened, of whom 102 were randomly allocated to the maintenance group (n=50) or the withdrawal group (n=52). Of the 100 participants included in the modified intention-to-treat analysis (49 maintenance, 51 withdrawal), 84 (84%) were women, 16 (16%) were men, 40 (40%) were White, 41 (41%) were Black, and 76 (76%) had a history of lupus nephritis. The average age was 42 (SD 12·7). By week 60, nine (18%) of 51 participants in the withdrawal group had clinically significant disease reactivation, compared to five (10%) of 49 participants in the maintenance group. The risk of clinically significant disease reactivation was 11% (95% CI 5-24) in the maintenance group and 18% (10-32) in the withdrawal group. The estimated increase in the risk of clinically significant disease reactivation with mycophenolate mofetil withdrawal was 7% (one-sided upper 85% confidence limit 15%). Similar rates of adverse events were observed in the maintenance group (45 [90%] of 50 participants) and the withdrawal group (46 [88%] of 52 participants). Infections were more frequent in the mycophenolate mofetil maintenance group (32 [64%]) compared with the withdrawal group (24 [46%]). INTERPRETATIONS Mycophenolate mofetil withdrawal is not significantly inferior to mycophenolate mofetil maintenance. Estimates for the rates of disease reactivation and increases in risk with withdrawal can assist clinicians in making informed decisions on withdrawing mycophenolate mofetil in patients with stable SLE. FUNDING The National Institute of Allergy and Infectious Diseases and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Eliza F Chakravarty
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Tammy Utset
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Diane L Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia Aranow
- Autoimmune and Musculoskeletal Disease, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, La Jolla, CA, USA
| | - Elena Massarotti
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Brad H Rovin
- Division of Nephrology, Ohio State University, Columbus, OH, USA
| | - S Sam Lim
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Vikas Majithia
- Division of Rheumatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Maria Dall'Era
- Division of Rheumatology, Russell/Engleman Rheumatology Research Center, University of California, San Francisco, CA, USA
| | - R John Looney
- Allergy Immunology Rheumatology Division, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Nancy J Olsen
- Division of Rheumatology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Kichul Ko
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Joel M Guthridge
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | - Jessica Springer
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | | | | | - Bill Barry
- Rho Federal Systems Division, Durham, NC, USA
| | | | - James McNamara
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | - Judith A James
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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2
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Adamska JZ, Zia A, Bloom MS, Crofford LJ, Furst DE, Goldmuntz E, Keyes-Elstein L, Mayes MD, McSweeney P, Nash RA, Pinckney A, Welch B, Love ZZ, Sullivan KM, Robinson W. Myeloablative autologous haematopoietic stem cell transplantation resets the B cell repertoire to a more naïve state in patients with systemic sclerosis. Ann Rheum Dis 2023; 82:357-364. [PMID: 36241361 PMCID: PMC9918657 DOI: 10.1136/ard-2021-221925] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/16/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Myeloablative autologous haematopoietic stem cell transplant (HSCT) was recently demonstrated to provide significant benefit over cyclophosphamide (CYC) in the treatment of diffuse cutaneous systemic sclerosis (dcSSc) in the Scleroderma: Cyclophosphamide or Transplantation (SCOT) trial. As dysregulation of the B cell compartment has previously been described in dcSSc, we sought to gain insight into the effects of myeloablative autologous HSCT as compared with CYC. METHODS We sequenced the peripheral blood immunoglobulin heavy chain (IGH) repertoires in patients with dcSSc enrolled in the SCOT trial. RESULTS Myeloablative autologous HSCT was associated with a sustained increase in IgM isotype antibodies bearing a low mutation rate. Clonal expression was reduced in IGH repertoires following myeloablative autologous HSCT. Additionally, we identified a underusage of immunoglobulin heavy chain V gene 5-51 in patients with dcSSc, and usage normalised following myeloablative autologous HSCT but not CYC treatment. CONCLUSIONS Together, these findings suggest that myeloablative autologous HSCT resets the IGH repertoire to a more naïve state characterised by IgM-expressing B cells, providing a possible mechanism for the elimination of pathogenic B cells that may contribute to the benefit of HSCT over CYC in the treatment of dcSSc.
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Affiliation(s)
- Julia Z Adamska
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California, USA,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Amin Zia
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California, USA,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Michelle S Bloom
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California, USA,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Leslie J Crofford
- Division of Rheumatology and Immunology, Vanderbilt University, Nashville, Tennessee, USA
| | - Daniel E Furst
- Rheumatology, Univ of Cal at Los Angeles, Los Angeles, California, USA
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, Maryland, USA
| | | | - Maureen D Mayes
- Rheumatology and Clinical Immunogenetics, The University of Texas Health Science Center Houston Medical School, Houston, Texas, USA
| | - Peter McSweeney
- Rocky Mountain Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado, USA
| | - Richard A Nash
- Rocky Mountain Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado, USA
| | | | - Beverly Welch
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, Maryland, USA
| | - Zelda Z Love
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Keith M Sullivan
- Department of Medicine, Duke University Health System, Durham, North Carolina, USA
| | - William Robinson
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California, USA .,VA Palo Alto Health Care System, Palo Alto, California, USA
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3
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Keyes-Elstein L, Pinckney A, Goldmuntz E, Welch B, Franks JM, Martyanov V, Wood TA, Crofford L, Mayes M, McSweeney P, Nash R, Georges G, Csuka M, Simms R, Furst D, Khanna D, St Clair EW, Whitfield ML, Sullivan KM. Clinical and Molecular Findings After Autologous Stem Cell Transplantation or Cyclophosphamide for Scleroderma: Handling Missing Longitudinal Data. Arthritis Care Res (Hoboken) 2023; 75:307-316. [PMID: 34533286 PMCID: PMC8926930 DOI: 10.1002/acr.24785] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/23/2021] [Accepted: 09/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Among individuals with systemic sclerosis (SSc) randomized to cyclophosphamide (CYC) (n = 34) or hematopoietic stem cell transplantation (HSCT) (n = 33), we examined longitudinal trends of clinical, pulmonary function, and quality of life measures while accounting for the influence of early failures on treatment comparisons. METHODS Assuming that data were missing at random, mixed-effects regression models were used to estimate longitudinal trends for clinical measures when comparing treatment groups. Results were compared to observed means and to longitudinal trends estimated from shared parameter models, assuming that data were missing not at random. Longitudinal trends for SSc intrinsic molecular subsets defined by baseline gene expression signatures (normal-like, inflammatory, and fibroproliferative signatures) were also studied. RESULTS Available observed means for pulmonary function tests appeared to improve over time in both arms. However, after accounting for participant loss, forced vital capacity in HSCT recipients increased by 0.77 percentage points/year but worsened by -3.70/year for CYC (P = 0.004). Similar results were found for diffusing capacity for carbon monoxide and quality of life indicators. Results for both analytic models were consistent. HSCT recipients in the inflammatory (n = 20) and fibroproliferative (n = 20) subsets had superior long-term trends compared to CYC for pulmonary and quality of life measures. HSCT was also superior for modified Rodnan skin thickness scores in the fibroproliferative subset. For the normal-like subset (n = 22), superiority of HSCT was less apparent. CONCLUSION Longitudinal trends estimated from 2 statistical models affirm the efficacy of HSCT over CYC in severe SSc. Failure to account for early loss of participants may distort estimated clinical trends over the long term.
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Affiliation(s)
| | | | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Beverly Welch
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | | | | | - Leslie Crofford
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Maureen Mayes
- University of Texas McGovern Medical School, Houston, TX
| | | | | | | | - M.E. Csuka
- Medical College of Wisconsin, Milwaukee, WI
| | - Robert Simms
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Daniel Furst
- University of California Los Angeles, Los Angeles, CA; University of Washington, Seattle, WA; University of Florence, Florence, Italy
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4
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Ayoglu B, Donato M, Furst DE, Crofford LJ, Goldmuntz E, Keyes-Elstein L, James J, Macwana S, Mayes MD, McSweeney P, Nash RA, Sullivan KM, Welch B, Pinckney A, Mao R, Chung L, Khatri P, Utz PJ. Characterising the autoantibody repertoire in systemic sclerosis following myeloablative haematopoietic stem cell transplantation. Ann Rheum Dis 2023; 82:670-680. [PMID: 36653124 PMCID: PMC10176357 DOI: 10.1136/ard-2021-221926] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/06/2021] [Accepted: 12/30/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Results from the SCOT (Scleroderma: Cyclophosphamide Or Transplantation) clinical trial demonstrated significant benefits of haematopoietic stem cell transplant (HSCT) versus cyclophosphamide (CTX) in patients with systemic sclerosis. The objective of this study was to test the hypothesis that transplantation stabilises the autoantibody repertoire in patients with favourable clinical outcomes. METHODS We used a bead-based array containing 221 protein antigens to profile serum IgG autoantibodies in participants of the SCOT trial. RESULTS Comparison of autoantibody profiles at month 26 (n=23 HSCT; n=22 CTX) revealed antibodies against two viral antigens and six self-proteins (SSB/La, CX3CL1, glycyl-tRNA synthetase (EJ), parietal cell antigen, bactericidal permeability-increasing protein and epidermal growth factor receptor (EGFR)) that were significantly different between treatment groups. Linear mixed model analysis identified temporal increases in antibody levels for hepatitis B surface antigen, CCL3 and EGFR in HSCT-treated patients. Eight of 32 HSCT-treated participants and one of 31 CTX-treated participants had temporally varying serum antibody profiles for one or more of 14 antigens. Baseline autoantibody levels against 20 unique antigens, including 9 secreted proteins (interleukins, IL-18, IL-22, IL-23 and IL-27), interferon-α2A, stem cell factor, transforming growth factor-β, macrophage colony-stimulating factor and macrophage migration inhibitory factor were significantly higher in patients who survived event-free to month 54. CONCLUSIONS Our results suggest that HSCT favourably alters the autoantibody repertoire, which remains virtually unchanged in CTX-treated patients. Although antibodies recognising secreted proteins are generally thought to be pathogenic, our results suggest a subset could potentially modulate HSCT in scleroderma.
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Affiliation(s)
- Burcu Ayoglu
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michele Donato
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Institute for Immunity Transplantation and Infection, Stanford, California, USA
| | - Daniel E Furst
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Leslie J Crofford
- Division of Rheumatology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | | | - Judith James
- Arthritis & Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA.,Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Susan Macwana
- Arthritis & Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Maureen D Mayes
- Department of Rheumatology, The University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - Keith M Sullivan
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Beverly Welch
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | | | - Rong Mao
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Lorinda Chung
- Departments of Medicine & Dermatology, Stanford University, Stanford, California, USA.,Palo Alto VA Health Care System, Palo Alto, California, USA
| | - Purvesh Khatri
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA .,Stanford Institute for Immunity Transplantation and Infection, Stanford, California, USA
| | - Paul J Utz
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA .,Stanford Institute for Immunity Transplantation and Infection, Stanford, California, USA
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5
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Shah A, Storek J, Woolson R, Pinckney A, Keyes-Elstein L, Wallace PK, Sempowski GD, McSweeney P, Mayes MD, Crofford L, Csuka ME, Phillips K, Khanna D, Simms R, Ballen K, LeClercq S, Clair WS, Nixon AB, Nash R, Wener M, Brasington R, Silver R, Griffith LM, Furst DE, Goldmuntz E, Sullivan KM. Lymphocyte subset abnormalities in early severe scleroderma favor a Th2 phenotype and are not altered by prior immunosuppressive therapy. Rheumatology (Oxford) 2022; 61:4155-4162. [PMID: 35108379 PMCID: PMC9536786 DOI: 10.1093/rheumatology/keac015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/14/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES The Scleroderma: Cyclophosphamide or Transplantation (SCOT) trial compared hematopoietic stem cell transplant to CYC treatment in patients with early SSc with progressive skin and lung or kidney involvement. Here we describe lymphocyte phenotype abnormalities at study entry and the relation to prior DMARD therapy. METHODS Lymphocyte subsets (n = 26) measured by flow cytometry were compared in 123 heathy controls and 71 SCOT participants, including those given (n = 57) or not given (n = 14) DMARDs within 12 months of randomization. RESULTS Compared with healthy controls, individuals with SSc showed significant reductions in central memory CD8 T cells, activated total and CD4 T cells, γ/δ T cells, memory B cells, myeloid and plasmacytoid dendritic cells and FOXP3+CD25+ Treg cells and increases in naïve CD4 T cells, effector memory CD4 T cells and effector CD8 T cells. A greater bias towards a IL-4+ Th2/T cytotoxic 2 (Tc2) phenotype based on the Th2:Th1 CD4 ratio and Tc2:Tc1 CD8 T cells was also found. Notably, no difference in any lymphocyte subset was observed between those given or not given prior DMARDs. CONCLUSIONS In patients with early, severe SSc, significant lymphocyte subset abnormalities were observed. Prior treatment with immunosuppressive therapy did not impact the immunophenotype, suggesting that lymphocyte disturbances in scleroderma appeared to be due to the disease itself. TRIAL REGISTRATION ClinicalTrials.gov (https://clinicaltrials.gov), NCT00114530.
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Affiliation(s)
- Ankoor Shah
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jan Storek
- Departments of Medicine and Oncology, University of Calgary, Calgary, AB, Canada
| | | | | | | | - Paul K Wallace
- Department of Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Peter McSweeney
- Department of Hematology/Oncology, Colorado Blood Cancer Institute, Denver, CO
| | | | - Leslie Crofford
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - M E Csuka
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kristine Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dinesh Khanna
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Robert Simms
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Karen Ballen
- Department of Medicine, University of Virginia, Charlottesville, VA
| | - Sharon LeClercq
- Departments of Medicine and Oncology, University of Calgary, Calgary, AB, Canada
| | | | - Andrew B Nixon
- Department of Medicine, Duke University, Durham, NC, USA
| | - Richard Nash
- Department of Hematology/Oncology, Colorado Blood Cancer Institute, Denver, CO
| | - Mark Wener
- Department of Oncology, Fred Hutchinson Cancer Research Center
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Richard Silver
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Linda M Griffith
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Daniel E Furst
- Department of Medicine, University of Washington, Seattle, WA
- Department of Medicine, University of California, Los Angeles, CA, USA
- University of Florence, Florence, Italy
| | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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6
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Meednu N, Barnard J, Callahan K, Coca A, Marston B, Thiele R, Tabechian D, Bolster M, Curtis J, Mackay M, Graf J, Keating R, Smith E, Boyle K, Keyes-Elstein L, Welch B, Goldmuntz E, Anolik JH. Activated Peripheral Blood B Cells in Rheumatoid Arthritis and Their Relationship to Anti-Tumor Necrosis Factor Treatment and Response: A Randomized Clinical Trial of the Effects of Anti-Tumor Necrosis Factor on B Cells. Arthritis Rheumatol 2022; 74:200-211. [PMID: 34347945 PMCID: PMC8795463 DOI: 10.1002/art.41941] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 11/18/2020] [Revised: 06/11/2021] [Accepted: 07/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE B cells can become activated in germinal center (GC) reactions in secondary lymphoid tissue and in ectopic GCs in rheumatoid arthritis (RA) synovium that may be tumor necrosis factor (TNF) and lymphotoxin (LT) dependent. This study was undertaken to characterize the peripheral B cell compartment longitudinally during anti-TNF therapy in RA. METHODS Participants were randomized in a 2:1 ratio to receive standard dosing regimens of etanercept (n = 43) or adalimumab (n = 20) for 24 weeks. Eligible participants met the American College of Rheumatology 1987 criteria for RA, had clinically active disease (Disease Activity Score in 28 joints >4.4), and were receiving stable doses of methotrexate. The primary mechanistic end point was the change in switched memory B cell fraction from baseline to week 12 in each treatment group. RESULTS B cell subsets remained surprisingly stable over the course of the study regardless of treatment group, with no significant change in memory B cells. Blockade of TNF and LT with etanercept compared to blockade of TNF alone with adalimumab did not translate into significant differences in clinical response. The frequencies of multiple activated B cell populations, including CD21- double-negative memory and activated naive B cells, were higher in RA nonresponders at all time points, and CD95+ activated B cell frequencies were increased in patients receiving anti-TNF treatment in the nonresponder group. In contrast, frequencies of transitional B cells-a putative regulatory subset-were lower in the nonresponders. CONCLUSION Overall, our results support the notion that peripheral blood B cell subsets are remarkably stable in RA and not differentially impacted by dual blockade of TNF and LT with etanercept or single blockade of TNF with adalimumab. Activated B cells do associate with a less robust response.
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Affiliation(s)
- Nida Meednu
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Jennifer Barnard
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Kelly Callahan
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Andreea Coca
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Bethany Marston
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Ralf Thiele
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Darren Tabechian
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | | | | | - Meggan Mackay
- Autoimmune & Musculoskeletal Disorders, the Feinstein Institute for Medical Research, Manhasset, NY
| | - Jonathan Graf
- Rosalind Russell/Ephraim P. Engleman Rheumatology Research Center, University of California, San Francisco, San Francisco, CA
| | | | | | - Karen Boyle
- Rho Federal Systems Division, Inc., Chapel Hill, NC
| | | | | | | | - Jennifer H. Anolik
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY 14642, USA
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7
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Zamanian RT, Pinckney A, Domsic RT, Medsger T, Keyes-Elstein L, Sweatt AJ, Welch B, Goldmuntz E, Nicolls MR, Chung L. Reply to Andréasson et al.: Multiple Manifestations of Systemic Sclerosis Affect Walk Distance. Am J Respir Crit Care Med 2021; 204:377-378. [PMID: 34107229 PMCID: PMC8513578 DOI: 10.1164/rccm.202104-1023le] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Roham T Zamanian
- Stanford University School of Medicine Stanford, California.,Vera Moulton Wall Center for Pulmonary Vascular Disease Stanford, California
| | | | - Robyn T Domsic
- University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Thomas Medsger
- University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | | | - Andrew J Sweatt
- Stanford University School of Medicine Stanford, California.,Vera Moulton Wall Center for Pulmonary Vascular Disease Stanford, California
| | - Beverly Welch
- National Institute of Allergy and Infectious Diseases Bethesda, Maryland
| | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases Bethesda, Maryland
| | - Mark R Nicolls
- Stanford University School of Medicine Stanford, California.,Vera Moulton Wall Center for Pulmonary Vascular Disease Stanford, California.,Veterans Affairs Palo Alto Health Care System Palo Alto, California
| | - Lorinda Chung
- Stanford University School of Medicine Stanford, California.,Veterans Affairs Palo Alto Health Care System Palo Alto, California
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Zamanian RT, Badesch D, Chung L, Domsic RT, Medsger T, Pinckney A, Keyes-Elstein L, D'Aveta C, Spychala M, White RJ, Hassoun PM, Torres F, Sweatt AJ, Molitor JA, Khanna D, Maecker H, Welch B, Goldmuntz E, Nicolls MR. Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med 2021; 204:209-221. [PMID: 33651671 PMCID: PMC8650794 DOI: 10.1164/rccm.202009-3481oc] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) is one of the most prevalent and deadly forms of PAH. B cells may contribute to SSc pathogenesis. Objectives: We investigated the safety and efficacy of B-cell depletion for SSc-PAH. Methods: In an NIH-sponsored, multicenter, double-blinded, randomized, placebo-controlled, proof-of-concept trial, 57 patients with SSc-PAH on stable-dose standard medical therapy received two infusions of 1,000 mg rituximab or placebo administered 2 weeks apart. The primary outcome measure was the change in 6-minute-walk distance (6MWD) at 24 weeks. Secondary endpoints included safety and invasive hemodynamics. We applied a machine learning approach to predict drug responsiveness. Measurements and Main Results: We randomized 57 subjects from 2010 to 2018. In the primary analysis, using data through Week 24, the adjusted mean change in 6MWD at 24 weeks favored the treatment arm but did not reach statistical significance (23.6 ± 11.1 m vs. 0.5 ± 9.7 m; P = 0.12). Although a negative study, when data through Week 48 were also considered, the estimated change in 6MWD at Week 24 was 25.5 ± 8.8 m for rituximab and 0.4 ± 7.4 m for placebo (P = 0.03). Rituximab treatment appeared to be safe and well tolerated. Low levels of RF (rheumatoid factor), IL-12, and IL-17 were sensitive and specific as favorable predictors of a rituximab response as measured by an improved 6MWD (receiver operating characteristic area under the curve, 0.88-0.95). Conclusions: B-cell depletion therapy is a potentially effective and safe adjuvant treatment for SSc-PAH. Future studies in these patients can confirm whether the identified biomarkers predict rituximab responsiveness. Clinical trial registered with www.clinicaltrails.gov (NCT01086540).
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Affiliation(s)
- Roham T Zamanian
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - David Badesch
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lorinda Chung
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Division of Rheumatology and Immunology, Stanford University, Stanford University School of Medicine, Stanford, California
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas Medsger
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Carla D'Aveta
- Rho Federal Systems Division, Durham, North Carolina
| | | | - R James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - Jerry A Molitor
- Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, Minnesota
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| | - Holden Maecker
- Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Beverly Welch
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Mark R Nicolls
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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9
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Brunner HI, Schanberg LE, Kimura Y, Dennos A, Co DO, Colbert RA, Fuhlbrigge RC, Goldmuntz E, Kingsbury DJ, Patty-Resk C, Mintz S, Onel K, Rider LG, Schneider R, Watts A, von Scheven E, Lovell DJ, Beukelman T. New Medications Are Needed for Children With Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2020; 72:1945-1951. [PMID: 32524767 DOI: 10.1002/art.41390] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/14/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To document the need for additional Food and Drug Administration (FDA)-approved medications for the treatment of juvenile idiopathic arthritis (JIA). METHODS The electronic medical records of JIA patients treated at Cincinnati Children's Hospital Medical Center (CCHMC) and data from JIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry were included in this study. Unmet medication need was defined in 2 ways: (a) the presence of chronically uncontrolled JIA, defined as a physician global assessment of JIA activity ≥3 (on a 0-10 scale, where 0 = inactive) OR ≥3 joints with active arthritis OR a patient global assessment of well-being ≥3 (on a 0-10 scale, where 0 = very well), despite sequential use of ≥2 biologic disease-modifying antirheumatic drugs (bDMARDs); and (b) the use of ≥1 bDMARD not approved for any JIA category. RESULTS At CCHMC, 829 of 1,599 JIA patients (52%) were treated with ≥1 bDMARD, and 304 (19%) had been exposed to ≥1 unapproved bDMARD. In the CARRA Registry, 4,766 of 7,379 children (65%) had received ≥1 bDMARD, and 1,122 (15%) had been prescribed ≥1 unapproved bDMARD. Of those children treated with ≥2 bDMARDs for whom complete data were available, 52% (255 of 487) at CCHMC and 45% (527 of 1,159) in the CARRA Registry had chronically uncontrolled JIA despite the use of ≥2 bDMARDs. CONCLUSION Despite the availability of bDMARDs currently approved for JIA, there is persistent need for additional therapies to control JIA signs and symptoms. Since FDA approval is critical to ensure access to bDMARDs, the study and licensing of new medications is critical to address the unmet medication need and to further improve JIA outcomes.
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Affiliation(s)
| | | | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack, New Jersey
| | - Anne Dennos
- Duke Center for AIDS Research, Durham, North Carolina
| | - Dominic O Co
- University of Wisconsin School of Medicine and Public Health, Milwaukee
| | | | | | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | | | | | - Sandra Mintz
- Children's Hospital of Los Angeles, Los Angeles, California
| | - Karen Onel
- Hospital for Special Surgery, New York, New York
| | - Lisa G Rider
- National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland
| | | | - Allen Watts
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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10
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Aranow C, Cush J, Bolster MB, Striebich CC, Dall'era M, Mackay M, Olech E, Frech T, Box J, Keating R, Wasko MC, St Clair W, Kivitz A, Huang W, Ricketts P, Welch B, Callahan S, Spychala M, Boyle K, York K, Keyes-Elstein L, Goldmuntz E, Diamond B, Davidson A. A double-blind, placebo-controlled, phase II, randomized study of lovastatin therapy in the treatment of mildly active rheumatoid arthritis. Rheumatology (Oxford) 2020; 59:1505-1513. [PMID: 31628482 DOI: 10.1093/rheumatology/kez471] [Citation(s) in RCA: 2] [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] [Received: 05/26/2019] [Revised: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES 3-hydroxy-3-methylglutaryl coenzyme-A (HMG Co-A) reductase inhibitors (statins) are standard treatment for hyperlipidaemia. In addition to lipid-lowering abilities, statins exhibit multiple anti-inflammatory effects. The objectives of this study were to determine whether treatment of patients with RA with lovastatin decreased CRP or reduced disease activity. METHODS We conducted a randomized double-blind placebo-controlled 12 week trial of lovastatin vs placebo in 64 RA patients with mild clinical disease activity but an elevated CRP. The primary efficacy end point was the reduction in mean log CRP. Secondary end points included disease activity, RF and anti-CCP antibody titres. Mechanistic end points included levels of serum cytokines. Safety was assessed; hepatic and muscle toxicities were of particular interest. RESULTS Baseline features were similar between groups. No significant difference in mean log CRP reduction between the two groups was observed, and disease activity did not change from baseline in either treatment group. Mechanistic analyses did not reveal significant changes in any biomarkers. A post hoc analysis of subjects not using biologic therapy demonstrated a significantly greater proportion achieving ⩾20% reduction in CRP from baseline in the lovastatin group compared with placebo (P-value = 0.007). No difference was observed in subjects receiving biologics. Lovastatin was well tolerated with no serious safety concerns. CONCLUSION This study showed no anti-inflammatory or clinical effects on RA disease activity after 12 weeks of treatment with lovastatin. Lovastatin had a modest effect on CRP in subjects not using biologics, suggesting statins may be anti-inflammatory in selected patients. TRIAL REGISTRATION ClinicalTrials.gov, http://clinicaltrials.gov, NCT00302952.
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Affiliation(s)
- Cynthia Aranow
- The Feinstein Institute for Medical Research, Manhasset, USA
| | - John Cush
- Division of Rheumatology, Baylor University Medical Center, Dallas, USA
| | - Marcy B Bolster
- Division of Rheumatology, Massachusetts General Hospital, Boston, USA
| | | | - Maria Dall'era
- Division of Rheumatology, University of California, San Francisco, USA
| | - Meggan Mackay
- The Feinstein Institute for Medical Research, Manhasset, USA
| | - Ewa Olech
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, USA
| | - Tracy Frech
- Department of Internal Medicine, University of Utah, Internal Medicine, Salt Lake City, USA
| | - Jane Box
- Box Arthritis & Rheumatology of the Carolinas, Charlotte, USA
| | - Richard Keating
- Division of Rheumatology, Scripps Green Hospital, La Jolla, USA
| | - Mary Chester Wasko
- Division of Rheumatology, Western Pennsylvania Hospital, Pittsburgh, USA
| | - William St Clair
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, USA
| | - Alan Kivitz
- Altoona Center for Clinical Research, Duncansville, USA
| | - Weiquang Huang
- The Feinstein Institute for Medical Research, Manhasset, USA
| | | | - Beverly Welch
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, USA
| | - Sherrie Callahan
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, USA
| | | | - Karen Boyle
- Rho Federal Systems Division, Chapel Hill, USA
| | - Kate York
- Rho Federal Systems Division, Chapel Hill, USA
| | | | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, USA
| | - Betty Diamond
- The Feinstein Institute for Medical Research, Manhasset, USA
| | - Anne Davidson
- The Feinstein Institute for Medical Research, Manhasset, USA
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11
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Franks JM, Martyanov V, Wang Y, Wood TA, Pinckney A, Crofford LJ, Keyes-Elstein L, Furst DE, Goldmuntz E, Mayes MD, McSweeney P, Nash RA, Sullivan KM, Whitfield ML. Machine learning predicts stem cell transplant response in severe scleroderma. Ann Rheum Dis 2020; 79:1608-1615. [PMID: 32933919 DOI: 10.1136/annrheumdis-2020-217033] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The Scleroderma: Cyclophosphamide or Transplantation (SCOT) trial demonstrated clinical benefit of haematopoietic stem cell transplant (HSCT) compared with cyclophosphamide (CYC). We mapped PBC (peripheral blood cell) samples from the SCOT clinical trial to scleroderma intrinsic subsets and tested the hypothesis that they predict long-term response to HSCT. METHODS We analysed gene expression from PBCs of SCOT participants to identify differential treatment response. PBC gene expression data were generated from 63 SCOT participants at baseline and follow-up timepoints. Participants who completed treatment protocol were stratified by intrinsic gene expression subsets at baseline, evaluated for event-free survival (EFS) and analysed for differentially expressed genes (DEGs). RESULTS Participants from the fibroproliferative subset on HSCT experienced significant improvement in EFS compared with fibroproliferative participants on CYC (p=0.0091). In contrast, EFS did not significantly differ between CYC and HSCT arms for the participants from the normal-like subset (p=0.77) or the inflammatory subset (p=0.1). At each timepoint, we observed considerably more DEGs in HSCT arm compared with CYC arm with HSCT arm showing significant changes in immune response pathways. CONCLUSIONS Participants from the fibroproliferative subset showed the most significant long-term benefit from HSCT compared with CYC. This study suggests that intrinsic subset stratification of patients may be used to identify patients with SSc who receive significant benefit from HSCT.
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Affiliation(s)
- Jennifer M Franks
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Viktor Martyanov
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Yue Wang
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Tammara A Wood
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Ashley Pinckney
- Rho Federal Systems Division, Chapel Hill, North Carolina, USA
| | - Leslie J Crofford
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | | | - Daniel E Furst
- Department of Medicine, Division of Rheumatology, University of California at Los Angeles, Los Angeles, California, USA
| | | | - Maureen D Mayes
- Rheumatology and Clinical Immunogenetics, The University of Texas Health Science Center Houston Medical School, Houston, Texas, USA
| | - Peter McSweeney
- Rocky Mountain Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado, USA
| | - Richard A Nash
- Rocky Mountain Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado, USA
| | - Keith M Sullivan
- Duke University Medical Center, Durham, North Carolina, United States
| | - Michael L Whitfield
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA .,Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
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12
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Chakravarty E, Utset T, Kamen DL, Contreras G, Mccune WJ, Kalunian KC, Aranow C, Clowse M, Goldmuntz E, Springer J, Keyes-Elstein L, Barry B, Pinckney A, James J. OP0167 SUCCESSFUL WITHDRAWAL OF MYCOPHENOLATE MOFETIL IN QUIESCENT SLE: RESULTS FROM A RANDOMIZED TRIAL. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.5110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Trials and clinical observations have demonstrated the efficacy of mycophenolate mofetil (MMF) for SLE treatment. Long-term use of MMF is associated with adverse events, pregnancy risks, drug monitoring, and increased cost. Current management continues therapy indefinitely. Whether immunosuppression may be safely withdrawn or whether risks of withdrawal outweigh the benefits of continuation is unknown.Objectives:To compare rates of clinically significant disease reactivation (CSDR), major flares, and all flares in patients with quiescent SLE on stable MMF randomized to maintain or withdraw MMF. The goal is to provide guidance for clinicians and patients on the risks of MMF withdrawal.Methods:Adults with quiescent SLE (SELENA-SLEDAI without serologies <4) receiving MMF for ≥2 years for nephritis or ≥ 1 year for non-nephritis were randomized 1:1 to unblinded MMF (maintenance arm, MA) or to a 12-week taper off MMF (withdrawal arm, WA) and followed through 60 weeks. Subjects were on stable hydroxychloroquine; steroids limited to ≤ 10 mg. CSDR, defined as a SLEDAI flare requiring immunosuppression, BILAG flares and adverse events were assessed. Event rates and time to flare were compared using Kaplan-Meier.Results:102 subjects were randomized (50 MA, 52 WA); 1 subject in each arm was ineligible and 10 terminated early (7 MA, 3 WA). Mean disease duration was 13 years; 76% had a history of nephritis; mean baseline SLEDAI was 2.2. 5 MA subjects (10%) had CSDR, compared to 9 WA (17%). Median time to CDSR was 38 weeks in both arms. BILAG A flares occurred in 1MA subject (pancreatitis) vs. 4 WA (cranial neuropathy, panniculitis, 2 nephritis). Kaplan-Meier curves overlapped for CDSR, BILAG A flares, and all SLEDAI flares (Figure). Based on these data, we are 86% confident that the increased risk of CDSR with MMF withdrawal is less than 15% over 60 weeks. AEs were similar between groups; infections occurred more commonly in MA (63 vs. 49).Conclusion:In this cohort of subjects with quiescent SLE on long term MMF serious flares occurred infrequently in subjects continuing or withdrawing MMF without differences in time to flare. MMF withdrawal may be considered in subjects with prolonged quiescent disease.Table 1.Baseline and Demographic CharacteristicsMaintenance armWithdrawal armTotalRandomized5052102Female, n (%)39 (78)47 (90)86 (84)White, n (%)25 (50)19 (37)44 (43)Black, n (%)19 (38)22 (42)41 (40)Hispanic/Latino, n (%)10 (20)12 (23)22 (22)Age, Years, mean (SD)42.4 (12.9)41.6 (12.5)42.0 (12.6)Disease Duration, Years, mean (SD)13.6 (8.2)12.2 (7.9)12.9 (8.0)H/O Lupus Nephritis, n (%)40 (80)38 (73)78 (76.5)On Baseline Steroids, n (%)18 (36)23 (44)41 (40)Prednisone Dose, mg, mean (SD)4.8 (2.7)3.3 (1.7)4.0 (2.3)MMF Duration, Years, mean (SD)6.8 (4.3)6.4 (4.3)6.6 (4.3)Baseline MMF Dose, mg, mean1,6121,6681,640SELENA-SLEDAI*, mean (SD)2.4 (1.76)1.9 (1.76)2.2 (1.77)Positive DsDNA, n (%)35 (70)27 (52)62 (61)Low C31, n (%)14 (28)9 (17)23 (23)Low C41, n (%)6 (12)5 (10)11 (11)Figure.Kaplan-Meier Estimates of Flare EndpointsDisclosure of Interests:Eliza Chakravarty: None declared, Tammy Utset: None declared, Diane L Kamen Consultant of: Consulted on SLE survey development for Lilly and consulted on SLE trial protocol development for EMD Serono in 2019, Gabriel Contreras Grant/research support from: Genentech, Merck, Consultant of: Genentech, Merck, William Joseph McCune: None declared, Kenneth C Kalunian: None declared, Cynthia Aranow: None declared, Megan Clowse Grant/research support from: GSK, Pfizer, Consultant of: UCB, Astra-Zeneca, Speakers bureau: UCB, Ellen Goldmuntz: None declared, Jessica Springer: None declared, Lynette Keyes-Elstein: None declared, Bill Barry: None declared, Ashley Pinckney: None declared, Judith James: None declared
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13
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Assassi S, Wang X, Chen G, Goldmuntz E, Keyes-Elstein L, Ying J, Wallace PK, Turner J, Zheng WJ, Pascual V, Varga J, Hinchcliff ME, Bellocchi C, McSweeney P, Furst DE, Nash RA, Crofford LJ, Welch B, Pinckney A, Mayes MD, Sullivan KM. Myeloablation followed by autologous stem cell transplantation normalises systemic sclerosis molecular signatures. Ann Rheum Dis 2019; 78:1371-1378. [PMID: 31391177 PMCID: PMC7167108 DOI: 10.1136/annrheumdis-2019-215770] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In the randomised scleroderma: Cyclophosphamide Or Transplantation (SCOT trial) (NCT00114530), myeloablation, followed by haematopoietic stem cell transplantation (HSCT), led to improved clinical outcomes compared with monthly cyclophosphamide (CYC) treatment in systemic sclerosis (SSc). Herein, the study aimed to determine global molecular changes at the whole blood transcript and serum protein levels ensuing from HSCT in comparison to intravenous monthly CYC in 62 participants enrolled in the SCOT study. METHODS Global transcript studies were performed at pretreatment baseline, 8 months and 26 months postrandomisation using Illumina HT-12 arrays. Levels of 102 proteins were measured in the concomitantly collected serum samples. RESULTS At the baseline visit, interferon (IFN) and neutrophil transcript modules were upregulated and the cytotoxic/NK module was downregulated in SSc compared with unaffected controls. A paired comparison of the 26 months to the baseline samples revealed a significant decrease of the IFN and neutrophil modules and an increase in the cytotoxic/NK module in the HSCT arm while there was no significant change in the CYC control arm. Also, a composite score of correlating serum proteins with IFN and neutrophil transcript modules, as well as a multilevel analysis showed significant changes in SSc molecular signatures after HSCT while similar changes were not observed in the CYC arm. Lastly, a decline in the IFN and neutrophil modules was associated with an improvement in pulmonary forced vital capacity and an increase in the cytotoxic/NK module correlated with improvement in skin score. CONCLUSION HSCT contrary to conventional treatment leads to a significant 'correction' in disease-related molecular signatures.
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Affiliation(s)
- Shervin Assassi
- Rheumatology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Xuan Wang
- Biostatistics, Baylor Institute for Immunology Research, Dallas, Texas, USA
| | - Guocai Chen
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ellen Goldmuntz
- Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, Maryland, USA
| | | | - Jun Ying
- Rheumatology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Paul K Wallace
- Flow and Image Cytometry, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Jacob Turner
- Mathematics and Statistics, Stephen F Austin State University, Nacogdoches, Texas, USA
| | - W Jim Zheng
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Virginia Pascual
- Pediatrics, Weill Cornell Medical College, New York, New York, USA
| | - John Varga
- Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Chiara Bellocchi
- Rheumatology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peter McSweeney
- Rocky Mountain Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado, USA
| | - Daniel E Furst
- Rheumatology, University of California Los Angeles, Los Angeles, California, USA
- Rheumatology, University of Washington, Seattle, Washington, USA
| | - Richard A Nash
- Rocky Mountain Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado, USA
| | | | - Beverly Welch
- Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, Maryland, USA
| | - Ashley Pinckney
- Rho Federal Systems Division, Chapel Hill, North Carolina, USA
| | - Maureen D Mayes
- Rheumatology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Keith M Sullivan
- Hematologic Malignancy and Cellular Therapy, Duke University, Durham, North Carolina, USA
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14
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Volkmann ER, Tashkin DP, Sim M, Li N, Goldmuntz E, Keyes-Elstein L, Pinckney A, Furst DE, Clements PJ, Khanna D, Steen V, Schraufnagel DE, Arami S, Hsu V, Roth MD, Elashoff RM, Sullivan KM. Short-term progression of interstitial lung disease in systemic sclerosis predicts long-term survival in two independent clinical trial cohorts. Ann Rheum Dis 2018; 78:122-130. [PMID: 30409830 DOI: 10.1136/annrheumdis-2018-213708] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/27/2018] [Accepted: 10/16/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess survival and identify predictors of survival in patients with systemic sclerosis-interstitial lung disease (SSc-ILD) who participated in the Scleroderma Lung Studies (SLS) I and II. METHODS SLS I randomised 158 patients with SSc-ILD to 1 year of oral cyclophosphamide (CYC) vs placebo. SLS II randomised 142 patients to 1 year of oral CYC followed by 1 year of placebo vs 2 years of mycophenolate mofetil. Counting process Cox proportional hazard modelling identified variables associated with long-term mortality in SLS I and II. Internal validation was performed using joint modelling. RESULTS After a median follow-up of 8 years, 42% of SLS I patients died, and when known the cause of death was most often attributable to SSc. There was no significant difference in the time to death between treatment arms in SLS I or II. Higher baseline skin score, older age, and a decline in the forced vital capacity (FVC) and the diffusing capacity for carbon monoxide (DLCO) over 2 years were independently associated with an increased risk of mortality in SLS I. The Cox model identified the same mortality predictor variables using the SLS II data. CONCLUSION In addition to identifying traditional mortality risk factors in SSc (skin score, age), this study demonstrated that a decline in FVC and DLCO over 2 years was a better predictor of mortality than baseline FVC and DLCO. These findings suggest that short-term changes in surrogate measures of SSc-ILD progression may have important effects on long-term outcomes.
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Affiliation(s)
- Elizabeth R Volkmann
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Donald P Tashkin
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Myung Sim
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Ning Li
- Department of Biomathematics, University of California, Los Angeles, California, USA
| | | | | | | | - Daniel E Furst
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Philip J Clements
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Dinesh Khanna
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Virginia Steen
- Department of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Dean E Schraufnagel
- Department of Medicine, University of Illinois Hospital, Chicago, Illinois, USA
| | - Shiva Arami
- Department of Medicine, University of Illinois Hospital, Chicago, Illinois, USA
| | - Vivien Hsu
- Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Michael D Roth
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Robert M Elashoff
- Department of Biomathematics, University of California, Los Angeles, California, USA
| | - Keith M Sullivan
- Department of Medicine, Duke University, Durham, North Carolina, USA
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Brunner HI, Rider LG, Kingsbury DJ, Co D, Schneider R, Goldmuntz E, Onel KB, Giannini EH, Lovell DJ. Pediatric Rheumatology Collaborative Study Group - over four decades of pivotal clinical drug research in pediatric rheumatology. Pediatr Rheumatol Online J 2018; 16:45. [PMID: 29996857 PMCID: PMC6042275 DOI: 10.1186/s12969-018-0261-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 06/20/2018] [Indexed: 11/10/2022] Open
Abstract
IMPORTANCE Specialized research networks are essential to achieve drug approvals for rare pediatric diseases. Such networks help realize the potential of global legislation enacted upon the recognition that most children are treated with drugs whose most beneficial dose and regimen have not been established in pediatric patients. The Pediatric Rheumatology Collaborative Study Group (PRCSG) is a North American clinical trials network that is specialized in the performance of clinical trials of new therapies for pediatric populations with rheumatic diseases. This review provides an overview of the strategies employed by this research network to achieve drug and biologic approvals for children with pediatric rheumatic diseases, particularly juvenile idiopathic arthritis. OBSERVATIONS Clinical trial conduct in rare pediatric diseases has required global recruitment. Supported or led by the PRCSG, highly responsive, validated, composite measures have been established to assess drug efficacy. For pediatric orphan diseases with high disease burdens, specialized investigative sites and study designs are needed to complete adequately powered trials at the high standard necessary to enable drug labeling by regulatory agencies. Novel trial designs have been utilized for more efficient testing of innovative drug candidates. All these have been developed or co-developed by the PRCSG research network. CONCLUSIONS AND RELEVANCE Specialized research networks in pediatric rheumatology, such as the PRCSG, have changed the landscape of available therapies and improved overall disease outcomes for children with pediatric rheumatic diseases.
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Affiliation(s)
- Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center & Cincinnati Children's Research Foundation, MLC 4010, Cincinnati, OH, 45229, USA.
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, USA
| | | | - Dominic Co
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rayfel Schneider
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, Rheumatologic Autoimmune Diseases Section, National Institutes of Health, Bethesda, MD, USA
| | - Karen B Onel
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward H Giannini
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center & Cincinnati Children's Research Foundation, MLC 4010, Cincinnati, OH, 45229, USA
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center & Cincinnati Children's Research Foundation, MLC 4010, Cincinnati, OH, 45229, USA
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16
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Hung EW, Mayes MD, Sharif R, Assassi S, Machicao VI, Hosing C, St Clair EW, Furst DE, Khanna D, Forman S, Mineishi S, Phillips K, Seibold JR, Bredeson C, Csuka ME, Nash RA, Wener MH, Simms R, Ballen K, Leclercq S, Storek J, Goldmuntz E, Welch B, Keyes-Elstein L, Castina S, Crofford LJ, Mcsweeney P, Sullivan KM. Gastric antral vascular ectasia and its clinical correlates in patients with early diffuse systemic sclerosis in the SCOT trial. J Rheumatol 2013; 40:455-60. [PMID: 23418384 DOI: 10.3899/jrheum.121087] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To describe the prevalence and clinical correlates of endoscopic gastric antral vascular ectasia (GAVE; "watermelon stomach") in early diffuse systemic sclerosis (SSc). METHODS Subjects with early, diffuse SSc and evidence of specific internal organ involvement were considered for the Scleroderma: Cyclophosphamide Or Transplant (SCOT) trial. In the screening procedures, all patients underwent upper gastrointestinal endoscopy. Patients were then categorized into those with or without endoscopic evidence of GAVE. Demographic data, clinical disease characteristics, and autoantibody data were compared using Pearson chi-square or Student t tests. RESULTS Twenty-three of 103 (22.3%) individuals were found to have GAVE on endoscopy. Although not statistically significant, anti-topoisomerase I (anti-Scl70) was detected less frequently among those with GAVE (18.8% vs 44.7%; p = 0.071). Similarly, anti-RNP antibodies (anti-U1 RNP) showed a trend to a negative association with GAVE (0 vs 18.4%; p = 0.066). There was no association between anti-RNA polymerase III and GAVE. Patients with GAVE had significantly more erythema or vascular ectasias in other parts of the stomach (26.1% vs 5.0%; p = 0.003). CONCLUSION Endoscopic GAVE was present on screening in almost one-fourth of these highly selected patients with early and severe diffuse SSc. While anti-Scl70 and anti-U1 RNP trended toward a negative association with GAVE, there was no correlation between anti-RNA Pol III and GAVE. Patients with GAVE had a higher frequency of other gastric vascular ectasias outside the antrum, suggesting that GAVE may represent part of the spectrum of the vasculopathy in SSc.
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Affiliation(s)
- Emily W Hung
- Rheumatology Associates of Houston, Division of Northwest Diagnostic Clinic, Houston, Texas, USA
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17
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Gai X, Xie HM, Perin JC, Takahashi N, Murphy K, Wenocur AS, D'arcy M, O'Hara RJ, Goldmuntz E, Grice DE, Shaikh TH, Hakonarson H, Buxbaum JD, Elia J, White PS. Rare structural variation of synapse and neurotransmission genes in autism. Mol Psychiatry 2012; 17:402-11. [PMID: 21358714 PMCID: PMC3314176 DOI: 10.1038/mp.2011.10] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [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] [Indexed: 02/08/2023]
Abstract
Autism spectrum disorders (ASDs) comprise a constellation of highly heritable neuropsychiatric disorders. Genome-wide studies of autistic individuals have implicated numerous minor risk alleles but few common variants, suggesting a complex genetic model with many contributing loci. To assess commonality of biological function among rare risk alleles, we compared functional knowledge of genes overlapping inherited structural variants in idiopathic ASD subjects relative to healthy controls. In this study we show that biological processes associated with synapse function and neurotransmission are significantly enriched, with replication, in ASD subjects versus controls. Analysis of phenotypes observed for mouse models of copy-variant genes established significant and replicated enrichment of observable phenotypes consistent with ASD behaviors. Most functional terms retained significance after excluding previously reported ASD loci. These results implicate several new variants that involve synaptic function and glutamatergic signaling processes as important contributors of ASD pathophysiology and suggest a sizable pool of additional potential ASD risk loci.
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Affiliation(s)
- X Gai
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - H M Xie
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J C Perin
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Takahashi
- Seaver Autism Center and Department of Psychiatry, Mt Sinai School of Medicine, New York, NY, USA
| | - K Murphy
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - A S Wenocur
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M D'arcy
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - R J O'Hara
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - D E Grice
- Department of Child and Adolescent Psychiatry, Columbia University, New York, NY, USA
| | - T H Shaikh
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, USA
| | - H Hakonarson
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA,Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA,Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J D Buxbaum
- Seaver Autism Center and Department of Psychiatry, Mt Sinai School of Medicine, New York, NY, USA
| | - J Elia
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, PA, USA,Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - P S White
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA,Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Room 1407 CHOP North, Philadelphia, PA 19104-4318, USA. E-mail:
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18
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Sullivan K, Froshaug D, Furst D, Nash R, Mayes M, Crofford L, McSweeney P, Goldmuntz E, Keyes-Elstein L, Khanna D, Sullivan K, Woolson R, Wallace P, Sempowski G, McSweeney P, Mayes M, Crofford L, Nash R, Furst D, Storek J, Quirici N, Corti L, Scavullo C, Ferri C, Manfredi A, Giuggioli D, Lambertenghi Deliliers G, Del Papa N, Foeldvari I, Wierk A, Fargue D. S.1.1 Organ function and quality of life correlates at randomization on the SCOT (Scleroderma: Cyclophosphamide Or Transplantion) Trial. Rheumatology (Oxford) 2012. [DOI: 10.1093/rheumatology/ker456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Hosing C, Nash R, McSweeney P, Mineishi S, Seibold J, Griffith LM, Shulman H, Goldmuntz E, Mayes M, Parikh CR, Crofford L, Keyes-Elstein L, Furst D, Steen V, Sullivan KM. Acute kidney injury in patients with systemic sclerosis participating in hematopoietic cell transplantation trials in the United States. Biol Blood Marrow Transplant 2010; 17:674-81. [PMID: 20708086 DOI: 10.1016/j.bbmt.2010.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 08/03/2010] [Indexed: 01/21/2023]
Abstract
Recipients of hematopoietic cell transplantation may be at risk for developing acute kidney injury (AKI), and this risk may be increased in patients who undergo transplantation for severe systemic sclerosis (SSc) due to underlying scleroderma renal disease. AKI after transplantation can increase treatment-related mortality. To better define these risks, we analyzed 91 patients with SSc who were enrolled in 3 clinical trials in the United States of autologous or allogeneic hematopoietic cell transplantation (HCT). Eleven (12%) of the 91 patients with SSc in these studies (8 undergoing autologous HCT, 1 undergoing allogeneic HCT, 1 pretransplantation, 1 given i.v. cyclophosphamide on a transplantation trial) experienced AKI, of whom 8 required dialysis and/or therapeutic plasma exchange. AKI injury in the 9 HCT recipients developed a median of 35 days (range, 0-90 days) after transplantation. Ten of 11 patients with AKI received angiotensin-converting enzyme inhibitor (ACE-I) therapy. The etiology of AKI was attributed to scleroderma renal crisis in 6 patients (including 2 with normotensive renal crisis), to AKI of uncertain etiology in 2 patients, and to AKI superimposed on scleroderma kidney disease in 3 patients. Eight of the 11 patients died, one each because of progression of SSc, multiorgan failure, gastrointestinal and pulmonary bleeding, pericardial tamponade and pulmonary complications, diffuse alveolar hemorrhage, pulmonary embolism, graft-versus-host disease, and malignancy. Limiting nephrotoxins, cautious use of corticosteroids, renal shielding during total body irradiation, strict control of blood pressure, and aggressive use of ACE-Is may be of importance in preventing renal complications after HCT for SSc.
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Affiliation(s)
- Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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20
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Chin AJ, Stephens P, Goldmuntz E, Leonard MB. Serum alkaline phosphatase reflects post-Fontan hemodynamics in children. Pediatr Cardiol 2009; 30:138-45. [PMID: 18685798 DOI: 10.1007/s00246-008-9292-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 07/11/2008] [Accepted: 07/11/2008] [Indexed: 11/30/2022]
Abstract
Although survivors of Fontan palliation for a single ventricle are known to have lower cardiac index than patients with two-ventricle surgical reconstructions, it is unclear whether two frequently observed sequelae, short stature and protein-losing enteropathy (PLE), have hemodynamic origins. A serum marker that reflects hemodynamic status would be a tremendous asset in the long-term management of children with these sequelae. The authors recently noted severely reduced total alkaline phosphatase (TALP) levels in two children with early-onset PLE after Fontan operations, both of whom had low cardiac output at cardiac catheterization. Catheter-based or surgical interventions that rapidly increased cardiac output in these two patients resulted not only in relief of PLE but also in a prompt TALP rise. To examine whether the apparent correlation of low TALP with impaired cardiac output also is seen in Fontan patients without PLE, this study retrospectively examined the TALP data from two other Fontan patients who underwent cardiac catheterization specifically to assess the potential benefit of vasodilator therapy. The TALP levels were abnormally low in both cases but increased after up-titration of angiotensin-converting enzyme inhibition. Serum TALP activity, an indicator of osteoblastic function particularly in pre-adolescence, may be a marker of low cardiac output after a Fontan operation.
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Affiliation(s)
- Alvin J Chin
- Division of Cardiology, Abramson Research Center, The Children's Hospital of Philadelphia, and Department of Pediatrics, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA.
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21
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Abstract
BACKGROUND Recent reports have identified mutations in the transcription factor GATA4 in familial cases of cardiac septal defects. The prevalence of GATA4 mutations in the population of patients with septal defects is unknown. Given that patients with septal and conotruncal defect can share a common genetic basis, it is unclear whether patients with additional types of CHD might also have GATA4 mutations. AIMS To explore these questions by investigating a large population of 628 patients with either septal or conotruncal defects for GATA4 sequence variants. METHODS The GATA4 coding region and exon-intron boundaries were investigated for sequence variants using denaturing high-performance liquid chromatography or conformation-sensitive gel electrophoresis. Samples showing peak or band shifts were reamplified from genomic DNA and sequenced. RESULTS Four missense sequence variants (Gly93Ala, Gln316Glu, Ala411Val, Asp425Asn) were identified in five patients (two with atrial septal defect, two with ventricular septal defect and one with tetralogy of Fallot), which were not seen in a control population. All four affected amino acid residues are conserved across species, and two of the sequence variants lead to changes in polarity. Ten synonymous sequence variants were also identified in 18 patients, which were not seen in the control population. CONCLUSIONS These data suggest that non-synonymous GATA4 sequence variants are found in a small percentage of patients with septal defects and are very uncommonly found in patients with conotruncal defects.
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Affiliation(s)
- A Tomita-Mitchell
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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22
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Karkera JD, Lee JS, Roessler E, Banerjee-Basu S, Ouspenskaia MV, Mez J, Goldmuntz E, Bowers P, Towbin J, Belmont JW, Baxevanis AD, Schier AF, Muenke M. Loss-of-function mutations in growth differentiation factor-1 (GDF1) are associated with congenital heart defects in humans. Am J Hum Genet 2007; 81:987-94. [PMID: 17924340 DOI: 10.1086/522890] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 07/13/2007] [Indexed: 01/07/2023] Open
Abstract
Congenital heart defects (CHDs) are among the most common birth defects in humans (incidence 8-10 per 1,000 live births). Although their etiology is often poorly understood, most are considered to arise from multifactorial influences, including environmental and genetic components, as well as from less common syndromic forms. We hypothesized that disturbances in left-right patterning could contribute to the pathogenesis of selected cardiac defects by interfering with the extrinsic cues leading to the proper looping and vessel remodeling of the normally asymmetrically developed heart and vessels. Here, we show that heterozygous loss-of-function mutations in the human GDF1 gene contribute to cardiac defects ranging from tetralogy of Fallot to transposition of the great arteries and that decreased TGF- beta signaling provides a framework for understanding their pathogenesis. These findings implicate perturbations of the TGF- beta signaling pathway in the causation of a major subclass of human CHDs.
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Affiliation(s)
- J D Karkera
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
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23
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Lambrechts D, Devriendt K, Driscoll DA, Goldmuntz E, Gewillig M, Vlietinck R, Collen D, Carmeliet P. Low expression VEGF haplotype increases the risk for tetralogy of Fallot: a family based association study. J Med Genet 2006; 42:519-22. [PMID: 15937089 PMCID: PMC1736071 DOI: 10.1136/jmg.2004.026443] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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24
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Abstract
The association between truncus arteriosus and chromosome 22q11 deletion is well recognized, but the frequency of a chromosome 22q11 deletion has not been characterized in a large series of patients with truncus arteriosus, and little is known about cardiovascular morphologic features associated with a chromosome 22q11 deletion in this group of patients. We prospectively enrolled 50 consecutive patients with truncus arteriosus who were admitted to The Children's Hospital of Philadelphia between November 1991 and December 2001. Patients were studied for chromosome 22q11 deletion using fluorescence in situ hybridization. Correlations between anatomic features and chromosome 22q11 deletion were assessed. A chromosome 22q11 deletion was detected in 20 of the 50 patients (40%). Anatomic features that were significantly associated with a chromosome 22q11 deletion included a right-sided aortic arch, an abnormal aortic arch branching pattern, both abnormal sidedness and branching of the aortic arch, and the combined category of either abnormal sidedness or branching of the aortic arch. There was a trend toward the association of discontinuous pulmonary arteries with a chromosome 22q11 deletion. Interruption of the aortic arch and truncal valve morphology and function did not correlate significantly with the presence of a chromosome 22q11 deletion. In conclusion, a chromosome 22q11 deletion is common in patients with truncus arteriosus, and those with abnormal sidedness and/or branching of the aortic arch are significantly more likely to have a deletion. Clinically important anatomic variables, such as abnormalities of the truncal valve and interrupted aortic arch, were not associated with a chromosome 22q11 deletion in this series.
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Affiliation(s)
- D B McElhinney
- Division of Cardiology, The Children's Hospital of Philadelphia, 3516 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA
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25
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Abstract
OBJECTIVE Cardiovascular anomalies are present in 75% to 80% of patients with a chromosome 22q11 deletion. In the majority of cases, the cardiovascular defect becomes evident in the neonatal period and is often the initial manifestation of the chromosome 22q11 deletion syndrome. However, a 22q11 deletion may also be associated with cardiovascular defects that are less obvious, such as a vascular ring, which may not be diagnosed until the patient is older. The objective of this study was to determine the frequency and types of cardiovascular anomalies in patients diagnosed with a chromosome 22q11 deletion beyond 6 months of age. METHODS We studied 29 patients diagnosed with a chromosome 22q11 deletion at a median age of 6.2 years (9 months to 45 years) who were subsequently referred for cardiovascular evaluation. Comprehensive cardiologic evaluation was performed, with transthoracic echocardiography (N = 28) and/or magnetic resonance imaging (N = 6), including imaging of the aortic arch. The frequency of cardiovascular anomalies diagnosed in these patients and the need for intervention were assessed. RESULTS Cardiovascular anomalies were detected in 11 (38%) patients: 3 with a vascular ring formed by a right aortic arch with an aberrant left subclavian artery and left-sided ligamentum arteriosum, 3 with a right aortic arch with mirror-image branching of the brachiocephalic arteries (no vascular ring; 1 with a patent ductus arteriosus), 4 with a left aortic arch with an aberrant right subclavian artery (no vascular ring; 1 with a patent ductus), and 1 with a left superior vena cava draining to the coronary sinus. The median age at diagnosis in these 11 patients was 3 years (9 months to 28 years). The remaining 18 patients had normal cardiovascular anatomy. All 3 patients with vascular rings subsequently underwent surgical repair, and 1 patient with a ductus arteriosus underwent transcatheter coil occlusion. CONCLUSIONS The frequency of cardiovascular anomalies necessitating intervention in patients referred for cardiovascular evaluation after diagnosis of a chromosome 22q11 deletion beyond 6 months of age is 14% in our experience. Routine screening for cardiovascular anomalies, including echocardiography and other imaging studies to identify the laterality and branching pattern of the aortic arch, is indicated in patients diagnosed with 22q11 deletion beyond 6 months of age and is particularly critical for patients with respiratory or feeding disorders.
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Affiliation(s)
- D B McElhinney
- Division of Cardiology, Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104-4318, USA
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26
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Gong W, Gottlieb S, Collins J, Blescia A, Dietz H, Goldmuntz E, McDonald-McGinn DM, Zackai EH, Emanuel BS, Driscoll DA, Budarf ML. Mutation analysis of TBX1 in non-deleted patients with features of DGS/VCFS or isolated cardiovascular defects. J Med Genet 2001; 38:E45. [PMID: 11748311 PMCID: PMC1734783 DOI: 10.1136/jmg.38.12.e45] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
BACKGROUND Recent reports have implicated mutations in the transcription factor NKX2.5 as a cause of tetralogy of Fallot (TOF). To estimate the frequency of NKX2.5 mutations in TOF patients and to further investigate the genotype-phenotype correlation of NKX2.5 mutations, we genotyped 114 TOF patients. METHODS AND RESULTS Patients were recruited prospectively (November 1992 through June 1999) and tested for a 22q11 deletion; those with 22q11 deletion or recognized chromosomal alteration were excluded from the present study. Patients were screened for NKX2.5 alterations by conformation-sensitive gel electrophoresis and sequencing of fragments with aberrant mobility. Four heterozygous mutations were identified in 6 unrelated patients with cases of TOF, including 3 with pulmonary atresia and 5 with right aortic arch; none had ECG evidence of PR interval prolongation. Three of 4 mutations (Glu21Gln, Arg216Cys, and Ala219Val) altered highly conserved amino acids, of which 2 mapped in the conserved NK2 domain. The fourth mutation (Arg25Cys) was identified in 3 unrelated probands in the present study and has been previously reported. No homeodomain mutations were identified. CONCLUSIONS NKX2.5 mutations are the first gene defects identified in nonsyndromic TOF patients. NKX2.5 mutation is present in >/=4% of TOF patients. Mutations identified in the present study mapped outside of the homeodomain, were not associated with atrioventricular conduction disturbances, and were not fully penetrant, in contrast to mutations previously reported that impair homeodomain function.
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Affiliation(s)
- E Goldmuntz
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA,
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28
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McElhinney DB, Hoydu AK, Gaynor JW, Spray TL, Goldmuntz E, Weinberg PM. Patterns of right aortic arch and mirror-image branching of the brachiocephalic vessels without associated anomalies. Pediatr Cardiol 2001; 22:285-91. [PMID: 11455394 DOI: 10.1007/s002460010231] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
It is unusual to have a right aortic arch with mirror-image branching of the brachiocephalic vessels and no associated congenital cardiac anomalies. Pathogenetic factors of this anomaly, and associated development of the derivatives of the pharyngeal arches, have not been explored extensively. Eleven patients with a mirror-image right aortic arch and no intracardiac anomalies have undergone evaluation at our institution since 1987. Of these, 4 had stenosis (n = 2) or atresia (n = 2) of the proximal left pulmonary artery. These included 2 with bilateral ductus arteriosus. Six patients had a vascular ring formed by a ductus arteriosus or ligamentum arteriosum from the descending aorta to the left pulmonary artery. Six patients were evaluated for deletion within the DiGeorge critical region of chromosome 22q11. All 6 of the patients with a vascular ring underwent division of the ductus arteriosus or ligamentum through a left lateral thoracotomy. None of the patients with stenosis or atresia of the LPA have undergone intervention. Two of the 6 patients who underwent evaluation for chromosome 22q11 deletion were found to have the deletion. At a median follow-up of 7 years (15 months to 12 years), the patients who underwent division of the ring are all alive and asymptomatic. Two of these patients have undergone repeat magnetic resonance imaging, 1 of whom had mild residual tracheal compression. A right aortic arch with mirror-image branching of the brachiocephalic vessels and no associated intracardiac anomalies is extremely uncommon. We have observed two basic patterns of this lesion: (1) with associated abnormalities of the proximal left pulmonary artery, (2) with a vascular ring formed by a ductus arteriosus or ligamentum from the descending aorta to the left pulmonary artery. Pathogenetic considerations are explored, with a focus on flow-related vascular development and the role of deletions within chromosome 22q11.
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Affiliation(s)
- D B McElhinney
- Divisions of Pediatric Cardiology and Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Room 9557, and University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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29
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McElhinney DB, Clark BJ, Weinberg PM, Kenton ML, McDonald-McGinn D, Driscoll DA, Zackai EH, Goldmuntz E. Association of chromosome 22q11 deletion with isolated anomalies of aortic arch laterality and branching. J Am Coll Cardiol 2001; 37:2114-9. [PMID: 11419896 DOI: 10.1016/s0735-1097(01)01286-4] [Citation(s) in RCA: 199] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the frequency of chromosome 22q11 deletions in patients with isolated anomalies of the aortic arch and its branches. BACKGROUND Chromosome 22q11 deletions are often present in patients with certain forms of congenital cardiovascular disease, including tetralogy of Fallot, truncus arteriosus and interruption of the aortic arch. Among patients with these anomalies, chromosome 22q11 deletion is more common in those with abnormal aortic arch laterality or branching. METHODS We studied 66 patients with isolated anomalies of the aortic arch and no associated intracardiac defects for deletions within chromosome 22q11, using fluorescence in situ hybridization with the cosmid probe N25 (D22S75). Arch anomalies included: double aortic arch (n = 22); right aortic arch with aberrant left subclavian artery (n = 28); right aortic arch with mirror-image branching and a vascular ring formed by a left-sided ductus from the descending aorta (n = 5); right aortic arch with mirror-image branching and no vascular ring (n = 4); and left aortic arch with aberrant right subclavian artery (n = 7). In addition, four patients had a cervical aortic arch, four had aortic coarctation and six had hypoplasia/atresia of the proximal pulmonary arteries. RESULTS Chromosome 22q11 deletions were found in 16 patients (24%) across the full spectrum of anomalies studied. Among the morphologic variables analyzed, only hypoplasia/atresia of the proximal pulmonary arteries correlated with the deletion (p = 0.03). Among patients with a double arch, the frequency of chromosome 22q11 deletion was higher in those with an atretic minor arch than it was in those with a patent minor arch (p = 0.02). CONCLUSIONS Chromosome 22q11 deletion is associated with isolated anomalies of laterality or branching of the aortic arch in 24% of cases in our series. These findings should alert the clinician to consider deletion screening in patients with isolated anomalies of the aortic arch.
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Affiliation(s)
- D B McElhinney
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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McDonald-McGinn DM, LaRossa D, Goldmuntz E, Sullivan K, Eicher P, Gerdes M, Moss E, Wang P, Solot C, Schultz P, Lynch D, Bingham P, Keenan G, Weinzimer S, Ming JE, Driscoll D, Clark BJ, Markowitz R, Cohen A, Moshang T, Pasquariello P, Randall P, Emanuel BS, Zackai EH. The 22q11.2 deletion: screening, diagnostic workup, and outcome of results; report on 181 patients. Genet Test 2001; 1:99-108. [PMID: 10464633 DOI: 10.1089/gte.1997.1.99] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A submicroscopic deletion of chromosome 22q11.2 has been identified in the majority of patients with the DiGeorge syndrome, velocardiofacial syndrome, conotruncal anomaly face syndrome, and in some patients with isolated conotruncal cardiac anomalies, Opitz G/BBB syndrome, and Cayler cardiofacial syndrome. We have evaluated 181 patients with this deletion. We describe our cohort of patients, how they presented, and what has been learned by having the same subspecialists evaluate all of the children. The results help define the extremely variable phenotype associated with this submicroscopic deletion and will assist clinicians in formulating a management plan based on these findings.
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Affiliation(s)
- D M McDonald-McGinn
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, PA 19104, USA
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31
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Abstract
The studies summarized demonstrate that CHD is a common, major malformation. The genetic cause of each specific lesion is heterogeneous. In addition, different types of CHD can result from the same chromosomal alteration or from mutations in the same gene. Although one might predict that genotype influences clinical outcome, further studies are required. At this time, routine clinical diagnostic tests to identify the specific genetic cause are available in only a few cases, namely, those with abnormal karyotypes or those with a 22q11 deletion. In those cases with single-gene defects, genetic testing is not clinically available at this time and most likely will not become available until we can predict the significance of each mutation and until technologic advances are made that allow for large-scale, accurate screening. In the meantime, continued research on the genetic cause of CHD promises to augment our understanding of the mechanisms underlying the normal and abnormal development of the cardiac structures. These investigations also promise to augment our ability to counsel families on the recurrence risk with greater accuracy and, in the future, will allow the physician to modify his or her clinical management based on genetic cause. Finally, identifying the cause and understanding the disease mechanism allows for early intervention that may modify the degree of cardiac maldevelopment or avoid cardiac malformation altogether.
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Affiliation(s)
- E Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Abstract
The genetic etiologies of multiple cardiovascular disorders have been identified recently. For the most part, familial cardiomyopathic, vascular, or arrhythmogenic disorders have been studied given the opportunity to identify the disease gene by linkage analyses, positional cloning, and analysis of candidate genes. Given that structural congenital heart disease rarely occurs in the context of large families, alternative approaches to understand the possible genetic etiologies have been taken. In particular, molecular evaluations of genetic syndromes in which cardiac defects are a cardinal feature are providing new insights into disease-related genes and developmental pathways. The identification of rare families with multiple affected members also has provided some insight into the genetic contribution to structural congenital heart defects. This review highlights the newest findings on the genetic etiology or implications in each of the subcategories of congenital cardiovascular disorders, and will provide the reader with both a brief overview and update. Particular note will be made of the genotype/phenotype analyses of hypertrophic cardiomyopathy and the long QT syndromes, as well as the identification of new disease-related genes for dilated cardiomyopathy, idiopathic ventricular fibrillation, and structural heart disease.
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Affiliation(s)
- E Goldmuntz
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania 19104-4318, USA
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Gerdes M, Solot C, Wang PP, Moss E, LaRossa D, Randall P, Goldmuntz E, Clark BJ, Driscoll DA, Jawad A, Emanuel BS, McDonald-McGinn DM, Batshaw ML, Zackai EH. Cognitive and behavior profile of preschool children with chromosome 22q11.2 deletion. Am J Med Genet 1999. [PMID: 10406665 DOI: 10.1002/(sici)1096-8628(19990716)85:2<127::aid-ajmg6>3.0.co;2-f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A microscopic deletion of chromosome 22q11.2 has been identified in most patients with the DiGeorge, velocardiofacial syndrome, conotruncal anomaly face syndrome, and in some patients with isolated conotruncal cardiac anomalies. This study presents the neurodevelopmental outcome, including cognitive development, language development, speech, neuromuscular development, and behavioral characteristics of 40 preschool children (ages 13 to 63 months) who have been diagnosed with the 22q11.2 deletion. The impact of cardiac disease, cardiac surgery, and the palatal anomalies on this population was also studied. In the preschool years, children with a 22q11.2 deletion are most commonly found to be developmentally delayed, have mild hypotonia, and language and speech delays. The more significantly delayed children are at high risk to be subsequently diagnosed with mild or moderate mental retardation. The global delays and the variations in intelligence found are directly associated with the 22q11.2 deletion and are not explained by physical anomalies such as palatal defects or cardiac defects, or therapeutic interventions such as cardiac surgery. Our findings demonstrate that there is a pattern of significant speech disorders within this population. All of the children had late onset of verbal speech. Behavioral outcomes included both inhibition and attention disorders. Early intervention services are strongly recommended beginning in infancy to address the delays in gross motor skills, speech and language, and global developmental delays.
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Affiliation(s)
- M Gerdes
- Division of Child Development, The Children's Hospital of Philadelphia, Pennsylvania 19104-4399, USA.
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Krantz ID, Smith R, Colliton RP, Tinkel H, Zackai EH, Piccoli DA, Goldmuntz E, Spinner NB. Jagged1 mutations in patients ascertained with isolated congenital heart defects. Am J Med Genet 1999; 84:56-60. [PMID: 10213047] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Mutations in Jagged1 cause Alagille syndrome (AGS), a pleiotropic disorder with involvement of the liver, heart, skeleton, eyes, and facial structures. Cardiac defects are seen in more than 95% of AGS patients. Most commonly these are right-sided defects ranging from mild peripheral pulmonic stenosis to severe forms of tetralogy of Fallot. AGS demonstrates highly variable expressivity with respect to all of the involved systems. This leads us to hypothesize that defects in Jagged1 can be found in patients with presumably isolated heart defects, such as tetralogy of Fallot or pulmonic stenosis. Two patients with heart defects of the type seen in AGS and their relatives were investigated for alterations in the Jagged1 gene. Jagged1 was screened by a combination of cytogenetic and molecular techniques. Patient 1 was studied because of a four-generation history of pulmonic stenosis. Molecular analysis showed a point mutation in Jagged1 in the patient and her mother. Patient 2 was investigated owing to the finding of tetralogy of Fallot and a "butterfly" vertebra on chest radiograph first noted at age 5 years. She was found to have a deletion of chromosome region 20p12 that encompassed the entire Jagged1 gene. The identification of these two patients suggests that other patients with right-sided heart defects may have subtle findings of AGS and Jagged1 mutations.
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Affiliation(s)
- I D Krantz
- Division of Human Genetics, Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, 19104, USA.
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35
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McDonald-McGinn DM, Kirschner R, Goldmuntz E, Sullivan K, Eicher P, Gerdes M, Moss E, Solot C, Wang P, Jacobs I, Handler S, Knightly C, Heher K, Wilson M, Ming JE, Grace K, Driscoll D, Pasquariello P, Randall P, Larossa D, Emanuel BS, Zackai EH. The Philadelphia story: the 22q11.2 deletion: report on 250 patients. Genet Couns 1999; 10:11-24. [PMID: 10191425] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A submicroscopic deletion of chromosome 22q11.2 has been identified in the majority of patients with the DiGeorge, velocardiofacial, and conotruncal anomaly face syndromes, and in some patients with the Opitz G/BBB and Cayler cardiofacial syndromes. We have been involved in the analysis of DiGeorge syndrome and related diagnoses since 1982 and have evaluated a large number of patients with the deletion. We describe our cohort of 250 patients whose clinical findings help to define the extremely variable phenotype associated with the 22q11.2 deletion and may assist clinicians in providing genetic counseling and guidelines for clinical management based on these findings.
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Affiliation(s)
- D M McDonald-McGinn
- Division of Human Genetics and molecular Biology, Children's Hospital of Philadelphia, Pennsylvania, USA
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Abstract
We have studied 92 patients with Alagille syndrome (AGS) to determine the frequency of clinical manifestations and to correlate the clinical findings with outcome. Liver biopsy specimens showed paucity of the interlobular ducts in 85% of patients. Cholestasis was seen in 96%, cardiac murmur in 97%, butterfly vertebrae in 51%, posterior embryotoxon in 78%, and characteristic facies in 96% of patients. Renal disease was present in 40% and intracranial bleeding or stroke occurred in 14% of patients. The presence of intracardiac congenital heart disease was the only clinical feature statistically associated with increased mortality (P <.001). Initial measures of hepatic function in infancy including absence of scintiscan excretion were not predictive of risk for transplantation or increased mortality. The hepatic histology of these AGS patients showed a significant increase in the prevalence of bile duct paucity (P =.002) and fibrosis (P <.001) with increasing age. Liver transplantation for hepatic decompensation was necessary in 21% (19 of 92) of patients with 79% survival 1-year posttransplantation. Current mortality is 17% (16 of 92). The factors that contributed significantly to mortality were complex congenital heart disease (15%), intracranial bleeding (25%), and hepatic disease or hepatic transplantation (25%). The 20-year predicted life expectancy is 75% for all patients, 80% for those not requiring liver transplantation, and 60% for those who required liver transplantation.
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Affiliation(s)
- K M Emerick
- Department of Pediatrics, and the Divisions of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine, Philadelphia, PA
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37
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Goldmuntz E, Clark BJ, Mitchell LE, Jawad AF, Cuneo BF, Reed L, McDonald-McGinn D, Chien P, Feuer J, Zackai EH, Emanuel BS, Driscoll DA. Frequency of 22q11 deletions in patients with conotruncal defects. J Am Coll Cardiol 1998; 32:492-8. [PMID: 9708481 DOI: 10.1016/s0735-1097(98)00259-9] [Citation(s) in RCA: 350] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study was designed to determine the frequency of 22q11 deletions in a large, prospectively ascertained sample of patients with conotruncal defects and to evaluate the deletion frequency when additional cardiac findings are also considered. BACKGROUND Chromosome 22q11 deletions are present in the majority of patients with DiGeorge, velocardiofacial and conotruncal anomaly face syndromes in which conotruncal defects are a cardinal feature. Previous studies suggest that a substantial number of patients with congenital heart disease have a 22q11 deletion. METHODS Two hundred fifty-one patients with conotruncal defects were prospectively enrolled into the study and screened for the presence of a 22q11 deletion. RESULTS Deletions were found in 50.0% with interrupted aortic arch (IAA), 34.5% of patients with truncus arteriosus (TA), and 15.9% with tetralogy of Fallot (TOF). Two of 6 patients with a posterior malalignment type ventricular septal defect (PMVSD) and only 1 of 20 patients with double outlet right ventricle were found to have a 22q11 deletion. None of the 45 patients with transposition of the great arteries had a deletion. The frequency of 22q11 deletions was higher in patients with anomalies of the pulmonary arteries, aortic arch or its major branches as compared to patients with a normal left aortic arch regardless of intracardiac anatomy. CONCLUSIONS A substantial proportion of patients with IAA, TA, TOF and PMVSD have a deletion of chromosome 22q11. Deletions are more common in patients with aortic arch or vessel anomalies. These results begin to define guidelines for deletion screening of patients with conotruncal defects.
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Affiliation(s)
- E Goldmuntz
- The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Medical Center, 19104, USA.
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38
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Abstract
The majority of patients with DiGeorge, velocardiofacial or conotruncal anomaly facial syndromes share a common genetic etiology, deletion of chromosomal region 22q11.2. This report describes a computational approach toward the identification and molecular characterization of a newly identified serine/threonine kinase from the minimal critical deleted region (MDGCR). A cosmid contig of the minimal critical region has been assembled and sequenced in its entirety. Database searches and computer analysis of one cosmid (111f11) for coding sequences identified two regions with high similarity to the mouse serine/threonine kinase, Tsk1. Our investigations demonstrate that one of these regions contains a testis-specific gene that undergoes differential splicing, while the other region is most likely a pseudogene. Northern blot analysis and cDNA cloning demonstrate that there is alternate processing of the 3'UTR without altering the conserved kinase domains within the open reading frame. Serine/threonine kinases can play a regulatory role and have been found to be expressed during early embryogenesis. Based on its position in the MDGCR and possible function, the gene reported here is a candidate for the features seen in the 22q11 deletion syndrome.
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Affiliation(s)
- E Goldmuntz
- The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, The Department of Pediatrics, 19104, USA.
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39
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Rychik J, Fogel MA, Donofrio MT, Goldmuntz E, Cohen MS, Spray TL, Jacobs ML. Comparison of patterns of pulmonary venous blood flow in the functional single ventricle heart after operative aortopulmonary shunt versus superior cavopulmonary shunt. Am J Cardiol 1997; 80:922-6. [PMID: 9382009 DOI: 10.1016/s0002-9149(97)00546-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In this study we investigated the patterns of pulmonary venous flow in children with functional single ventricles to obtain a better understanding of the determinants of transpulmonary blood flow. Sixty-eight patients with functional single ventricles and aortopulmonary shunt (n = 34, group I), or superior cavopulmonary connection (n = 34, group II) underwent transesophageal Doppler echocardiographic assessment of flow in the left upper pulmonary vein before undergoing the next stage of surgery. Twelve patients from group II also underwent simultaneous evaluation of superior vena caval flow. Biphasic forward pulmonary venous flow was noted in 62 patients in sinus rhythm (S wave in systole, D wave in diastole); in 6 patients with junctional rhythm, significant early systolic reversal of flow was present. Both the S- and D-wave velocity-time integrals (VTI) were greater in group I than in group II (S(VTI) 9.9 +/- 4.2 vs 8.0 +/- 2.6, p = 0.02; D(VTI) 8.0 +/- 3.5 vs 4.2 +/- 2.6, p <0.001). In both groups, pulmonary venous flow was predominantly systolic; however, the proportion of flow during ventricular systole was significantly greater in group II than in group I (S(VTI)/D(VTI) group II: 2.4 +/- 1.5; group I 1.4 +/- 0.5, p = 0.001; percent systolic fraction of pulmonary venous flow group II = 67%, group I = 56%, p <0.001). Analysis of superior vena caval flow in group II revealed a single predominant wave with onset at early systole and peak in late systole at a mean of 150 ms after the pulmonary venous S-wave peak. Our data suggest that ventricular systole (i.e., atrial relaxation, atrioventricular valve descent) asserts great influence on transpulmonary blood flow in the functional single ventricle.
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Affiliation(s)
- J Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia,and the University of Pennsylvania School of Medicine, 19104, USA
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40
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McDonald-McGinn DM, Driscoll DA, Emanuel BS, Goldmuntz E, Clark BJ, Solot C, Cohen M, Schultz P, LaRossa D, Randall P, Zackai EH. Detection of a 22q11.2 deletion in cardiac patients suggests a risk for velopharyngeal incompetence. Pediatrics 1997; 99:E9. [PMID: 9113966 DOI: 10.1542/peds.99.5.e9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Conotruncal cardiac anomalies frequently occur in patients with DiGeorge or velocardiofacial syndrome. Additionally, these patients may have overt or submucousal cleft palate, as well as velopharyngeal incompetence (VPI). Previous studies have demonstrated that the majority of these patients have a submicroscopic deletion of chromosome 22q11.2. We hypothesized that a subpopulation of newborns and children with congenital heart defects caused by a 22q11.2 deletion are at a high risk for having unrecognized palatal abnormalities. Therefore, we proposed to evaluate a cohort of patients with conotruncal cardiac malformations associated with a 22q11.2 deletion to determine the frequency of palatal abnormalities. METHODS We identified 14 deletion-positive patients with congenital cardiac defects who had no overt cleft palate. Of the 14 patients evaluated for the 22q11.2 deletion, 8 patients were recruited from a previous study looking for deletions among patients with isolated conotruncal cardiac anomalies. Informed consent was obtained in these cases. The remaining patients had the deletion study on a clinical basis, ie, conotruncal cardiac defect and an absent thymus, immunodeficiency, or minor dysmorphia appreciated by the clinical geneticist. These patients were evaluated by a plastic surgeon and speech pathologist looking for more subtle palatal anomalies such as a submucousal cleft palate, absence of the musculous uvuli, and VPI. Some patients underwent videofluoroscopy or nasendoscopy depending on their degree of symptoms and age. VPI was not ruled out until objective evaluation by a speech pathologist and plastic surgeon was obtained. In addition, the child had to be old enough to provide an adequate speech sample. RESULTS Of the 14 patients evaluated, 6 patients older than 1 year were found to have VPI. It is noteworthy that 3 of these patients were older than 5 years and had remained unrecognized until this study. The remaining 6 patients had inconclusive studies based on their age (younger than 26 months) and their inability to participate in adequate speech evaluations. Two of these patients, however, had histories of nasal regurgitation suggesting VPI and, in addition, had incomplete closure of the velopharyngeal mechanism during crying and swallowing observed during nasendoscopic examination-consistent with the diagnosis of VPI. Thus, 8 of 14 patients evaluated had evidence of VPI by history and examination. The remaining 6 patients will require further study when they are older before a definitive palatal diagnosis can be made. CONCLUSIONS A significant number of patients with a 22q11.2 deletion in a cardiac clinic may have unrecognized palatal problems. Recognition of such abnormalities will afford patients the opportunity for intervention as needed, ie, speech therapy and/or surgical intervention. Notably, two of our patients with findings suggesting VPI were infants and will, therefore, be afforded the opportunity for close follow-up and early intervention. Furthermore, three school-aged children had palatal abnormalities that were unrecognized until this study. Thus, we recommend 22q11.2 deletion studies in patients with conotruncal cardiac malformations, followed by extensive palatal and speech evaluations when a deletion is present.
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Affiliation(s)
- D M McDonald-McGinn
- Institute of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, PA 19104, USA
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41
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Abstract
The phenotype associated with a 22q11 deletion is highly variable and still under investigation. Of particular interest to cardiologists and cardiac developmental biologists is the finding that many patients with a 22q11 deletion have conotruncal cardiac defects and aortic arch anomalies. Despite the phenotypic variability, the vast majority of patients have a similar large deletion spanning approximately 2 megabases. The low-frequency repeated sequences at either end of the commonly deleted region may be responsible for the size of the deletion and account for the instability of this chromosomal region. Molecular studies of patients with the DGS/VCFS phenotype and unique chromosomal rearrangements have allowed a minimal critical region for the disease to be defined. Multiple genes have been identified in the minimal critical and larger deleted region. These genes are being investigated for their potential role in the disease pathophysiology by screening for mutations in nondeleted patients with the phenotype and by analysis of the pattern of expression in the developing mouse embryo. Further experimentation in the mouse mammalian model system will be of great utility to help determine whether haploinsufficiency of one critical gene or several genes within the DGCR results in the disease phenotype. Modifying factors, both genetic and environmental, must also be considered. Further investigation into the disease mechanism leading to the DGS/VCFS phenotype will hopefully further our understanding of cardiac development and disease.
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Affiliation(s)
- E Goldmuntz
- Division of Cardiology, University of Pennsylvania, Philadelphia, USA
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42
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Sun B, Wells J, Goldmuntz E, Silver P, Remmers EF, Wilder RL, Caspi RR. A simplified, competitive RT-PCR method for measuring rat IFN-gamma mRNA expression. J Immunol Methods 1996; 195:139-48. [PMID: 8814329 DOI: 10.1016/0022-1759(96)00099-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [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: 02/02/2023]
Abstract
We describe an adaptation of competitive RT-PCR to quantitate rat IFN-gamma mRNA expression. An IFN-gamma DNA mimic that shared the same primers and had an identical sequence to the target mRNA except for deletion of 66 nucleotides was created by a simple PCR amplification from target cDNA. To reduce variations of initial RNA concentrations, beta-actin cDNAs from each target RNA sample were normalized using the densitometric data. A known amount of pretitrated DNA competitor was then used to analyze the relative levels of target cDNA in different samples by PCR co-amplification. The amplification efficiency for both target and competitor remained constant throughout the PCR reaction, and the ratio of target to competitor PCR product remained proportional to the initial ratio of target to competitor. Relative mRNA levels among samples determined by this method were comparable to levels determined by northern blot analysis. They were also comparable to levels of IFN-gamma protein estimated by ELISA. We conclude that this method can be used to estimate the relative abundance of the target mRNA. This method is adaptable to quantitation of other cytokines and is particularly valuable if there are numerous samples or if the amount of initial mRNA is limited.
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Affiliation(s)
- B Sun
- Section of Immunoregulation, National Eye Institute, NIH, Bethesda, MD 20892, USA
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43
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Budarf ML, Eckman B, Michaud D, McDonald T, Gavigan S, Buetow KH, Tatsumura Y, Liu Z, Hilliard C, Driscoll D, Goldmuntz E, Meese E, Zwarthoff EC, Williams S, McDermid H, Dumanski JP, Biegel J, Bell CJ, Emanuel BS. Regional localization of over 300 loci on human chromosome 22 using a somatic cell hybrid mapping panel. Genomics 1996; 35:275-88. [PMID: 8661140 DOI: 10.1006/geno.1996.0358] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A somatic cell hybrid panel, consisting of 25 cell lines, has been developed to localize loci subregionally on chromosome 22. Over 300 markers in the form of STSs or hybridization probes have been assigned to one of 24 unique regions or "bins" using this panel. This ordered collection of markers will aid in the assembly of physical maps and contigs of chromosome 22 and assist in positional cloning of disease loci mapped to chromosome 22.
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Affiliation(s)
- M L Budarf
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, 19104, USA
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Goldmuntz E, Wang Z, Roe BA, Budarf ML. Cloning, genomic organization, and chromosomal localization of human citrate transport protein to the DiGeorge/velocardiofacial syndrome minimal critical region. Genomics 1996; 33:271-6. [PMID: 8660975 DOI: 10.1006/geno.1996.0191] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
DiGeorge syndrome (DGS) and velocardiofacial syndrome have been shown to be associated with microdeletions of chromosomal regions 22q11. More recently, patients with conotruncal anomaly face syndrome and some nonsyndromic patients with isolated forms of conotruncal cardiac defects have been found to have 22q11 microdeletions as well. The commonly deleted region, called the DiGeorge chromosomal region (DGCR), spans approximately 1.2 Mb and is estimated to contain at least 30 genes. We report a computational approach for gene identification that makes use of large-scale sequencing of cosmids from a contig spanning the DGCR. Using this methodology, we have mapped the human homolog of a rodent citrate transport protein to the DGCR. We have isolated a partial cDNA containing the complete open reading frame and have determined the genomic structure by comparing the genomic sequence from the cosmid to the sequence of the cDNA clone. Whether the citrate transport protein can be implicated in the biological etiology of DGS or other 22q11 microdeletion syndromes remains to be defined.
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Affiliation(s)
- E Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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45
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Wilson TA, Blethen SL, Vallone A, Alenick DS, Nolan P, Katz A, Amorillo TP, Goldmuntz E, Emanuel BS, Driscoll DA. DiGeorge anomaly with renal agenesis in infants of mothers with diabetes. Am J Med Genet 1993; 47:1078-82. [PMID: 8291527 DOI: 10.1002/ajmg.1320470729] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We report on 2 infants with the DiGeorge anomaly born to diabetic mothers treated with insulin. Both infants had unilateral renal agenesis. One of the mothers has manifestations suggestive of velo-cardio-facial syndrome (VCFS). Cytogenetic studies on both patients and the mother with apparent VCFS were normal. Molecular studies utilizing probes from the DiGeorge critical region did not demonstrate a 22q11 microdeletion in either patient or the mother with apparent VCFS. We conclude that maternal diabetes is a pathogenetic factor in the DiGeorge anomaly, and infants of diabetic mothers who have this anomaly should also be screened for renal agenesis.
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Affiliation(s)
- T A Wilson
- Department of Pediatrics, State University of New York, Stony Brook 11794-8111
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46
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Goldmuntz E, Driscoll D, Budarf ML, Zackai EH, McDonald-McGinn DM, Biegel JA, Emanuel BS. Microdeletions of chromosomal region 22q11 in patients with congenital conotruncal cardiac defects. J Med Genet 1993; 30:807-12. [PMID: 7901419 PMCID: PMC1016559 DOI: 10.1136/jmg.30.10.807] [Citation(s) in RCA: 162] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Congenital conotruncal cardiac defects occur with increased frequency in patients with DiGeorge syndrome (DGS). Previous studies have shown that the majority of patients with DGS or velocardiofacial syndrome (VCFS) have a microdeletion within chromosomal region 22q11. We hypothesised that patients with conotruncal defects who were not diagnosed with DGS or VCFS would also have 22q11 deletions. Seventeen non-syndromic patients with one of three types of conotruncal defects most commonly seen in DGS or VCFS were evaluated for a 22q11 deletion. DNA probes from within the DiGeorge critical region were used. Heterozygosity at a locus was assessed using restriction fragment length polymorphisms. Copy number was determined by dosage analysis using Southern blot analysis of fluorescence in situ hybridisation of metaphase spreads. Five of 17 patients were shown to have a 22q11 deletion when evaluated by dosage analysis. This study shows a genetic contribution to the development of some conotruncal cardiac malformations and alters knowledge regarding the risk of heritability of these defects in certain cases.
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Affiliation(s)
- E Goldmuntz
- Department of Pediatrics, Children's Hospital of Philadelphia, PA 19104
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Sano H, Engleka K, Mathern P, Hla T, Crofford LJ, Remmers EF, Jelsema CL, Goldmuntz E, Maciag T, Wilder RL. Coexpression of phosphotyrosine-containing proteins, platelet-derived growth factor-B, and fibroblast growth factor-1 in situ in synovial tissues of patients with rheumatoid arthritis and Lewis rats with adjuvant or streptococcal cell wall arthritis. J Clin Invest 1993; 91:553-65. [PMID: 7679410 PMCID: PMC287978 DOI: 10.1172/jci116235] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Fibroblast growth factor (FGF)-1 and PDGF-B-like factors have been implicated in the pathobiology of RA and animal models of this disease. Since the receptors for FGF-1 and PDGF are tyrosine kinases, we examined the expression of tyrosine phosphorylated proteins (phosphotyrosine, P-Tyr) in synovial tissues from patients with RA and osteoarthritis (OA), and rats with streptococcal cell wall (SCW) and adjuvant arthritis (AA). Synovia from patients with RA and LEW/N rats with SCW and AA arthritis, in contrast to controls, stained intensely with anti-P-Tyr antibody. The staining colocalized with PDGF-B and FGF-1 staining. Comparative immunoblot analysis showed markedly enhanced expression of a 45-kD P-Tyr protein in the inflamed synovia. Treatment with physiological concentrations of dexamethasone suppressed both arthritis and P-Tyr expression in AA. P-Tyr was only transiently expressed in athymic nude Lewis rats and was not detected in relatively arthritis-resistant F344/N rats. These data suggest that (a) FGF-1 and PDGF-B-like factors are upregulated and may induce tyrosine phosphorylation of proteins in vivo in inflammatory joint diseases, (b) persistent high level P-Tyr expression is T lymphocyte dependent, correlates with disease severity, and is strain dependent in rats, (c) corticosteroids, in physiological concentrations, downregulate P-Tyr expression in these lesions.
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Affiliation(s)
- H Sano
- Arthritis and Rheumatism Branch, National Institute of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health, Bethesda, Maryland 20892
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