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Aripova N, Thiele GM, Duryee MJ, Hunter CD, Yang Y, Roul P, Ascherman DP, Matson SM, Kunkel G, Cannon GW, Wysham KD, Kerr GS, Monach PA, Baker JF, Poole JA, Mikuls TR, England BR. Antibodies to Malondialdehyde-Acetaldehyde Adduct Are Associated with Prevalent and Incident Rheumatoid Arthritis-Associated Interstitial Lung Disease in U.S. Veterans. Arthritis Rheumatol 2024. [PMID: 38766737 DOI: 10.1002/art.42916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To determine the associations of protein-specific anti-malondialdehyde acetaldehyde (MAA) antibodies with prevalent and incident rheumatoid arthritis-interstitial lung disease (RA-ILD). METHODS Within a multicenter, prospective cohort of U.S. Veterans with RA, RA-ILD was validated by medical record review of clinical diagnoses, chest imaging, and pathology. Serum antibodies to MAA-albumin, MAA-collagen, MAA-fibrinogen, and MAA-vimentin (IgA, IgM, and IgG) were measured by a standardized ELISA. Associations of anti-MAA antibodies with prevalent and incident RA-ILD were assessed using multivariable regression models adjusting for established RA-ILD risk factors. RESULTS Among 2,739 RA participants (88% male, mean age 64 years), there were 114 prevalent and 136 incident RA-ILD cases (average time to diagnosis: 6.6 years). Higher IgM anti-MAA-collagen (per 1 SD: aOR 1.28 [1.02-1.61]), IgA anti-MAA-fibrinogen (aOR 1.48 [1.14-1.92]), and IgA (aOR 1.78 [1.34-2.37]) and IgG (aOR 1.48 [1.14-1.92]) anti-MAA-vimentin antibodies were associated with prevalent RA-ILD. In incident analyses, higher IgA (per 1 SD: aHR 1.40 [1.11-1.76]) and IgM (aHR 1.29 [1.04-1.60]) anti-MAA-albumin antibody concentrations were associated with increased ILD risk. Participants with IgA (aHR 2.13 [1.16-3.90]) or IgM (aHR 1.98 [1.08-3.64]) anti-MAA-albumin antibody concentrations in the highest quartile had an approximate 2-fold increased risk of incident RA-ILD. Across all isotypes, anti-MAA-fibrinogen, -collagen, and -vimentin antibodies were not significantly associated with incident RA-ILD. CONCLUSIONS Protein-specific anti-MAA antibodies to collagen, fibrinogen, and vimentin were associated with prevalent RA-ILD. IgA and IgM anti-MAA-albumin antibodies were associated with a higher risk of incident RA-ILD. These findings suggest that MAA-modifications and resultant immune responses may contribute to RA-ILD pathogenesis.
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Affiliation(s)
- Nozima Aripova
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Geoffrey M Thiele
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Michael J Duryee
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Carlos D Hunter
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Punyasha Roul
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Dana P Ascherman
- Division of Rheumatology, Pittsburgh VA and University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Scott M Matson
- Division of Pulmonary, Critical Care and Sleep, University of Kansas, Kansas City, KS, USA
| | - Gary Kunkel
- Division of Rheumatology, University of Utah and VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Grant W Cannon
- Division of Rheumatology, University of Utah and VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Katherine D Wysham
- Division of Rheumatology, VA Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - Gail S Kerr
- Division of Rheumatology, Washington D.C. Veterans Affairs Medical Center, Georgetown and Howard University Hospitals, Washington, DC, USA
| | | | - Joshua F Baker
- Division of Rheumatology, Corporal Michael J. Crescenz VA and University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jill A Poole
- Division of Allergy & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ted R Mikuls
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Bryant R England
- Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
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Trottier CA, La J, Li L, Fillmore NR, Monach PA, Doron S, Branch-Elliman W. Longitudinal trends in 30-day mortality attributable to SARS-CoV-2 among vaccinated and unvaccinated US veteran patients. Infect Control Hosp Epidemiol 2024; 45:393-395. [PMID: 37960943 DOI: 10.1017/ice.2023.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Affiliation(s)
- Caitlin A Trottier
- Division of Infectious Diseases and Geographic Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jennifer La
- Veterans' Affairs (VA) Boston Cooperative Studies Program, Boston, Massachusetts
| | - Lucy Li
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nathanael R Fillmore
- Veterans' Affairs (VA) Boston Cooperative Studies Program, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul A Monach
- Veterans' Affairs (VA) Boston Cooperative Studies Program, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Shira Doron
- Division of Infectious Diseases and Geographic Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Westyn Branch-Elliman
- Veterans' Affairs (VA) Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Infectious Diseases Section, VA Boston Healthcare System, Boston, Massachusetts
- VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts
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Karadag O, Bolek EC, Ayan G, Mohammad AJ, Grayson PC, Pagnoux C, Martín-Nares E, Monti S, Abe Y, Alberici F, Alibaz-Oner F, Cuthbertson D, Dagna L, Direskeneli H, Khalidi NA, Koening C, Langford CA, McAlear CA, Monach PA, Moroni L, Padoan R, Seo P, Warrington KJ, Hocevar A, Hinojosa-Azaola A, Furuta S, Emmi G, Ozen S, Jayne D, Merkel PA. Clinical Characteristics and Outcomes of Polyarteritis Nodosa: An International Study. Arthritis Rheumatol 2024. [PMID: 38343337 DOI: 10.1002/art.42817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/30/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE We describe the demographics, clinical features, disease course, and survival of polyarteritis nodosa (PAN) through an international collaboration (GLOBAL-PAN). METHODS Patients with PAN were recruited between 1990 and 2020 from observational cohorts of nine countries across Europe, Japan, and North America. Eligibility was retrospectively defined using the European Medicines Agency classification algorithm. Patients with PAN related to hepatitis B virus (n = 12) and two monogenic diseases mimicking PAN, deficiency of adenosine deaminase 2 enzyme (n = 16) or familial Mediterranean fever (n = 11), were excluded. Data regarding organ involvement, relapse, disease-related damage, and survival were analyzed. RESULTS Three hundred fifty-eight patients (female:male ratio 174:184), including those with systemic PAN (sPAN, n = 282) and cutaneous PAN (n = 76), were included. Twenty-five were pediatric onset. Mean ± SD age at diagnosis was 44.3 ± 18.1 years. Constitutional symptoms (71.5%), cutaneous involvement (70.5%), musculoskeletal findings (69.1%), and neurologic features (48.0%) were common manifestations. Among patients with sPAN, gastrointestinal involvement and proteinuria over 400 mg/day were reported in 52.2% and 11.2%, respectively. During a median (interquartile range) 59.6 (99.5) months of follow-up, relapse occurred in 48.5% of patients. One, 5- and 10-year survival rates for sPAN were 97.1%, 94.0%, and 89.0%, respectively. Predictors of death for sPAN included age ≥65 years at diagnosis, serum creatinine at diagnosis >140 μmol/L, gastrointestinal manifestations, and central nervous system (CNS) involvement. CONCLUSION The spectrum of PAN remains a complex, multifaceted disease. Relapse is common. Age ≥65 years and serum creatinine >140 μmol/L at diagnosis, as well as gastrointestinal and CNS involvement, are independent predictors of death in sPAN.
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Affiliation(s)
| | | | | | - Aladdin J Mohammad
- Skåne University Hospital, Lund, Sweden, and University of Cambridge, Cambridge, UK
| | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | - Eduardo Martín-Nares
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Yoshiyuki Abe
- Juntendo University School of Medicine, Tokyo, Japan
| | - Federico Alberici
- University of Brescia and Spedali Civili Hospital, Azienda Socio Sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | | | | | - Lorenzo Dagna
- IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | | | | | | | - Luca Moroni
- IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | | | - Phillip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | - Alojzija Hocevar
- University Medical Centre Ljubljana and University of Ljubljana, Ljubljana, Slovenia
| | - Andrea Hinojosa-Azaola
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Seza Ozen
- Hacettepe University, Ankara, Turkey
| | - David Jayne
- University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
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Anand ST, Vo AD, La J, Do NV, Fillmore NR, Brophy M, Branch-Elliman W, Monach PA. Severe COVID-19 in Vaccinated Adults With Hematologic Cancers in the Veterans Health Administration. JAMA Netw Open 2024; 7:e240288. [PMID: 38393725 PMCID: PMC10891464 DOI: 10.1001/jamanetworkopen.2024.0288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/04/2024] [Indexed: 02/25/2024] Open
Abstract
Importance With SARS-CoV-2 transforming into an endemic disease and with antiviral treatments available, it is important to establish which patients remain at risk of severe COVID-19 despite vaccination. Objective To quantify the associations of clinical and demographic variables with odds of severe COVID-19 among patients with hematologic cancers. Design, Setting, and Participants This case-control study included all patients with hematologic malignant neoplasms in the national Veterans Health Administration (VHA) who had documented SARS-CoV-2 infection after vaccination. Groups of patients with severe (cases) vs nonsevere (controls) COVID-19 were compared. Data were collected between January 1, 2020, and April 5, 2023, with data on infection collected between January 1, 2021, and September 30, 2022. All patients with diagnostic codes for hematologic malignant neoplasms who had documented vaccination followed by documented SARS-CoV-2 infection and for whom disease severity could be assessed were included. Data were analyzed from July 28 to December 30, 2023. Exposures Clinical (comorbidities, predominant viral variant, treatment for malignant neoplasm, booster vaccination, and antiviral treatment) and demographic (age and sex) variables shown in prior studies to be associated with higher or lower rates of severe COVID-19. Comorbidities included Alzheimer disease or dementia, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, heart failure, and peripheral vascular disease. Main Outcome and Measures The main outcome was severe COVID-19 compared with nonsevere SARS-CoV-2 infection. Severe COVID-19 was defined as death within 28 days, mechanical ventilation, or hospitalization with use of dexamethasone or evidence of hypoxemia or use of supplemental oxygen. Multivariable logistic regression was used to estimate the associations of demographic and clinical variables with the odds of severe COVID-19, expressed as adjusted odds ratios (aORs) with 95% CIs. Results Among 6122 patients (5844 [95.5%] male, mean [SD] age, 70.89 [11.57] years), 1301 (21.3%) had severe COVID-19. Age (aOR per 1-year increase, 1.05; 95% CI, 1.04-1.06), treatment with antineoplastic or immune-suppressive drugs (eg, in combination with glucocorticoids: aOR, 2.32; 95% CI, 1.93-2.80), and comorbidities (aOR per comorbidity, 1.35; 95% CI, 1.29-1.43) were associated with higher odds of severe disease, whereas booster vaccination was associated with lower odds (aOR, 0.73; 95% CI, 0.62-0.86). After oral antiviral drugs became widely used in March 2022, 20 of 538 patients (3.7%) with SARS-CoV-2 infection during this period had progression to severe COVID-19. Conclusions and Relevance In this case-control study of patients with hematologic cancers, odds of severe COVID-19 remained high through mid-2022 despite vaccination, especially in patients requiring treatment.
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Affiliation(s)
- Sonia T. Anand
- VA Boston Cooperative Studies Program, Boston, Massachusetts
| | - Austin D. Vo
- VA Boston Cooperative Studies Program, Boston, Massachusetts
| | - Jennifer La
- VA Boston Cooperative Studies Program, Boston, Massachusetts
| | - Nhan V. Do
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
| | - Nathanael R. Fillmore
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mary Brophy
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
| | - Westyn Branch-Elliman
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts
| | - Paul A. Monach
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Anand ST, Vo AD, La J, Brophy M, Do NV, Fillmore NR, Branch-Elliman W, Monach PA. Risk of severe coronavirus disease 2019 despite vaccination in patients requiring treatment with immune-suppressive drugs: A nationwide cohort study of US Veterans. Transpl Infect Dis 2024; 26:e14168. [PMID: 37966134 DOI: 10.1111/tid.14168] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/29/2023] [Accepted: 10/01/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Patients taking immune-suppressive drugs are at increased risk of severe coronavirus disease 2019 (COVID-19), not fully ameliorated by vaccination. We assessed the contributions of clinical and demographic factors to the risk of severe disease despite vaccination in patients taking immune-suppressive medications for solid organ transplantation (SOT), rheumatoid arthritis (RA), inflammatory bowel disease (IBD), or psoriasis. METHODS Veterans Health Administration electronic health records were used to identify patients diagnosed with RA, IBD, psoriasis, or SOT who had been vaccinated against severe acute respiratory syndrome coronavirus 2, were subsequently infected, and had received immune-suppressive drugs within 3 months before infection. The association of severe (defined as hypoxemia, mechanical ventilation, dexamethasone use, or death) versus non-severe COVID-19 with the use of immune-suppressive and antiviral drugs and clinical covariates was assessed by multivariable logistic regression. RESULTS Severe COVID-19 was more common in patients with SOT (230/1011, 22.7%) than RA (173/1355, 12.8%), IBD (51/742, 6.9%), or psoriasis (82/1125, 7.3%). Age was strongly associated with severe COVID-19, adjusted odds ratio (aOR) of 1.04 (CI 1.03-1.05) per year. Comorbidities indicating chronic brain, heart, lung, or kidney damage were also associated with severity, aOR 1.35-2.38. The use of glucocorticoids was associated with increased risk (aOR 1.66, CI 1.39-2.18). Treatment with antivirals was associated with reduced severity, for example, aOR 0.28 (CI 0.13-0.62) for nirmatrelvir/ritonavir. CONCLUSION The risk of severe COVID-19 despite vaccination is substantial in patients taking immune-suppressive drugs, more so in patients with SOT than in patients with inflammatory diseases. Age and severe comorbidities contribute to risk, as in the general population. Oral antivirals were very beneficial but not widely used.
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Affiliation(s)
- Sonia T Anand
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Austin D Vo
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Jennifer La
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Mary Brophy
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Nhan V Do
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Nathanael R Fillmore
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Westyn Branch-Elliman
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA
| | - Paul A Monach
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Monach PA, Anand ST, Fillmore NR, La J, Branch-Elliman W. Underuse of Antiviral Drugs to Prevent Progression to Severe COVID-19 - Veterans Health Administration, March-September 2022. MMWR Morb Mortal Wkly Rep 2024; 73:57-61. [PMID: 38271286 PMCID: PMC10824546 DOI: 10.15585/mmwr.mm7303a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Antiviral drugs reduce the rate of progression to severe COVID-19 when given to patients with mild-to-moderate disease within 5 days of symptom onset. Despite being recommended for patients at high risk for progression to severe COVID-19 because of age or chronic conditions, reported antiviral use among the general adult population has been ≤35%. To ascertain reasons for underuse of antiviral medications to prevent severe COVID-19 and propose interventions accordingly, a detailed review was conducted of 110 Veterans Health Administration patients with mild-to-moderate infection at high risk for progression because of underlying conditions (organ transplantation or hematologic malignancies) who did not receive an antiviral drug. Among these 110 patients, all of whom had received COVID-19 vaccine, 22 (20.0%) were offered treatment but declined, and 88 (80.0%) were not offered treatment. Among the 88 patients not offered treatment, provider reasons included symptom duration of >5 days (22.7%), concern about possible drug interactions (5.7%), or absence of symptoms (22.7%); however, among nearly one half (43 of 88; 48.9%) of these patients, no reason other than mild symptoms was given. Among 24 (55.8%) of those 43 patients, follow-up was limited to telephone calls to report test results and inquire about symptom evolution, with no documentation of treatment being offered. These findings suggest that education of patients, providers, and medical personnel tasked with follow-up calls, combined with advance planning in the event of a positive test result, might improve the rate of recommended antiviral medication use to prevent severe COVID-19-associated illness, including death.
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Monach PA. Complement. Arthritis Rheumatol 2024; 76:1-8. [PMID: 37551641 DOI: 10.1002/art.42671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
The role of complement in human autoimmune, inflammatory, and infectious diseases is reviewed, focusing on clinical applicability. A typical case is presented in which serum testing for C3 and C4 is performed to help assess a syndrome with a broad differential diagnosis. The review includes a discussion of complement deficiency states, consumption of complement by diseases characterized by immune-complex formation and deposition, usefulness and interpretation of laboratory tests for complement, and development of drugs targeting specific components of the complement pathway for a growing number of indications.
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Affiliation(s)
- Paul A Monach
- VA Boston Healthcare System and Harvard Medical School, Boston, Massachusetts
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Bloom JL, Pickett K, Silveira L, Fuhlbrigge RC, Cuthbertson D, Akuthota P, Corbridge TC, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Pagnoux C, Rhee RL, Seo P, Silver J, Specks U, Warrington KJ, Wechsler ME, Merkel PA. The Association Between Age at Diagnosis and Disease Characteristics and Damage in Patients With ANCA-Associated Vasculitis. Arthritis Rheumatol 2023; 75:2216-2227. [PMID: 37433067 PMCID: PMC10782596 DOI: 10.1002/art.42651] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE This study examined the relationship between age at diagnosis and disease characteristics and damage in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS Analysis of a prospective longitudinal cohort of patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA) in the Vasculitis Clinical Research Consortium (2013-2021). Disease cohorts were divided by age at diagnosis (years): children (<18), young adults (18-40), middle-aged adults (41-65), and older adults (>65). Data included demographics, ANCA type, clinical characteristics, Vasculitis Damage Index (VDI) scores, ANCA Vasculitis Index of Damage (AVID) scores, and novel disease-specific and non-disease-specific damage scores built from VDI and AVID items. RESULTS Analysis included data from 1020 patients with GPA/MPA and 357 with EGPA. Female predominance in GPA/MPA decreased with age at diagnosis. AAV in childhood was more often GPA and proteinase 3-ANCA positive. Children with GPA/MPA experienced more subglottic stenosis and alveolar hemorrhage; children and young adults with EGPA experienced more alveolar hemorrhage, need for intubation, and gastrointestinal involvement. Older adults (GPA/MPA) had more neurologic manifestations. After adjusting for disease duration, medications, tobacco, and ANCA, all damage scores increased with age at diagnosis for GPA/MPA (P < 0.001) except the disease-specific damage score, which did not differ (P = 0.44). For EGPA, VDI scores increased with age at diagnosis (P < 0.009), whereas all other scores were not significantly different. CONCLUSION Age at diagnosis is associated with clinical characteristics in AAV. Although VDI and AVID scores increase with age at diagnosis, this is driven by non-disease-specific damage items.
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Affiliation(s)
| | | | | | | | | | | | | | - Nader A. Khalidi
- St. Joseph’s Healthcare Hamilton, McMaster University, Ontario, Canada
| | | | | | | | | | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, MD, USA
| | - Jared Silver
- US Medical Affairs - Respiratory GSK, Durham, NC, USA
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Trottier C, La J, Li LL, Alsoubani M, Vo AD, Fillmore NR, Branch-Elliman W, Doron S, Monach PA. Maintaining the Utility of Coronavirus Disease 2019 Pandemic Severity Surveillance: Evaluation of Trends in Attributable Deaths and Development and Validation of a Measurement Tool. Clin Infect Dis 2023; 77:1247-1256. [PMID: 37348870 PMCID: PMC10640692 DOI: 10.1093/cid/ciad381] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Death within a specified time window following a positive SARS-CoV-2 test is used by some agencies for attributing death to COVID-19. With Omicron variants, widespread immunity, and asymptomatic screening, there is cause to re-evaluate COVID-19 death attribution methods and develop tools to improve case ascertainment. METHODS All patients who died following microbiologically confirmed SARS-CoV-2 in the Veterans Health Administration (VA) and at Tufts Medical Center (TMC) were identified. Records of selected vaccinated VA patients with positive tests in 2022, and of all TMC patients with positive tests in 2021-2022, were manually reviewed to classify deaths as COVID-19-related (either directly caused by or contributed to), focused on deaths within 30 days. Logistic regression was used to develop and validate a surveillance model for identifying deaths in which COVID-19 was causal or contributory. RESULTS Among vaccinated VA patients who died ≤30 days after a positive test in January-February 2022, death was COVID-19-related in 103/150 cases (69%) (55% causal, 14% contributory). In June-August 2022, death was COVID-19-related in 70/150 cases (47%) (22% causal, 25% contributory). Similar results were seen among the 71 patients who died at TMC. A model including hypoxemia, remdesivir, and anti-inflammatory drugs had positive and negative predictive values of 0.82-0.95 and 0.64-0.83, respectively. CONCLUSIONS By mid-2022, "death within 30 days" did not provide an accurate estimate of COVID-19-related death in 2 US healthcare systems with routine admission screening. Hypoxemia and use of antiviral and anti-inflammatory drugs-variables feasible for reporting to public health agencies-would improve classification of death as COVID-19-related.
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Affiliation(s)
- Caitlin Trottier
- Division of Infectious Diseases and Geographic Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jennifer La
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Lucy L Li
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Majd Alsoubani
- Division of Infectious Diseases and Geographic Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Austin D Vo
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Nathanael R Fillmore
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Westyn Branch-Elliman
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infectious Diseases Section, VA Boston Healthcare System, Boston, Massachusetts, USA
- VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA
- VA National Artificial Intelligence Institute, Washington, DC, USA
| | - Shira Doron
- Division of Infectious Diseases and Geographic Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paul A Monach
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts, USA
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Almaani S, Song H, Suthanthira M, Toy C, Fussner LA, Meara A, Nagaraja H, Cuthbertson D, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Warrington KJ, Monach PA, Merkel PA, Rovin B, Birmingham D. Urine and Plasma Complement Ba Levels During Disease Flares in Patients With Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis. Kidney Int Rep 2023; 8:2421-2427. [PMID: 38025219 PMCID: PMC10658281 DOI: 10.1016/j.ekir.2023.08.017] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Although the alternative complement pathway has been implicated in the pathogenesis of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV), the specific nature of its involvement is unclear. This study measured levels of urine and plasma complement fragment Ba at multiple time points in a group of patients with AAV. Methods The complement fragment Ba was measured by enzyme-linked immunosorbent assay in serial urine and plasma samples from 21 patients with AAV who developed a renal flare, 19 who developed a nonrenal flare, and 20 in long-term remission. Urine Ba levels were corrected for urine creatinine concentration. Changes in Ba levels were modeled using mixed linear-effect models. A logistic regression model was fit to predict a renal flare using Ba levels at the time of flare versus the nonrenal flare and long-term remission groups. Results Data from 60 patients with AAV were used for this analysis; 53% were male, 93% were White, and 74% had antiproteinase3-ANCA. Urine Ba levels increased at renal flare (P < 0.001) but remained stable during a nonrenal flare or long-term remission. Plasma Ba levels were stable over time in all groups. Urine Ba levels predicted a renal flare with an area under the curve of 0.76 (P < 0.001), with a cutoff of 12.53 ng/mg urine creatinine yielding a sensitivity of 76.2% and a specificity of 68.4%. Conclusion Urine Ba levels, but not plasma Ba levels, are increased at the time of a renal flare in AAV, suggesting intrarenal complement activation and highlighting the potential use of this biomarker for surveillance of active renal vasculitis.
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Affiliation(s)
- Salem Almaani
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Huijuan Song
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Meshora Suthanthira
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher Toy
- Department of Soil and Crop Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Lynn A. Fussner
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexa Meara
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Haikady Nagaraja
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, Florida, USA
| | - Nader A. Khalidi
- Division of Rheumatology, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | | | | | - Carol A. McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Larry W. Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, Colorado, USA
| | - Christian Pagnoux
- Division of Rheumatology, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Ulrich Specks
- Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Antoine G. Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth J. Warrington
- Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul A. Monach
- Veteran’s Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Peter A. Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brad Rovin
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Birmingham
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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11
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Michailidou D, Grayson PC, Hermanson P, Chapa JAG, Cuthbertson D, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Sreih AG, Warrington KJ, Monach PA, Merkel PA, Lood C. Mitochondrial-mediated inflammation and platelet activation in giant cell arteritis. Clin Immunol 2023; 255:109746. [PMID: 37625669 PMCID: PMC10543636 DOI: 10.1016/j.clim.2023.109746] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
Markers of extracellular mitochondria are present in giant cell arteritis (GCA) patients. However, their role in promoting inflammation and platelet activation is no known. To investigate this, isolated mitochondria were opsonized with plasma from GCA patients or healthy individuals and incubated with peripheral blood mononuclear cells (PBMCs) or platelets and assessed for inflammatory cytokine production and platelet activation. Plasma from GCA patients promoted increased mitochondrial-mediated cytokine production by PBMCs as compared to healthy controls (p < 0.05). Mitochondria opsonized with plasma factors from patients with GCA induced higher platelet activation as compared to mitochondria opsonized with plasma factors from healthy individuals (p = 0.0015). Platelet levels of P-selectin were associated with disease activity in GCA (r = 0.34, p = 0.01). GCA patients have impaired ability to regulate the clearance of extracellular mitochondria, possibly contributing to excessive inflammation and platelet activation. Targeting key drivers of mitochondrial extrusion and/or their clearance could lead to new therapeutic interventions in GCA.
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Affiliation(s)
- Despina Michailidou
- Division of Rheumatology, University of Washington, Seattle, WA, USA; Division of Rheumatology, University of Oklahoma Health Sciences Center, Oklahoma, OK, USA; Division of Rheumatology, Oklahoma City VA Health Care System, Oklahoma, OK, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Payton Hermanson
- Division of Rheumatology, University of Washington, Seattle, WA, USA
| | | | - David Cuthbertson
- Health Informatics Institute, University of South Florida, South Florida, FL, USA
| | - Nader A Khalidi
- Division of Rheumatology, Mc Master University, Ontario, Canada
| | | | | | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Larry W Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, CO, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Lood
- Division of Rheumatology, University of Washington, Seattle, WA, USA.
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12
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Monach PA. The Future of Vasculitis: A Manifesto. Rheum Dis Clin North Am 2023; 49:713-729. [PMID: 37331742 DOI: 10.1016/j.rdc.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Predictions for a general path forward in vasculitis care and research are provided based on advances made in the past 20 years. Prospects for advances in translational research with potential to improve care are highlighted, including identification of hemato-inflammatory diseases, autoantigens, disease mechanisms in animal models, and biomarkers. A list of active randomized trials is provided, and areas of potential paradigm shifts in care are highlighted. The importance of patient involvement and international collaboration is noted, and a plea is made for innovative trial designs that would improve access of patients to trials and to clinical experts at referral centers.
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Affiliation(s)
- Paul A Monach
- Rheumatology Section, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 01230, USA.
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13
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Junek ML, Zhao L, Garner S, Cuthbertson D, Pagnoux C, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Rhee RL, Seo P, Specks U, Sreih AG, Warrington K, Wechsler ME, Merkel PA, Khalidi NA. Ocular manifestations of ANCA-associated vasculitis. Rheumatology (Oxford) 2023; 62:2517-2524. [PMID: 36440847 PMCID: PMC10321114 DOI: 10.1093/rheumatology/keac663] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 09/25/2022] [Accepted: 11/12/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) is a group of multisystem diseases that can have several ocular manifestations. There are published data on ocular manifestations of granulomatosis with polyangiitis (GPA), but few for eosinophilic granulomatosis with polyangiitis (EGPA) or microscopic polyangiitis (MPA). There is little information concerning chronicity, complications, and association with other cranial manifestations of AAV. METHODS This study retrospectively analysed longitudinal multicentre cohorts of individuals with AAV followed between 2006 and 2022. Data included diagnosis, demographics, cranial manifestations of disease, presence of manifestations at onset of disease and/or follow-up, and ocular complications of disease. Univariate and multivariable logistic regression analysis assessed associations across disease manifestations. RESULTS Data from 1441 patients were analysed, including 395 with EGPA, 876 with GPA, and 170 with MPA. Ocular manifestations were seen within 23.1% of patients: 39 (9.9%) with EGPA, 287 (32.7%) with GPA, and 12 (7.1%) with MPA at any time in the disease course. There were more ocular manifestations at onset (n = 224) than during follow-up (n = 120). The most common disease-related manifestations were conjunctivitis/episcleritis and scleritis. In multivariable analysis, dacryocystitis, lacrimal duct obstruction, and retro-orbital disease were associated with sinonasal manifestations of GPA; ocular manifestations were associated with hearing loss in MPA. The most common ocular complications and/or damage seen were cataracts (n = 168) and visual impairment (n = 195). CONCLUSION Ocular manifestations occur in all forms of AAV, especially in GPA. Clinicians should be mindful of the wide spectrum of ocular disease in AAV, caused by active vasculitis, disease-associated damage, and toxicities of therapy.
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Affiliation(s)
- Mats L Junek
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | - Lily Zhao
- Division of Ophthalmology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | - Stephanie Garner
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | - Paul A Monach
- Rheumatology Section, Veteran’s Affairs Boston Healthcare System, Boston, MA, USA
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | - Nader A Khalidi
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
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14
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Doron S, Monach PA, Brown CM, Branch-Elliman W. Improving COVID-19 Disease Severity Surveillance Measures: Statewide Implementation Experience. Ann Intern Med 2023. [PMID: 37186921 DOI: 10.7326/m23-0618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 05/17/2023] Open
Abstract
Measurement of the burden of COVID-19 on U.S. hospitals has been an important element of the public health response to the pandemic. However, because of variation in testing density and policies, the metric is not standardized across facilities. Two types of burdens exist, one related to the infection control measures that patients who test positive for SARS-CoV-2 require and one from the care of severely ill patients receiving treatment of COVID-19. With rising population immunity from vaccination and infection, as well as the availability of therapeutics, severity of illness has declined. Prior research showed that dexamethasone administration was highly correlated with other disease severity metrics and sensitive to the changing epidemiology associated with the emergence of immune-evasive variants. On 10 January 2022, the Massachusetts Department of Public Health began requiring hospitals to expand surveillance to include reports of both the total number of "COVID-19 hospitalizations" daily and the number of inpatients who received dexamethasone at any point during their hospital stay. All 68 acute care hospitals in Massachusetts submitted COVID-19 hospitalization and dexamethasone data daily to the Massachusetts Department of Public Health over a 1-year period. A total of 44 196 COVID-19 hospitalizations were recorded during 10 January 2022 to 9 January 2023, of which 34% were associated with dexamethasone administration. The proportion of patients hospitalized with COVID-19 who had received dexamethasone was 49.6% during the first month of surveillance and decreased to a monthly average of approximately 33% by April 2022, where it has remained since (range, 28.7% to 33%). Adding a single data element to mandated reporting to estimate the frequency of severe COVID-19 in hospitalized patients was feasible and provided actionable information for health authorities and policy makers. Updates to surveillance methods are necessary to match data collection with public health response needs.
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Affiliation(s)
- Shira Doron
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts (S.D.)
| | - Paul A Monach
- Rheumatology Section, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts (P.A.M.)
| | - Catherine M Brown
- Massachusetts Department of Public Health, Boston, Massachusetts (C.M.B.)
| | - Westyn Branch-Elliman
- Harvard Medical School; Department of Medicine, Veterans Affairs Boston Healthcare System; and Veterans Affairs Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts (W.B.)
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15
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Moura MC, Thompson GE, Nelson DR, Fussner LA, Hummel AM, Jenne DE, Emerling D, Fervenza FC, Kallenberg CGM, Langford CA, McCune WJ, Merkel PA, Monach PA, Seo P, Spiera RF, St. Clair EW, Ytterberg SR, Stone JH, Robinson WH, Specks U. Activation of a Latent Epitope Causing Differential Binding of Antineutrophil Cytoplasmic Antibodies to Proteinase 3. Arthritis Rheumatol 2023; 75:748-759. [PMID: 36515151 PMCID: PMC10191989 DOI: 10.1002/art.42418] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/17/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Proteinase 3 (PR3) is the major antigen for antineutrophil cytoplasmic antibodies (ANCAs) in the systemic autoimmune vasculitis, granulomatosis with polyangiitis (GPA). PR3-targeting ANCAs (PR3-ANCAs) recognize different epitopes on PR3. This study was undertaken to study the effect of mutations on PR3 antigenicity. METHODS The recombinant PR3 variants, iPR3 (clinically used to detect PR3-ANCAs) and iHm5 (containing 3 point mutations in epitopes 1 and 5 generated for epitope mapping studies) immunoassays and serum samples from patients enrolled in ANCA-associated vasculitis (AAV) trials were used to screen for differential PR3-ANCA binding. A patient-derived monoclonal ANCA 518 (moANCA518) that selectively binds to iHm5 within the mutation-free epitope 3 and is distant from the point mutations of iHm5 was used as a gauge for remote epitope activation. Selective binding was determined using inhibition experiments. RESULTS Rather than reduced binding of PR3-ANCAs to iHm5, we found substantially increased binding of the majority of PR3-ANCAs to iHm5 compared to iPR3. This differential binding of PR3-ANCA to iHm5 is similar to the selective moANCA518 binding to iHm5. Binding of iPR3 to monoclonal antibody MCPR3-2 also induced recognition by moANCA518. CONCLUSION The preferential binding of PR3-ANCAs from patients, such as the selective binding of moANCA518 to iHm5, is conferred by increased antigenicity of epitope 3 on iHm5. This can also be induced on iPR3 when captured by monoclonal antibody MCPR2. This previously unrecognized characteristic of PR3-ANCA interactions with its target antigen has implications for studying antibody-mediated autoimmune diseases, understanding variable performance characteristics of immunoassays, and design of potential novel treatment approaches.
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Affiliation(s)
- Marta Casal Moura
- Mayo Clinic and Foundation, Rochester, MN, USA
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | | | - Lynn A. Fussner
- Mayo Clinic and Foundation, Rochester, MN, USA
- Ohio State University, Columbus, OH, USA
| | | | - Dieter E. Jenne
- Max-Planck-Institute for Biological Intelligence, 82152 Martinsried, Germany
| | | | | | | | | | | | | | - Paul A. Monach
- VA Boston Healthcare System, Rheumatology, Boston, MA, USA
| | - Philip Seo
- Johns Hopkins University, Baltimore, MD, USA
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16
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Berti A, Hillion S, Konig MF, Moura MC, Hummel AM, Carmona E, Peikert T, Fervenza FC, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, Brunetta P, Clair EW, Harris KM, Stone JH, Grandi G, Pers JO, Specks U, Cornec D. Autoreactive Plasmablasts After B Cell Depletion With Rituximab and Relapses in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2023; 75:736-747. [PMID: 36281741 PMCID: PMC10280646 DOI: 10.1002/art.42388] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/04/2022] [Accepted: 10/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Autoreactive B cells are responsible for antineutrophil cytoplasmic antibody (ANCA) production in ANCA-associated vasculitis (AAV). Rituximab (RTX) depletes circulating B cells, including autoreactive B cells. We aimed to evaluate changes and associations with relapse of the circulating autoreactive B cell pool following therapeutic B cell depletion in AAV. METHODS Sequential flow cytometry was performed on 148 samples of peripheral blood mononuclear cells from 23 patients with proteinase 3 (PR3)-ANCA-positive AAV who were treated with RTX for remission induction and monitored after stopping therapy during long-term follow-up in a prospective clinical trial. PR3 was used as a ligand to target autoreactive PR3-specific (PR3+) B cells. B cell recurrence was considered as the first blood sample with ≥10 B cells/μl after RTX treatment. RESULTS At B cell recurrence, PR3+ B cell frequency among B cells was higher than baseline (P < 0.01). Within both PR3+ and total B cells, frequencies of transitional and naive subsets were higher at B cell recurrence than at baseline, while memory subsets were lower (P < 0.001 for all comparisons). At B cell recurrence, frequencies of B cells and subsets did not differ between patients who experienced relapse and patients who remained in remission. In contrast, the plasmablast frequency within the PR3+ B cell pool was higher in patients who experienced relapse and associated with a shorter time to relapse. Frequencies of PR3+ plasmablasts higher than baseline were more likely to be found in patients who experienced relapse within the following 12 months compared to those in sustained remission (P < 0.05). CONCLUSION The composition of the autoreactive B cell pool varies significantly following RTX treatment in AAV, and early plasmablast enrichment within the autoreactive pool is associated with future relapses.
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Affiliation(s)
- Alvise Berti
- Division of Pulmonary & Critical Care Medicine, Thoracic Disease Research Unit, Mayo Clinic, Rochester, Minnesota, and Center for Medical Sciences (CISMed), Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Italy, and Rheumatology Unit, Santa Chiara Hospital, APSS Trento, Italy
| | - Sophie Hillion
- Jacques-Olivier Pers, DDS, PhD, Divi Cornec, MD, PhD: Université de Bretagne Occidendale, Brest, Bretagne, France
| | - Maximilian F. Konig
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marta Casal Moura
- Division of Pulmonary & Critical Care Medicine, Thoracic Disease Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Amber M. Hummel
- Division of Pulmonary & Critical Care Medicine, Thoracic Disease Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Eva Carmona
- Division of Pulmonary & Critical Care Medicine, Thoracic Disease Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Tobias Peikert
- Division of Pulmonary & Critical Care Medicine, Thoracic Disease Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Cees G. M. Kallenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, Groningen, The Netherlands
| | | | - Peter A. Merkel
- Division of Rheumatology, Department of Medicine, and Department of Biostatistics, Epidemiology, and Informatics, Division of Clinical Epidemiology, University of Pennsylvania, Philadelphia
| | | | - Philip Seo
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert F. Spiera
- Weill Cornell Medical College, Hospital for Special Surgery, New York
| | | | | | | | - John H. Stone
- Massachusetts General Hospital Rheumatology Unit, Boston
| | - Guido Grandi
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Italy
| | - Jacques-Olivier Pers
- Jacques-Olivier Pers, DDS, PhD, Divi Cornec, MD, PhD: Université de Bretagne Occidendale, Brest, Bretagne, France
| | - Ulrich Specks
- Division of Pulmonary & Critical Care Medicine, Thoracic Disease Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Divi Cornec
- Jacques-Olivier Pers, DDS, PhD, Divi Cornec, MD, PhD: Université de Bretagne Occidendale, Brest, Bretagne, France
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Branch-Elliman W, Monach PA. Moving towards a precision approach for prevention of severe COVID-19. Lancet 2023; 401:1423-1424. [PMID: 37120280 PMCID: PMC10139313 DOI: 10.1016/s0140-6736(23)00443-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/27/2023] [Indexed: 05/01/2023]
Affiliation(s)
| | - Paul A Monach
- VA Boston Healthcare System, Harvard Medical School, Boston, MA 02130, USA.
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18
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Monach PA, Branch-Elliman W. More data needed on efficacy and safety of monovalent vaccines against SARS-CoV-2 omicron variants. Lancet Infect Dis 2023; 23:654-655. [PMID: 37119830 PMCID: PMC10132782 DOI: 10.1016/s1473-3099(23)00274-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/01/2023]
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19
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Beaudette-Zlatanova B, Lew RA, Otis JD, Branch-Elliman W, Bacorro E, Dubreuil M, Eyvazzadeh C, Kaur M, Lazzari AA, Libbey C, Monach PA. Pilot Study of Low-Dose Naltrexone for the Treatment of Chronic Pain Due to Arthritis: A Randomized, Double-blind, Placebo-Controlled, Crossover Clinical Trial. Clin Ther 2023:S0149-2918(23)00113-3. [PMID: 37045708 DOI: 10.1016/j.clinthera.2023.03.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE Low-dose naltrexone (LDN) is commonly used to control pain and other symptoms, especially in patients with autoimmune diseases, but with limited evidence. This study tests the efficacy of LDN in reducing chronic pain in patients with osteoarthritis (OA) and inflammatory arthritis (IA), where existing approaches often fail to adequately control pain. METHODS In this randomized, double-blind, placebo-controlled, crossover clinical trial, each patient received 4.5 mg LDN for 8 weeks and placebo for 8 weeks. Outcome measures were patient reported, using validated questionnaires. The primary outcome was differences in pain interference during the LDN and placebo periods, using the Brief Pain Inventory (scale, 0-70). Secondary outcomes included changes in mean pain severity, fatigue, depression, and multiple domains of health-related quality of life. The painDETECT questionnaire classified pain as nociceptive, neuropathic, or mixed. Data were analyzed using mixed-effects models. FINDINGS Seventeen patients with OA and 6 with IA completed the pilot study. Most patients described their pain as nociceptive (n = 9) or mixed (n = 8) rather than neuropathic (n = 3). There was no difference in change in pain interference after treatment with LDN (mean [SD], -23 [19.4]) versus placebo (mean [SD], -22 [19.2]; P = 0.90). No significant differences were seen in pain severity, fatigue, depression, or health-related quality of life. IMPLICATIONS In this small pilot study, findings do not support LDN being efficacious in reducing nociceptive pain due to arthritis. Too few patients were enrolled to rule out modest benefit or to assess inflammatory or neuropathic pain. CLINICALTRIALS gov identifier: NCT03008590.
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Affiliation(s)
- Britte Beaudette-Zlatanova
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts; VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts
| | - Robert A Lew
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts
| | - John D Otis
- Research Service, VA Boston Healthcare System, Boston, Massachusetts
| | - Westyn Branch-Elliman
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts; Infectious Diseases Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Eugene Bacorro
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Maureen Dubreuil
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | | | - Maneet Kaur
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Antonio A Lazzari
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Caryn Libbey
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Paul A Monach
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts; VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts.
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20
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Michailidou D, Kuley R, Wang T, Hermanson P, Grayson PC, Cuthbertson D, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Warrington KJ, Monach PA, Merkel PA, Lood C. Neutrophil extracellular trap formation in anti-neutrophil cytoplasmic antibody-associated and large-vessel vasculitis. Clin Immunol 2023; 249:109274. [PMID: 36878421 PMCID: PMC10066833 DOI: 10.1016/j.clim.2023.109274] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/07/2023]
Abstract
Levels of neutrophil extracellular traps (NETs) were measured in plasma of healthy controls (HC, n = 30) and patients with granulomatosis with polyangiitis (GPA, n = 123), microscopic polyangiitis (MPA, n = 61), Takayasu's arteritis (TAK, n = 58), and giant cell arteritis (GCA, n = 68), at times of remission or activity and correlated with levels of the platelet-derived thrombospondin-1 (TSP-1). Levels of NETs were elevated during active disease in patients with GPA (p < 0.0001), MPA (p = 0.0038), TAK (p < 0.0001), and GCA (p < 0.0001), and in remission for GPA, p < 0.0001, MPA, p = 0.005, TAK, p = 0.03, and GCA, p = 0.0009. All cohorts demonstrated impaired NET degradation. Patients with GPA (p = 0.0045) and MPA (p = 0.005) had anti-NET IgG antibodies. Patients with TAK had anti-histone antibodies (p < 0.01), correlating with presence of NETs. Levels of TSP-1 were increased in all patients with vasculitis, and associated with NET formation. NET formation is a common process in vasculitides. Targeting NET formation or degradation could be potential therapeutic approaches for vasculitides.
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Affiliation(s)
| | - Runa Kuley
- Division of Rheumatology, University of Washington, Seattle, USA; Center for Life Sciences, Mahindra University, Hyderabad, India
| | - Ting Wang
- Division of Rheumatology, University of Washington, Seattle, USA
| | - Payton Hermanson
- Division of Rheumatology, University of Washington, Seattle, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, South Florida, FL, USA
| | - Nader A Khalidi
- Division of Rheumatology, Mc Master University, Ontario, Canada
| | | | | | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Larry W Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, CO, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Lood
- Division of Rheumatology, University of Washington, Seattle, USA.
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21
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Casal Moura M, Deng Z, Brooks SR, Tew W, Fervenza FC, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Prunotto M, Grayson PC, Specks U. Risk of relapse of ANCA-associated vasculitis among patients homozygous for the proteinase 3 gene Val119Ile polymorphism. RMD Open 2023; 9:e002935. [PMID: 36990659 PMCID: PMC10069578 DOI: 10.1136/rmdopen-2022-002935] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The frequency of proteinase 3 gene (PRTN3) polymorphisms in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is not fully characterised. We hypothesise that the presence of a PRTN3 gene polymorphism (single nucleotide polymorphism (SNP) rs351111) is relevant for clinical outcomes. METHODS DNA variant calling for SNP rs351111 (chr.19:844020, c.355G>A) in PRTN3 gene assessed the allelic frequency in patients with PR3-AAV included in the Rituximab in ANCA-Associated Vasculitis trial. This was followed by RNA-seq variant calling to characterise the mRNA expression. We compared clinical outcomes between patients homozygous for PRTN3-Ile119 or PRTN3-Val119. RESULTS Whole blood samples for DNA calling were available in 188 patients. 75 patients with PR3-AAV had the allelic variant: 62 heterozygous PRTN3-Val119Ile and 13 homozygous for PRTN3-Ile119. RNA-seq was available for 89 patients and mRNA corresponding to the allelic variant was found in 32 patients with PR3-AAV: 25 heterozygous PRTN3-Val119Ile and 7 homozygous for PRTN3-Ile119. The agreement between the DNA calling results and mRNA expression of the 86 patients analysed by both methods was 100%. We compared the clinical outcomes of 64 patients with PR3-AAV: 51 homozygous for PRTN3-Val119 and 13 homozygous for PRTN3-Ile119. The frequency of severe flares at 18 months in homozygous PRTN3-Ile119 was significantly higher when compared with homozygous PRTN3-Val119 (46.2% vs 19.6%, p=0.048). Multivariate analysis identified homozygous PR3-Ile119 as main predictor of severe relapse (HR 4.67, 95% CI 1.16 to 18.86, p=0.030). CONCLUSION In patients with PR3-AAV, homozygosity for PRTN3-Val119Ile polymorphism appears associated with higher frequency of severe relapse. Further studies are necessary to better understand the association of this observation with the risk of severe relapse.
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Affiliation(s)
- Marta Casal Moura
- Pulmonary and Critical Care Medicine, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
- Biomedicina, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Zuoming Deng
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Stephen R Brooks
- Office of Science and Technology, Biodata Mining and Discovery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Wei Tew
- ITGR Diagnostics Discovery, Genentech Inc, South San Francisco, California, USA
| | - Fernando C Fervenza
- Nephrology and Hypertension, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
| | - Cees G M Kallenberg
- Rheumatology and Clinical Immunology, University of Groningen, Groningen, The Netherlands
| | - Carol A Langford
- Rheumatic and Immunologic Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul A Monach
- Department of Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Philip Seo
- Rheumatology, Johns Hopkins, Baltimore, Maryland, USA
| | - Robert F Spiera
- Department of Medicine, Hospital for Special Surgery, New York, New York, USA
| | | | - John H Stone
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marco Prunotto
- School of Pharmaceutical Sciences, University of Geneva, Geneve, Switzerland
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Ulrich Specks
- Pulmonary and Critical Care Medicine, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
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22
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La J, Fillmore NR, Do NV, Brophy M, Monach PA, Branch-Elliman W. Factors associated with the speed and scope of diffusion of COVID-19 therapeutics in a nationwide healthcare setting: a mixed-methods investigation. Health Res Policy Syst 2022; 20:134. [PMID: 36517793 PMCID: PMC9749626 DOI: 10.1186/s12961-022-00935-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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The global COVID-19 pandemic is an opportunity to evaluate factors associated with high levels of adoption of different therapeutics in a real-world setting. The aim of this nationwide, retrospective cohort study was to evaluate the diffusion and adoption of novel therapeutics with an emerging evidence basis and to identify factors that influenced physicians' treatment decisions. METHODS Cohort creation: A cohort of Veteran patients with a microbiologically confirmed diagnosis of SARS-CoV2 were identified, and cases were classified by disease severity (outpatient, inpatient with mild and severe disease, intensive care unit ICU]). After classification of disease severity, the proportion of cases (outpatients) and admissions (inpatients) in each category receiving each type of medication were plotted as a function of time. Identification of milestones and guidance changes: Key medications used for the management of COVID-19 milestones in the release of primary research results in various forms (e.g. via press release, preprint or publication in a traditional medical journal), policy events and dates of key guidelines were identified and plotted as a timeline. After a timeline was created, time points were compared to changes in medication use, and factors potentially impacting the magnitude (i.e. proportion of patients who received the treatment) and the speed (i.e. the slope of the change in use) of practice changes were evaluated. RESULTS Dexamethasone and remdesivir, the first two medications with clinical trial data to support their use, underwent the most rapid, complete and sustained diffusion and adoption; the majority of practice changes occurred after press releases and preprints were available and prior to guideline changes, although some additional uptake occurred following guideline updates. Medications that were not "first in class", that were identified later in the pandemic, and that had higher perceived risk had slower and less complete uptake regardless of the strength and quality of the evidence supporting the intervention. CONCLUSIONS Our findings suggest that traditional and social media platforms and preprint releases were major catalysts of practice change, particularly prior to the identification of effective treatments. The "first available treatment in class" impact appeared to be the single most important factor determining the speed and scope of diffusion.
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Affiliation(s)
- Jennifer La
- VA Boston Cooperative Studies Program, Boston, MA United States of America
| | - Nathanael R. Fillmore
- VA Boston Cooperative Studies Program, Boston, MA United States of America ,grid.410370.10000 0004 4657 1992Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132 United States of America ,grid.65499.370000 0001 2106 9910Dana Farber Cancer Institute, Boston, MA United States of America ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA United States of America
| | - Nhan V. Do
- VA Boston Cooperative Studies Program, Boston, MA United States of America ,grid.410370.10000 0004 4657 1992Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132 United States of America ,grid.189504.10000 0004 1936 7558Boston University School of Medicine, Boston, MA United States of America
| | - Mary Brophy
- VA Boston Cooperative Studies Program, Boston, MA United States of America ,grid.410370.10000 0004 4657 1992Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132 United States of America ,grid.189504.10000 0004 1936 7558Boston University School of Medicine, Boston, MA United States of America
| | - Paul A. Monach
- VA Boston Cooperative Studies Program, Boston, MA United States of America ,grid.410370.10000 0004 4657 1992Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132 United States of America ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA United States of America
| | - Westyn Branch-Elliman
- grid.410370.10000 0004 4657 1992Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132 United States of America ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA United States of America ,VA Boston Center for Healthcare Organization and Implementation Research, Boston, MA United States of America
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23
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Vo AD, La J, Wu JTY, Strymish JM, Ronan M, Brophy M, Do NV, Branch-Elliman W, Fillmore NR, Monach PA. Factors Associated With Severe COVID-19 Among Vaccinated Adults Treated in US Veterans Affairs Hospitals. JAMA Netw Open 2022; 5:e2240037. [PMID: 36264571 PMCID: PMC9585432 DOI: 10.1001/jamanetworkopen.2022.40037] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE With a large proportion of the US adult population vaccinated against SARS-CoV-2, it is important to identify who remains at risk of severe infection despite vaccination. OBJECTIVE To characterize risk factors for severe COVID-19 disease in a vaccinated population. DESIGN, SETTING, AND PARTICIPANTS This nationwide, retrospective cohort study included US veterans who received a SARS-CoV-2 vaccination series and later developed laboratory-confirmed SARS-CoV-2 infection and were treated at US Department of Veterans Affairs (VA) hospitals. Data were collected from December 15, 2020, through February 28, 2022. EXPOSURES Demographic characteristics, comorbidities, immunocompromised status, and vaccination-related variables. MAIN OUTCOMES AND MEASURES Development of severe vs nonsevere SARS-CoV-2 infection. Severe disease was defined as hospitalization within 14 days of a positive SARS-CoV-2 diagnostic test and either blood oxygen level of less than 94%, receipt of supplemental oxygen or dexamethasone, mechanical ventilation, or death within 28 days. Association between severe disease and exposures was estimated using logistic regression models. RESULTS Among 110 760 patients with infections following vaccination (97 614 [88.1%] men, mean [SD] age at vaccination, 60.8 [15.3] years; 26 953 [24.3%] Black, 11 259 [10.2%] Hispanic, and 71 665 [64.7%] White), 10 612 (9.6%) had severe COVID-19. The strongest association with risk of severe disease after vaccination was age, which increased among patients aged 50 years or older with an adjusted odds ratio (aOR) of 1.42 (CI, 1.40-1.44) per 5-year increase in age, such that patients aged 80 years or older had an aOR of 16.58 (CI, 13.49-20.37) relative to patients aged 45 to 50 years. Immunocompromising conditions, including receipt of different classes of immunosuppressive medications (eg, leukocyte inhibitor: aOR, 2.80; 95% CI, 2.39-3.28) or cytotoxic chemotherapy (aOR, 2.71; CI, 2.27-3.24) prior to breakthrough infection, or leukemias or lymphomas (aOR, 1.87; CI, 1.61-2.17) and chronic conditions associated with end-organ disease, such as heart failure (aOR, 1.74; CI, 1.61-1.88), dementia (aOR, 2.01; CI, 1.83-2.20), and chronic kidney disease (aOR, 1.59; CI, 1.49-1.69), were also associated with increased risk. Receipt of an additional (ie, booster) dose of vaccine was associated with reduced odds of severe disease (aOR, 0.50; CI, 0.44-0.57). CONCLUSIONS AND RELEVANCE In this nationwide, retrospective cohort of predominantly male US Veterans, we identified risk factors associated with severe disease despite vaccination. Findings could be used to inform outreach efforts for booster vaccinations and to inform clinical decision-making about patients most likely to benefit from preexposure prophylaxis and antiviral therapy.
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Affiliation(s)
- Austin D. Vo
- VA Boston Cooperative Studies Program, Boston, Massachusetts
| | - Jennifer La
- VA Boston Cooperative Studies Program, Boston, Massachusetts
| | - Julie T.-Y. Wu
- VA Palo Alto Healthcare System, Palo Alto, California
- Stanford University School of Medicine, Stanford, California
| | - Judith M. Strymish
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Matthew Ronan
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
| | - Mary Brophy
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Nhan V. Do
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Westyn Branch-Elliman
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts
| | - Nathanael R. Fillmore
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Paul A. Monach
- VA Boston Cooperative Studies Program, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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24
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Michailidou D, Duvvuri B, Kuley R, Cuthbertson D, Grayson PC, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Warrington KJ, Mustelin T, Monach PA, Merkel PA, Lood C. Neutrophil activation in patients with anti-neutrophil cytoplasmic autoantibody-associated vasculitis and large-vessel vasculitis. Arthritis Res Ther 2022; 24:160. [PMID: 35768848 PMCID: PMC9241246 DOI: 10.1186/s13075-022-02849-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To assess markers of neutrophil activation such as calprotectin and N-formyl methionine (fMET) in anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) and large-vessel vasculitis (LVV). Methods Levels of fMET, and calprotectin, were measured in the plasma of healthy controls (n=30) and patients with AAV (granulomatosis with polyangiitis (GPA, n=123), microscopic polyangiitis (MPA, n=61)), and LVV (Takayasu’s arteritis (TAK, n=58), giant cell arteritis (GCA, n=68)), at times of remission or flare. Disease activity was assessed by physician global assessment. In vitro neutrophil activation assays were performed in the presence or absence of formyl peptide receptor 1 (FPR1) inhibitor cyclosporine H. Results Levels of calprotectin, and fMET were elevated in patients with vasculitis as compared to healthy individuals. Levels of fMET correlated with markers of systemic inflammation: C-reactive protein (r=0.82, p<0.0001), and erythrocyte sedimentation rate (r=0.235, p<0.0001). The neutrophil activation marker, calprotectin was not associated with disease activity. Circulating levels of fMET were associated with neutrophil activation (p<0.01) and were able to induce de novo neutrophil activation via FPR1-mediated signaling. Conclusion Circulating fMET appears to propagate neutrophil activation in AAV and LVV. Inhibition of fMET-mediated FPR1 signaling could be a novel therapeutic intervention for systemic vasculitides.
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Affiliation(s)
- Despina Michailidou
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - Bhargavi Duvvuri
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - Runa Kuley
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, South Florida, Tampa, FL, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Nader A Khalidi
- Division of Rheumatology, Mc Master University, Hamilton, Ontario, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | | | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Larry W Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, CO, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Tomas Mustelin
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Lood
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA.
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25
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Doubelt I, Springer JM, Kermani TA, Sreih AG, Burroughs C, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford C, McAlear CA, Moreland LW, Monach PA, Shaw DG, Seo P, Specks U, Warrington KJ, Young K, Merkel PA, Pagnoux C. Self-Reported Data and Physician-Reported Data in Patients With Eosinophilic Granulomatosis With Polyangiitis: Comparative Analysis. Interact J Med Res 2022; 11:e27273. [PMID: 35612893 PMCID: PMC9178459 DOI: 10.2196/27273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 07/03/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Patient-based registries can help advance research on rare diseases such as eosinophilic granulomatosis with polyangiitis (EGPA), a complex multiorgan form of antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis. Objective The aim of this study is to compare patient-reported and physician-reported data on manifestations, treatments, and outcomes for patients with EGPA. Methods We completed a comparative analysis of patients ≥18 years with EGPA in Canada and the United States from the following 2 cohorts: (1) The Vasculitis Patient-Powered Research Network (VPPRN), a self-enrolled secure portal with patient-entered data updated quarterly (2014-2019) and (2) the Vasculitis Clinical Research Consortium (VCRC) observational studies, a physician-entered database (2003-2019) of patients who fulfilled the 1990 American College of Rheumatology classification criteria for EGPA. The studied parameters included demographic characteristics, clinical manifestations, ANCA status, treatments, and relapses. Results Data from 195 patients with a validated diagnosis of EGPA in the VPPRN and 354 patients enrolled in the VCRC were analyzed. Compared to the VCRC cohort, the patients in the VPPRN cohort were more likely to be female (135/195, 69.2% compared to 209/354, 59%; P=.02) and younger at diagnosis (47.3 compared to 50.0 years; P=.03); both cohorts reported similar frequencies of asthma (177/184, 96.2% in the VPPRN cohort compared to 329/354, 92.9% in the VCRC cohort; P=.13) and cardiac manifestations (44/153, 28.8% compared to 75/354, 21.2%; P=.06), but the VPPRN cohort reported less frequent lung manifestations other than asthma and more frequent disease manifestations in all other organ systems. The ANCA positivity was 48.9% (64/131) in the VPPRN patients compared to 38.9% (123/316; P=.05) in the VCRC cohort. Relapsing disease after study enrollment was reported in 32.3% (63/195) of patients in the VPPRN compared to 35.7% (99/277) of patients in the VCRC. Most therapies (GC, cyclophosphamide, mepolizumab) were used at similar frequencies in both groups, except for rituximab with VPPRN patients reporting more use than the VCRC cohort (47/195, 24.1% compared to 29/277, 10.5%; P<.001). Conclusions Overall, patients and physicians report manifestations of EGPA at similar frequencies. However, observed differences between patient and physician reports imply the potential occurrence of selection biases. These results support the use of patient-reported data in EGPA but also the need for careful consideration of disease-specific definitions for the study of EGPA and how patient- and physician-reported data are collected. Trial Registration ClinicalTrials.gov NCT00315380, https://clinicaltrials.gov/ct2/show/NCT00315380; ClinicalTrials.gov NCT01241305, https://clinicaltrials.gov/ct2/show/NCT01241305
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Affiliation(s)
- Irena Doubelt
- Vasculitis Clinic, Mount Sinai Hospital, Toronto, ON, Canada.,Division of Rheumatology, University of Toronto, Toronto, ON, Canada
| | - Jason M Springer
- Division of Rheumatology and Immunology, Medical Center, Vanderbilt University, Nashville, TN, United States
| | - Tanaz A Kermani
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Cristina Burroughs
- Health Informatics Institute, University of South Florida, Tampa, FL, United States
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, FL, United States
| | - Simon Carette
- Vasculitis Clinic, Mount Sinai Hospital, Toronto, ON, Canada.,Division of Rheumatology, University of Toronto, Toronto, ON, Canada
| | - Nader A Khalidi
- Division of Rheumatology, McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah Hospital, Salt Lake City, UT, United States
| | - Carol Langford
- Division of Rheumatology, Cleveland Clinic, Cleveland, OH, United States
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Larry W Moreland
- Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Paul A Monach
- Division of Rheumatology, Veterans Affairs Boston Healthcare System, Boston, MA, United States
| | - Dianne G Shaw
- Vasculitis Foundation, Kansas City, MO, United States
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, College of Medicine and Science, Mayo Clinic, Rochester, MN, United States
| | - Kenneth J Warrington
- Division of Rheumatology, College of Medicine and Science, Mayo Clinic, Rochester, MN, United States
| | - Kalen Young
- Vasculitis Foundation, Kansas City, MO, United States
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, Toronto, ON, Canada.,Division of Rheumatology, University of Toronto, Toronto, ON, Canada
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26
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Brooks R, Baker JF, Yang Y, Roul P, Kerr GS, Reimold AM, Kunkel G, Wysham KD, Singh N, Lazaro D, Monach PA, Poole JA, Ascherman DP, Mikuls TR, England BR. The impact of disease severity measures on survival in U.S. veterans with rheumatoid arthritis-associated interstitial lung disease. Rheumatology (Oxford) 2022; 61:4667-4677. [PMID: 35377443 PMCID: PMC9960484 DOI: 10.1093/rheumatology/keac208] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 02/08/2022] [Revised: 03/26/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To determine whether RA and interstitial lung disease (ILD) severity measures are associated with survival in patients with RA-ILD. METHODS We studied US veterans with RA-ILD participating in a multicentre, prospective RA cohort study. RA disease activity (28-joint DAS [DAS28-ESR]) and functional status (multidimensional HAQ [MDHAQ]) were collected longitudinally while pulmonary function tests (forced vital capacity [FVC], diffusing capacity for carbon monoxide) were obtained from medical records. Vital status and cause of death were determined from the National Death Index and administrative data. Predictors of death were assessed using multivariable Cox regression models adjusting for age, sex, smoking status, ILD duration, comorbidity burden and medications. RESULTS We followed 227 RA-ILD participants (93% male and mean age of 69 years) over 1073 person-years. Median survival after RA-ILD diagnosis was 8.5 years. Respiratory diseases (28%) were the leading cause of death, with ILD accounting for 58% of respiratory deaths. Time-varying DAS28-ESR (adjusted hazard ratio [aHR] 1.21; 95% CI: 1.03, 1.41) and MDHAQ (aHR 1.85; 95% CI: 1.29, 2.65) were separately associated with mortality independent of FVC and other confounders. Modelled together, the presence of either uncontrolled disease activity (moderate/high DAS28-ESR) or FVC impairment (<80% predicted) was significantly associated with mortality risk. Those with a combination of moderate/high disease activity and FVC <80% predicted had the highest risk of death (aHR 4.43; 95% CI: 1.70, 11.55). CONCLUSION Both RA and ILD disease severity measures are independent predictors of survival in RA-ILD. These findings demonstrate the prognostic value of monitoring the systemic features of RA-ILD.
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Affiliation(s)
- Rebecca Brooks
- VA Nebraska-Western Iowa Health Care System and Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Joshua F Baker
- Corporal Michael J. Crescenz VA and Division of Rheumatology, University of Pennsylvania, Philadelphia, PA
| | - Yangyuna Yang
- VA Nebraska-Western Iowa Health Care System and Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Punyasha Roul
- VA Nebraska-Western Iowa Health Care System and Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Gail S Kerr
- Division of Rheumatology, Washington DC VA, Howard University and Georgetown University, Washington, DC
| | - Andreas M Reimold
- Dallas VA and Division of Rheumatic Diseases, University of Texas Southwestern, Dallas, TX
| | - Gary Kunkel
- VA Salt Lake City and Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Katherine D Wysham
- VA Puget Sound Health Care System and Division of Rheumatology, University of Washington, Seattle, WA
| | - Namrata Singh
- VA Puget Sound Health Care System and Division of Rheumatology, University of Washington, Seattle, WA
| | | | | | - Jill A Poole
- Division of Allergy & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Dana P Ascherman
- Pittsburgh VA and Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Bryant R England
- Correspondence to: Bryant R. England, VA Nebraska-Western Iowa Health Care System and Division of Rheumatology & Immunology, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE 68198-6270, USA. E-mail:
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Jinno S, Monach PA, Nakazawa T. Utility of lower extremity magnetic resonance imaging followed by muscle biopsy for myeloperoxidase-antineutrophil cytoplasmic antibodies positive antineutrophil cytoplasmic antibody-associated vasculitis: a single-centre study. Clin Exp Rheumatol 2022; 41:984. [PMID: 35616584 DOI: 10.55563/clinexprheumatol/eqd0ch] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Sadao Jinno
- Department of Rheumatology, Osaka Saiseikai Nakatsu Hospital, Osaka, and Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan.
| | | | - Takashi Nakazawa
- Department of Rheumatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
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28
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Branch-Elliman W, Ferguson R, Doros G, Woods P, Leatherman S, Strymish J, Datta R, Goswami R, Jankowich MD, Shah NR, Taylor TH, Page ST, Schiller SJ, Shannon C, Hau C, Flynn M, Holmberg E, Visnaw K, Dhond R, Brophy M, Monach PA. Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. PLoS One 2022; 17:e0263591. [PMID: 35213547 PMCID: PMC8880885 DOI: 10.1371/journal.pone.0263591] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE AND OBJECTIVE The aim of this pragmatic, embedded, adaptive trial was to measure the effectiveness of the subcutaneous anti-IL-6R antibody sarilumab, when added to an evolving standard of care (SOC), for clinical management of inpatients with moderate to severe COVID-19 disease. DESIGN Two-arm, randomized, open-label controlled trial comparing SOC alone to SOC plus sarilumab. The trial used a randomized play-the-winner design and was fully embedded within the electronic health record (EHR) system. SETTING 5 VA Medical Centers. PARTICIPANTS Hospitalized patients with clinical criteria for moderate to severe COVID-19 but not requiring mechanical ventilation, and a diagnostic test positive for SARS-CoV-2. INTERVENTIONS Sarilumab, 200 or 400 mg subcutaneous injection. SOC was not pre-specified and could vary over time, e.g., to include antiviral or other anti-inflammatory drugs. MAIN OUTCOMES AND MEASURES The primary outcome was intubation or death within 14 days of randomization. All data were extracted remotely from the EHR. RESULTS Among 162 eligible patients, 53 consented, and 50 were evaluated for the primary endpoint of intubation or death. This occurred in 5/20 and 1/30 of participants in the sarilumab and SOC arms respectively, with the majority occurring in the initial 9 participants (3/4 in the sarilumab and 1/5 in the SOC) before the sarilumab dose was increased to 400 mg and before remdesivir and dexamethasone were widely adopted. After interim review, the unblinded Data Monitoring Committee recommended that the study be stopped due to concern for safety: a high probability that rates of intubation or death were higher with addition of sarilumab to SOC (92.6%), and a very low probability (3.4%) that sarilumab would be found to be superior. CONCLUSIONS AND RELEVANCE This randomized trial of patients hospitalized due to respiratory compromise from COVID-19 but not mechanical ventilation found no benefit from subcutaneous sarilumab when added to an evolving SOC. The numbers of patients and events were too low to allow definitive conclusions to be drawn, but this study contributes valuable information about the role of subcutaneous IL-6R inhibition in the treatment of hospitalized COVID-19 patients. Methods developed and piloted during this trial will be useful in conducting future studies more efficiently. TRIAL REGISTRATION Clinicaltrials.gov-NCT04359901; https://clinicaltrials.gov/ct2/show/NCT04359901?cond=NCT04359901&draw=2&rank=1.
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Affiliation(s)
- Westyn Branch-Elliman
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ryan Ferguson
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Evans Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Gheorghe Doros
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Patricia Woods
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Sarah Leatherman
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Judith Strymish
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Rupak Datta
- Hospital Epidemiology and Infection Prevention Program, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America
- Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Rekha Goswami
- Section of Infectious Diseases, VA Maine Healthcare System, Togus, Maine, United States of America
| | - Matthew D. Jankowich
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Providence VA Medical Center, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Nishant R. Shah
- Division of Cardiology, Department of Medicine, Providence VA Medical Center, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Thomas H. Taylor
- Infectious Diseases and Rheumatology, White River Jct. VA Medical Center, Hartford, Vermont, United States of America
| | - Sarah T. Page
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Sara J. Schiller
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Colleen Shannon
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Cynthia Hau
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Maura Flynn
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Erika Holmberg
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Karen Visnaw
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Rupali Dhond
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Evans Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Mary Brophy
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Paul A. Monach
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
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Li LL, Zheng C, La J, Do NV, Monach PA, Strymish JM, Fillmore NR, Branch-Elliman W. Impact of prior SARS-CoV-2 infection on incidence of hospitalization and adverse events following mRNA SARS-CoV-2 vaccination: A nationwide, retrospective cohort study. Vaccine 2022; 40:1082-1089. [PMID: 35078665 PMCID: PMC8768509 DOI: 10.1016/j.vaccine.2022.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies evaluated the SARS-CoV-2 vaccine safety or compared adverse events following vaccination to those from infection. Limited data about the impact of prior infection on post-vaccine adverse events are available. The objective of this study was to evaluate the impact of prior SARS-CoV-2 infection on outcomes shortly after vaccination using a longitudinal design. METHODS Nationwide, multicenter, retrospective cohort study of hospitalization, death, and pre-specified adverse event rates among Veterans who received mRNA vaccines within the Veterans Health Administration between 12/11/2020 and 8/31/2021. Daily incidence rates were compared before and after vaccine doses, stratified by history of microbiologically-confirmed SARS-CoV-2. RESULTS 3,118,802 patients received a first dose and 2,979,326 a second, including 102,829 with a history of SARS-CoV-2 infection. Daily incident hospitalization rates were unchanged before and after the second dose among patients without previous infection (28.8/100,000 post-dose versus 28.6/100,000 pre-dose, p = 0.92). In previously-infected patients, the hospitalization rate increased above baseline one day following vaccination (158.2/100,000 after dose 2 versus 57.3/100,000 pre-dose, p < 0.001), then returned to baseline. Chart review indicated vaccine side effects, such as fever, constitutional symptoms, weakness, or falls, as the definite (39%) or possible (18%) cause of hospitalization. Affected patients had mean age 75, and 90% had at least one serious comorbidity. Hospitalizations were brief (median 2 days), with rapid return to baseline health. Worse baseline health among previously-infected patients prevented conclusions about mortality risk. CONCLUSIONS Two-dose mRNA vaccine regimens are safe in a population with many comorbidities. Transient increased risks of hospitalization were identified among patients with prior SARS-CoV-2, absolute risk ∼1:1000. Findings support additional study regarding the optimal dosing schedule in this population. FUNDING None.
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Affiliation(s)
- Lucy L Li
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, United States
| | - Chunlei Zheng
- VA Boston MAVERIC, United States; Boston University School of Medicine, Boston, MA, United States
| | | | - Nhan V Do
- VA Boston MAVERIC, United States; VA Boston Healthcare System, Department of Medicine, Boston, MA, United States; Boston University School of Medicine, Boston, MA, United States
| | - Paul A Monach
- VA Boston MAVERIC, United States; VA Boston Healthcare System, Department of Medicine, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Judith M Strymish
- VA Boston Healthcare System, Department of Medicine, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Nathanael R Fillmore
- VA Boston MAVERIC, United States; Harvard Medical School, Boston, MA, United States; Dana Farber Cancer Institute, Boston, MA, United States
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; VA Boston Center for Healthcare Organization and Implementation Research. Boston, MA, United States.
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30
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Berti A, Hillion S, Hummel AM, Son YM, Chriti N, Peikert T, Carmona EM, Abdulahad WH, Heeringa P, Harris KM, St Clair EW, Brunetta P, Fervenza FC, Langford CA, Kallenberg CG, Merkel PA, Monach PA, Seo P, Spiera RF, Stone JH, Grandi G, Sun J, Pers JO, Specks U, Cornec D. Circulating autoreactive proteinase 3+ B cells and tolerance checkpoints in ANCA-associated vasculitis. JCI Insight 2021; 6:150999. [PMID: 34618687 PMCID: PMC8663783 DOI: 10.1172/jci.insight.150999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Little is known about the autoreactive B cells in antineutrophil cytoplasmic antibody–associated (ANCA-associated) vasculitis (AAV). We aimed to investigate tolerance checkpoints of circulating antigen-specific proteinase 3–reactive (PR3+) B cells. METHODS Multicolor flow cytometry in combination with bioinformatics and functional in vitro studies were performed on baseline samples of PBMCs from 154 well-characterized participants of the RAVE trial (NCT00104299) with severely active PR3-AAV and myeloperoxidase-AAV (MPO-AAV) and 27 healthy controls (HCs). Clinical data and outcomes from the trial were correlated with PR3+ B cells (total and subsets). RESULTS The frequency of PR3+ B cells among circulating B cells was higher in participants with PR3-AAV (4.77% median [IQR, 3.98%–6.01%]) than in participants with MPO-AAV (3.16% median [IQR, 2.51%–5.22%]) and participants with AAV compared with HCs (1.67% median [IQR, 1.27%–2.16%], P < 0.001 for all comparisons), implying a defective central tolerance checkpoint in patients with AAV. Only PBMCs from participants with PR3-AAV contained PR3+ B cells capable of secreting PR3-ANCA IgG in vitro, proving they were functionally distinct from those of participants with MPO-AAV and HCs. Unsupervised clustering identified subtle subsets of atypical autoreactive PR3+ memory B cells accumulating through the maturation process in patients with PR3-AAV. PR3+ B cells were enriched in the memory B cell compartment of participants with PR3-AAV and were associated with higher serum CXCL13 levels, suggesting an increased germinal center activity. PR3+ B cells correlated with systemic inflammation (C-reactive protein and erythrocyte sedimentation rate, P < 0.05) and complete remission (P < 0.001). CONCLUSION This study suggests the presence of defective central antigen-independent and peripheral antigen-dependent checkpoints in patients with PR3-AAV, elucidating the selection process of autoreactive B cells. Trial registration ClinicalTrials.gov NCT00104299. Funding The Vasculitis Foundation, the National Institute of Allergy and Infectious Diseases of the NIH, and the Mayo Foundation for Education and Research.
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Affiliation(s)
- Alvise Berti
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Rheumatology Unit, S. Chiara Regional Hospital and Department of CIBIO, University of Trento, Trento, Italy
| | - Sophie Hillion
- INSERM UMR1227, Lymphocytes B et Autoimmunité, University of Brest, CHRU Brest, Brest, France
| | - Amber M Hummel
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Young Min Son
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nedra Chriti
- INSERM UMR1227, Lymphocytes B et Autoimmunité, University of Brest, CHRU Brest, Brest, France
| | - Tobias Peikert
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eva M Carmona
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wayel H Abdulahad
- Department of Rheumatology and Clinical Immunology and Department of Pathology and Medical Biology, University of Groningen, Groningen, Netherlands
| | - Peter Heeringa
- Department of Rheumatology and Clinical Immunology and Department of Pathology and Medical Biology, University of Groningen, Groningen, Netherlands
| | | | - E William St Clair
- Division of Rheumatology, Duke University Medical Center, Durham, North Carolina, USA
| | - Paul Brunetta
- Genentech Inc., South San Francisco, California, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Carol A Langford
- Center for Vasculitis Care and Research, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cees Gm Kallenberg
- Department of Rheumatology and Clinical Immunology and Department of Pathology and Medical Biology, University of Groningen, Groningen, Netherlands
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul A Monach
- Brigham and Women's Hospital and VA Boston Healthcare System, Boston Massachusetts, USA
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert F Spiera
- Vasculitis & Scleroderma Program, Hospital for Special Surgery, New York, New York, USA
| | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Guido Grandi
- Rheumatology Unit, S. Chiara Regional Hospital and Department of CIBIO, University of Trento, Trento, Italy
| | - Jie Sun
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacques-Olivier Pers
- INSERM UMR1227, Lymphocytes B et Autoimmunité, University of Brest, CHRU Brest, Brest, France
| | - Ulrich Specks
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Divi Cornec
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.,INSERM UMR1227, Lymphocytes B et Autoimmunité, University of Brest, CHRU Brest, Brest, France
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Monach PA, Warner RL, Lew R, Tómasson G, Specks U, Stone JH, Fervenza FC, Hoffman GS, Kallenberg CGM, Langford CA, Seo P, St Clair EW, Spiera R, Johnson KJ, Merkel PA. Serum Biomarkers of Disease Activity in Longitudinal Assessment of Patients with ANCA-Associated Vasculitis. ACR Open Rheumatol 2021; 4:168-176. [PMID: 34792864 PMCID: PMC8843765 DOI: 10.1002/acr2.11366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/01/2021] [Accepted: 09/13/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Improved biomarkers of current disease activity and prediction of relapse are needed in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). For clinical relevance, biomarkers must perform well longitudinally in patients on treatment and in patients with nonsevere flares. METHODS Twenty-two proteins were measured in 347 serum samples from 74 patients with AAV enrolled in a clinical trial. Samples were collected at Month 6 after remission induction, then every 3 months until Month 18, or at the time of flare. Associations of protein concentrations with concurrent disease activity and with future flare were analyzed using mixed-effects models, Cox proportional hazards models, and conditional logistic regression. RESULTS Forty-two patients had flares during the 12-month follow-up period, and 32 remained in remission. Twenty-two patients had severe flares. Six experimental markers (CXCL13, IL-6, IL-8, IL-15, IL-18BP, and matrix metalloproteinase-3 [MMP-3]) and ESR were associated with disease activity using all three methods (P < 0.05, with P < 0.01 in at least one method). A rise in IL-8, IL-15, or IL-18BP was associated temporally with flare. Combining C-reactive protein (CRP), IL-18BP, neutrophil gelatinase-associated lipocalin (NGAL), and sIL-2Rα improved association with active AAV. CXCL13 and MMP-3 were increased during treatment with prednisone, independent of disease activity. Marker concentrations during remission were not predictive of future flare. CONCLUSION Serum biomarkers of inflammation and tissue damage and repair have been previously shown to be strongly associated with severe active AAV were less strongly associated with active AAV in a longitudinal study that included mild flares and varying treatment. Markers rising contemporaneously with flare or with an improved association in combination merit further study.
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Affiliation(s)
- Paul A Monach
- Boston University, Boston, Massachusetts.,VA Boston Healthcare System, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Robert Lew
- Boston University, Boston, Massachusetts
| | | | | | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
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Kermani TA, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland L, Pagnoux C, Seo P, Specks U, Sreih A, Warrington KJ, Merkel PA. Hypothyroidism in vasculitis. Rheumatology (Oxford) 2021; 61:2942-2950. [PMID: 34730828 PMCID: PMC9607991 DOI: 10.1093/rheumatology/keab817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/03/2021] [Revised: 10/27/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To study the prevalence, risk and clinical associations of hypothyroidism among several forms of vasculitis. METHODS Patients with GCA, Takayasu's arteritis (TAK), PAN and the three forms of ANCA-associated vasculitis [AAV; granulomatosis with polyangiitis (GPA), microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis (EGPA)] enrolled in a prospective, multicentre, longitudinal study were included. RESULTS The study included data on 2085 patients [63% female, 90% White] with a mean age of 54.6 years (s.d. 17.2). Diagnoses were GCA (20%), TAK (11%), PAN (5%), GPA (42%), microscopic polyangiitis (8%) and EGPA (14%). Hypothyroidism was present in 217 patients (10%) (83% female), with a mean age 59.8 years (s.d. 14.5). Age- and sex-adjusted risk of hypothyroidism was GCA, odds ratio (OR) 0.61 (95% CI 0.41, 0.90); TAK, OR 0.57 (95% CI 0.31, 1.03); PAN, OR 0.59 (95% CI 0.25, 1.38); GPA, OR 1.51 (95% CI 1.12, 2.05); microscopic polyangiitis, OR 1.81 (95% CI 1.18, 2.80) and EGPA, OR 0.82 (95% CI 0.52, 1.30). Among patients with AAV, age- and sex-adjusted risk of hypothyroidism was higher with positive MPO-ANCA [OR 1.89 (95% CI 1.39, 2.76)]. The clinical manifestations of vasculitis were similar in patients with and without hypothyroidism, except transient ischaemic attacks, which were more frequently observed in patients with GCA and hypothyroidism (12% vs 2%; P = 0.001). CONCLUSIONS Differences in the risk of hypothyroidism among vasculitides may be due to genetic susceptibilities or immune responses. This study confirms an association of hypothyroidism with MPO-ANCA.
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Affiliation(s)
- Tanaz A Kermani
- Correspondence to: Tanaz A. Kermani, Division of Rheumatology, University of California Los Angeles,2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA 90404, USA. E-mail:
| | - David Cuthbertson
- Department of Biostatistics and Informatics, Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Simon Carette
- Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto
| | - Nader A Khalidi
- Department of Medicine, Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | - Curry L Koening
- Department of Medicine, Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Carol A Langford
- Department of Medicine, Division of Rheumatology, Cleveland Clinic, Cleveland, OH
| | - Carol A McAlear
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Paul A Monach
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Larry Moreland
- Department of Medicine, Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA
| | - Christian Pagnoux
- Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto
| | - Philip Seo
- Department of Medicine, Division of Rheumatology, Johns Hopkins University, Baltimore, MD
| | - Ulrich Specks
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Antoine Sreih
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Kenneth J Warrington
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Peter A Merkel
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology, University of Pennsylvania, Philadelphia, PA
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Monach PA, Branch-Elliman W. Reconsidering 'minimal risk' to expand the repertoire of trials with waiver of informed consent for research. BMJ Open 2021; 11:e048534. [PMID: 34521663 PMCID: PMC8442055 DOI: 10.1136/bmjopen-2020-048534] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Progress in therapeutic research is slowed by the regulatory burden of clinical trials, which provide the best evidence for guiding treatment. There is a long delay from evidence generation to adoption, highlighting the need for designs that link evidence generation to implementation. OBJECTIVE To identify clinical trial designs that confer minimal risk above that inherent in clinical care, to obviate the need for cumbersome consenting processes to enrol patients in prospective clinical research studies. These designs extend the scope of the Learning Healthcare System, a framework for leveraging retrospective 'big data' to advance clinical research, to include data collected from prospective controlled trials. SUMMARY Pragmatic trials may use simplified eligibility criteria, unblinded interventions and objective outcome measures that can all be monitored through the electronic health records (EHR), to reduce costs and speed study conduct. Most pragmatic trials continue to suffer from substantial regulatory burden. Written consent to participate in research can be waived only if the research produces minimal risk above what is encountered in everyday life. However, the 'consent' processes for prescribing Federal Drug Administration-approved medications in clinical medicine are informal, even when they involve decisions of uncertain benefit and higher levels of risk. We propose that trial designs that mimic clinical decision-making in areas of uncertainty (clinical equipoise) and in which no data are generated outside of usual care (ideally by EHR embedding) confer minimal additional risk. Trial designs meeting this standard could, therefore, be conducted with minimal documentation of consent, even when interventions contain different risks. To align with risk encountered in clinical practice, allocation to treatment arms should change (adaptive randomisation) as data are collected and analysed. Embedding of informatics tools into the EHR has the additional benefit that, as adaptive randomisation progresses, evidence-generation transitions into implementation via decision-support tools-the ultimate realisation of the Learning Healthcare System.
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Affiliation(s)
- Paul A Monach
- Rheumatology Section, VA Boston Health Care System Jamaica Plain Campus, Boston, Massachusetts, USA
| | - Westyn Branch-Elliman
- Infectious Diseases Section, VA Boston Health Care System West Roxbury Campus, West Roxbury, Massachusetts, USA
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Branch-Elliman W, Monach PA. Not What Anyone Signed up for: Unnecessary and Insurmountable Barriers Encountered in Conducting Clinical Trials in COVID-19. Narrat Inq Bioeth 2021; 11:8-15. [PMID: 34334456 DOI: 10.1353/nib.2021.0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Doubelt I, Cuthbertson D, Carette S, Chung SA, Forbess LJ, Khalidi NA, Koening CL, Langford C, McAlear CA, Moreland LW, Monach PA, Seo P, Specks U, Spiera RF, Springer JM, Sreih AG, Warrington KJ, Merkel PA, Pagnoux C. Clinical Manifestations and Long-Term Outcomes of Eosinophilic Granulomatosis With Polyangiitis in North America. ACR Open Rheumatol 2021; 3:404-412. [PMID: 34032390 PMCID: PMC8207688 DOI: 10.1002/acr2.11263] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/29/2021] [Indexed: 11/08/2022] Open
Abstract
Objective To describe clinical manifestations and outcomes in patients with eosinophilic granulomatosis with polyangiitis (EGPA) in North America. Methods Analysis of patients aged 18 years or older who fulfilled the 1990 American College of Rheumatology Classification Criteria for EGPA enrolled in the Vasculitis Clinical Research Consortium from 2003 to 2019. Main clinical characteristics, treatments, outcomes, and accumulated damage were studied. Results The cohort included 354 patients; 59% female; age at diagnosis of 50.0 (±14) years; 39% were antineutrophil cytoplasm antibody (ANCA) positive. Time from diagnosis to last follow‐up was 7.0 (±6.2) years; 49.4% had one or more relapse. Patients positive for ANCA more commonly had neurological and kidney involvement when compared with patients negative for ANCA, who had more cardiac and lung manifestations. At last study visit, only 35 (12.6%) patients had been off all therapy for more than 2 years during their follow‐up. The overall mortality rate was 4.0% and did not differ by ANCA status or cyclophosphamide use. Scores on the Vasculitis Damage Index (VDI) for 134 patients with two or more visits and more than 1 year of follow‐up increased from 1.7 (±1.8) at enrollment (3.7 [±5.1] years after diagnosis) to 3.35 (±2.1) at last follow‐up (7.5 [±5.8] years after diagnosis), mainly represented by chronic asthma (67.5%), peripheral neuropathy (49.6%), and chronic sinusitis (31.3%). Longer duration of glucocorticoid use and relapse were associated with higher VDI scores. Conclusion This analysis describes the many clinical manifestations and varied outcomes of EGPA and highlights the ongoing need to attain more sustained, long‐term remission to limit the accrual of disease‐related damage.
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Affiliation(s)
- Irena Doubelt
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Simon Carette
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Lindsy J Forbess
- Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Nader A Khalidi
- McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | | | | | - Larry W Moreland
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Paul A Monach
- Division of Rheumatology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
| | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland, United States
| | - Ulrich Specks
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | - Robert F Spiera
- Hospital for Special Surgery, New York, New York, United States
| | | | | | - Kenneth J Warrington
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | | | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Grieshaber-Bouyer R, Radtke FA, Cunin P, Stifano G, Levescot A, Vijaykumar B, Nelson-Maney N, Blaustein RB, Monach PA, Nigrovic PA. The neutrotime transcriptional signature defines a single continuum of neutrophils across biological compartments. Nat Commun 2021; 12:2856. [PMID: 34001893 PMCID: PMC8129206 DOI: 10.1038/s41467-021-22973-9] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [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] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 04/01/2021] [Indexed: 02/05/2023] Open
Abstract
Neutrophils are implicated in multiple homeostatic and pathological processes, but whether functional diversity requires discrete neutrophil subsets is not known. Here, we apply single-cell RNA sequencing to neutrophils from normal and inflamed mouse tissues. Whereas conventional clustering yields multiple alternative organizational structures, diffusion mapping plus RNA velocity discloses a single developmental spectrum, ordered chronologically. Termed here neutrotime, this spectrum extends from immature pre-neutrophils, largely in bone marrow, to mature neutrophils predominantly in blood and spleen. The sharpest increments in neutrotime occur during the transitions from pre-neutrophils to immature neutrophils and from mature marrow neutrophils to those in blood. Human neutrophils exhibit a similar transcriptomic pattern. Neutrophils migrating into inflamed mouse lung, peritoneum and joint maintain the core mature neutrotime signature together with new transcriptional activity that varies with site and stimulus. Together, these data identify a single developmental spectrum as the dominant organizational theme of neutrophil heterogeneity.
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Affiliation(s)
- Ricardo Grieshaber-Bouyer
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine V, Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix A Radtke
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine V, Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Pierre Cunin
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Giuseppina Stifano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anaïs Levescot
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brinda Vijaykumar
- Division of Immunology, Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA, USA
| | - Nathan Nelson-Maney
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel B Blaustein
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul A Monach
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Rheumatology Section, VA Boston Healthcare System, Boston, MA, USA
| | - Peter A Nigrovic
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Schnappauf O, Moura NS, Aksentijevich I, Stoffels M, Ombrello AK, Hoffmann P, Barron K, Remmers EF, Hershfield M, Kelly SJ, Cuthbertson D, Carette S, Chung SA, Forbess L, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland L, Pagnoux C, Seo P, Springer JM, Sreih AG, Warrington KJ, Ytterberg SR, Kastner DL, Grayson PC, Merkel PA. Sequence-Based Screening of Patients With Idiopathic Polyarteritis Nodosa, Granulomatosis With Polyangiitis, and Microscopic Polyangiitis for Deleterious Genetic Variants in ADA2. Arthritis Rheumatol 2021; 73:512-519. [PMID: 33021335 PMCID: PMC9945880 DOI: 10.1002/art.41549] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/06/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Deficiency of adenosine deaminase 2 (DADA2) is a monogenic form of vasculitis that can resemble polyarteritis nodosa (PAN). This study was undertaken to identify potential disease-causing sequence variants in ADA2 in patients with idiopathic PAN, granulomatosis with polyangiitis (GPA), or microscopic polyangiitis (MPA). METHODS Patients with idiopathic PAN (n = 118) and patients with GPA or MPA (n = 1,107) were screened for rare nonsynonymous variants in ADA2 using DNA sequencing methods. ADA-2 enzyme activity was assessed in selected serum samples. RESULTS Nine of 118 patients with PAN (7.6%) were identified as having rare nonsynonymous variants in ADA2. Four patients (3.4%) were biallelic for pathogenic or likely pathogenic variants, and 5 patients (4.2%) were monoallelic carriers for 3 variants of uncertain significance and 2 likely pathogenic variants. Serum samples from 2 patients with PAN with biallelic variants were available and showed markedly reduced ADA-2 enzyme activity. ADA-2 enzyme testing of 86 additional patients revealed 1 individual with strongly reduced ADA-2 activity without detectable pathogenic variants. Patients with PAN and biallelic variants in ADA2 were younger at diagnosis than patients with 1 or no variant in ADA2, with no other clinical differences noted. None of the patients with GPA or MPA carried biallelic variants in ADA2. CONCLUSION A subset of patients with idiopathic PAN meet genetic criteria for DADA2. Given that tumor necrosis factor inhibition is efficacious in DADA2 but is not conventional therapy for PAN, these findings suggest that ADA-2 testing should strongly be considered in patients with hepatitis B virus-negative idiopathic PAN.
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Affiliation(s)
- Oskar Schnappauf
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Natalia Sampaio Moura
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Ivona Aksentijevich
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Monique Stoffels
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Amanda K. Ombrello
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Patrycja Hoffmann
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Karyl Barron
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Elaine F. Remmers
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | | | | | - Paul A. Monach
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Daniel L. Kastner
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Peter C. Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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Abstract
Giant cell arteritis (GCA) is a granulomatous systemic vasculitis of large- and medium-sized arteries that affects the elderly. In recent years, advances in diagnostic imaging have revealed a greater degree of large vessel involvement than previously recognized, distinguishing classical cranial- from large vessel (LV)- GCA. GCA often co-occurs with the poorly understood inflammatory arthritis/bursitis condition polymyalgia rheumatica (PMR) and has overlapping features with other non-infectious granulomatous vasculitides that affect the aorta, namely Takayasu Arteritis (TAK) and the more recently described clinically isolated aortitis (CIA). Here, we review the literature focused on the immunopathology of GCA on the background of the three settings in which comparisons are informative: LV and cranial variants of GCA; PMR and GCA; the three granulomatous vasculitides (GCA, TAK, and CIA). We discuss overlapping and unique features between these conditions across clinical presentation, epidemiology, imaging, and conventional histology. We propose a model of GCA where abnormally activated circulating cells, especially monocytes and CD4+ T cells, enter arteries after an unknown stimulus and cooperate to destroy it and review the evidence for how this mechanistically occurs in active disease and improves with treatment.
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Affiliation(s)
- Michelle L Robinette
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Deepak A Rao
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Paul A Monach
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.,Rheumatology Section, VA Boston Healthcare System, Boston, MA, United States
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Lee H, Tedeschi SK, Chen SK, Monach PA, Kim E, Liu J, Pethoe-Schramm A, Yau V, Kim SC. Identification of Acute Giant Cell Arteritis in Real-World Data Using Administrative Claims-Based Algorithms. ACR Open Rheumatol 2021; 3:72-78. [PMID: 33491920 PMCID: PMC7882520 DOI: 10.1002/acr2.11218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 12/28/2022] Open
Abstract
Objective The objective of this study was to validate claims‐based algorithms for identifying acute giant cell arteritis (GCA) that will help generate real‐world evidence on comparative effectiveness research and epidemiologic studies. Among patients identified by the GCA algorithm, we further investigated whether GCA flares could be detected by using claims data. Methods We developed five claims‐based algorithms based on a combination of International Classification of Diseases, Ninth Revision (ICD‐9) diagnosis codes, specialist visits, and dispensed medications using Medicare Parts A, B, and D linked to electronic medical records (2006‐2014). Acute cases of GCA were determined by chart review using the treating physician’s diagnosis of GCA as the gold standard. Among the patients identified with acute GCA, we assessed if a GCA flare occurred during the year after initial diagnosis. Results The number of patients identified by each algorithm ranged from 220 to 896. Positive predictive values (PPVs) of the algorithms ranged from 60.7% to 84.8%. Requirement for disease‐specific workups, multiple diagnosis codes, or specialist visits improved the PPVs. The highest PPV (84.8%) was noted in an algorithm that required two or more diagnosis codes of GCA from inpatient, emergency department, or outpatient rheumatology visits plus a prednisone‐equivalent dose greater than or equal to 40 mg/day occurring 14 days before or after the second ICD‐9 diagnosis date, with the cumulative days’ supply greater than or equal to 14 days. Among patients identified as having GCA, 18.2% of patients had definite evidence of a flare and 25% had a potential flare. Conclusion A claims‐based algorithm requiring two or more ICD‐9 diagnosis codes from inpatient, emergency department, or outpatient rheumatology visits and high‐dose glucocorticoid dispensing can be a useful tool to identify acute GCA cases in large administrative claims databases.
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Affiliation(s)
- Hemin Lee
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sara K Tedeschi
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sarah K Chen
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul A Monach
- Brigham and Women's Hospital, Harvard Medical School, and US Department of Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Erin Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jun Liu
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Seoyoung C Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Ortiz-Fernández L, Saruhan-Direskeneli G, Alibaz-Oner F, Kaymaz-Tahra S, Coit P, Kong X, Kiprianos AP, Maughan RT, Aydin SZ, Aksu K, Keser G, Kamali S, Inanc M, Springer J, Akar S, Onen F, Akkoc N, Khalidi NA, Koening C, Karadag O, Kiraz S, Forbess L, Langford CA, McAlear CA, Ozbalkan Z, Yavuz S, Çetin GY, Alpay-Kanitez N, Chung S, Ates A, Karaaslan Y, McKinnon-Maksimowicz K, Monach PA, Ozer HT, Seyahi E, Fresko I, Cefle A, Seo P, Warrington KJ, Ozturk MA, Ytterberg SR, Cobankara V, Onat AM, Duzgun N, Bıcakcıgil M, Yentür SP, Lally L, Manfredi AA, Baldissera E, Erken E, Yazici A, Kısacık B, Kaşifoğlu T, Dalkilic E, Cuthbertson D, Pagnoux C, Sreih A, Reales G, Wallace C, Wren JD, Cunninghame-Graham DS, Vyse TJ, Sun Y, Chen H, Grayson PC, Tombetti E, Jiang L, Mason JC, Merkel PA, Direskeneli H, Sawalha AH. Identification of susceptibility loci for Takayasu arteritis through a large multi-ancestral genome-wide association study. Am J Hum Genet 2021; 108:84-99. [PMID: 33308445 DOI: 10.1016/j.ajhg.2020.11.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/17/2020] [Indexed: 12/21/2022] Open
Abstract
Takayasu arteritis is a rare inflammatory disease of large arteries. We performed a genetic study in Takayasu arteritis comprising 6,670 individuals (1,226 affected individuals) from five different populations. We discovered HLA risk factors and four non-HLA susceptibility loci in VPS8, SVEP1, CFL2, and chr13q21 and reinforced IL12B, PTK2B, and chr21q22 as robust susceptibility loci shared across ancestries. Functional analysis proposed plausible underlying disease mechanisms and pinpointed ETS2 as a potential causal gene for chr21q22 association. We also identified >60 candidate loci with suggestive association (p < 5 × 10-5) and devised a genetic risk score for Takayasu arteritis. Takayasu arteritis was compared to hundreds of other traits, revealing the closest genetic relatedness to inflammatory bowel disease. Epigenetic patterns within risk loci suggest roles for monocytes and B cells in Takayasu arteritis. This work enhances understanding of the genetic basis and pathophysiology of Takayasu arteritis and provides clues for potential new therapeutic targets.
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Gribbons KB, Ponte C, Carette S, Craven A, Cuthbertson D, Hoffman GS, Khalidi NA, Koening CL, Langford CA, Maksimowicz-McKinnon K, McAlear CA, Monach PA, Moreland LW, Pagnoux C, Quinn KA, Robson JC, Seo P, Sreih AG, Suppiah R, Warrington KJ, Ytterberg SR, Luqmani R, Watts R, Merkel PA, Grayson PC. Patterns of Arterial Disease in Takayasu Arteritis and Giant Cell Arteritis. Arthritis Care Res (Hoboken) 2020; 72:1615-1624. [PMID: 31444857 DOI: 10.1002/acr.24055] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To identify and validate, using computer-driven methods, patterns of arterial disease in Takayasu arteritis (TAK) and giant cell arteritis (GCA). METHODS Patients with TAK or GCA were studied from the Diagnostic and Classification Criteria for Vasculitis (DCVAS) cohort and a combined North American cohort. Case inclusion required evidence of large-vessel involvement, defined as stenosis, occlusion, or aneurysm by angiography/ultrasonography, or increased 18 F-fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET) in at least 1 of 11 specified arterial territories. K-means cluster analysis identified groups of patients based on the pattern of arterial involvement. Cluster groups were identified in the DCVAS cohort and independently validated in the North American cohort. RESULTS A total of 1,068 patients were included (DCVAS cohort: TAK = 461, GCA = 217; North American cohort: TAK = 225, GCA = 165). Six distinct clusters of patients were identified in DCVAS and validated in the North American cohort. Patients with TAK were more likely to have disease in the abdominal vasculature, bilateral disease of the subclavian and carotid arteries, or focal disease limited to the left subclavian artery than GCA (P < 0.01). Patients with GCA were more likely to have diffuse disease, involvement of bilateral axillary/subclavian arteries, or minimal disease without a definable pattern than TAK (P < 0.01). Patients with TAK were more likely to have damage by angiography, and patients with GCA were more likely to have arterial FDG uptake by PET without associated vascular damage. CONCLUSION Arterial patterns of disease highlight both shared and divergent vascular patterns between TAK and GCA and should be incorporated into classification criteria for large-vessel vasculitis.
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Affiliation(s)
- K Bates Gribbons
- National Institute of Arthritis and Musculoskeletal and Skin Diseases/NIH, Bethesda, Maryland
| | | | - Simon Carette
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | - Paul A Monach
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | | | - Christian Pagnoux
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kaitlin A Quinn
- National Institute of Arthritis and Musculoskeletal and Skin Diseases/NIH, Bethesda, Maryland, and Georgetown University, Washington, DC
| | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | - Ravi Suppiah
- Auckland District Health Board, Auckland, New Zealand
| | | | | | | | - Richard Watts
- Norwich Medical School, University of East Anglia, Norwich, and University of Oxford, Oxford, UK
| | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases/NIH, Bethesda, Maryland
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Aghayev A, Bay CP, Tedeschi S, Monach PA, Campia U, Gerhard-Herman M, Steigner ML, Mitchell RN, Docken WP, DiCarli M. Clinically isolated aortitis: imaging features and clinical outcomes: comparison with giant cell arteritis and giant cell aortitis. Int J Cardiovasc Imaging 2020; 37:1433-1443. [PMID: 33128155 DOI: 10.1007/s10554-020-02087-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
(1) describe imaging features of CIA, (2) compare dilation rate and wall thickening of aortic aneurysms in patients with CIA versus those with giant cell arteritis/aortitis (GCA), (3) present clinical outcomes of CIA patients. Retrospective search of electronic records from 2004 to 2018 yielded 71 patients, 52 of whom were female, with a mean age of 67.5 ± 9.0 years old, with a new clinical diagnosis of cranial or extracranial GCA (GCA group), and giant cell aortitis revealed by the aortic biopsy (CIA group). Comparisons between groups were conducted using the Wilcoxon rank-sum and Fisher's exact tests. Survival from the date of initial diagnosis to the end of data collection was compared between the two groups through a log-rank test. CIA patients (n = 23; 32%) presented with cardiovascular symptoms, and none had systemic inflammatory symptoms. Inflammatory markers were significantly higher among GCA patients than among CIA patients (p < 0.0001). The CIA group demonstrated thoracic aortic aneurysms without wall thickening. None of the GCA patients (n = 48; 68%) had aneurysmal dilation in the aorta at the time of diagnosis. None of the four CIA patients had FDG uptake in the aorta, while nine out of 13 GCA patients had FDG uptake in the vessels. There was no statistically significant difference in the survival between the two groups (p = 0.12). CIA patients presented with cardiovascular symptoms and was characterized by aneurysm of the aorta without the involvement of the infrarenal aortic segment. The role of FDG-PET/CT in CIA is less certain, though none of the patients in this cohort had FDG uptake in the vessels.
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Affiliation(s)
- Ayaz Aghayev
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Camden P Bay
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Tedeschi
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul A Monach
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Gerhard-Herman
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael L Steigner
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Richard N Mitchell
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - William P Docken
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo DiCarli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Thompson GE, Fussner LA, Hummel AM, Schroeder DR, Silva F, Snyder MR, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Specks U. Clinical Utility of Serial Measurements of Antineutrophil Cytoplasmic Antibodies Targeting Proteinase 3 in ANCA-Associated Vasculitis. Front Immunol 2020; 11:2053. [PMID: 33013868 PMCID: PMC7495134 DOI: 10.3389/fimmu.2020.02053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The utility of ANCA testing as an indicator of disease activity in ANCA-associated vasculitis (AAV) remains controversial. This study aimed to determine the association of ANCA testing by various methods and subsequent remission and examine the utility of a widely used automated addressable laser-bead immunoassay (ALBIA) to predict disease relapses. Methods: Data from the Rituximab vs. Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial were used. ANCA testing was performed by direct ELISA, capture ELISA, and ALBIA. Cox proportional hazards regression models were used to evaluate the association of PR3-ANCA level and subsequent remission or relapse. The ALBIA results are routinely reported as >8 when the value is high. For this study, samples were further titrated. A decrease and increase in PR3-ANCA were defined as a halving or doubling in value, respectively. Results: A decrease in ANCA by ALBIA at 2 months was associated with shorter time to sustained remission (HR 4.52, p = 0.035). A decrease in ANCA by direct ELISA at 4 months was associated with decreased time to sustained remission (HR 1.77, p = 0.050). There were no other associations between ANCA decreases or negativity and time to remission. An increase in PR3-ANCA by ALBIA was found in 78 of 93 subjects (84%). Eleven (14%) had a PR3-ANCA value which required titration for detection of an increase. An increase of ANCA by ALBIA was associated with severe relapse across various subgroups. Conclusions: A decrease in ANCA by ALBIA at 2 months and by direct ELISA at 4 months may be predictive of subsequent remission. These results should be confirmed in a separate cohort with similarly protocolized sample and clinical data collection. A routinely used automated ALBIA for PR3-ANCA measurement is comparable to direct ELISA in predicting relapse in PR3-AAV. Without titration, 14% of the increases detected by ALBIA would have been missed. Titration is recommended when this assay is used for disease monitoring. The association of an increase in PR3-ANCA with the risk of subsequent relapse remains complex and is affected by disease phenotype and remission induction agent.
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Affiliation(s)
- Gwen E Thompson
- Essentia Health, Division of Pulmonary and Critical Care, Fargo, ND, United States.,Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Amber M Hummel
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Darrell R Schroeder
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Francisco Silva
- Department of Rheumatology, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Melissa R Snyder
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Carol A Langford
- Cleveland Clinic, Division of Rheumatology, Cleveland, OH, United States
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, United States
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| | - Robert F Spiera
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, United States
| | | | - John H Stone
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, United States
| | - Ulrich Specks
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
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Goel R, Gribbons KB, Carette S, Cuthbertson D, Hoffman GS, Joseph G, Khalidi NA, Koening CL, Kumar S, Langford C, Maksimowicz-McKinnon K, McAlear CA, Monach PA, Moreland LW, Nair A, Pagnoux C, Quinn KA, Ravindran R, Seo P, Sreih AG, Warrington KJ, Ytterberg SR, Merkel PA, Danda D, Grayson PC. Derivation of an angiographically based classification system in Takayasu's arteritis: an observational study from India and North America. Rheumatology (Oxford) 2020; 59:1118-1127. [PMID: 31580452 DOI: 10.1093/rheumatology/kez421] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/08/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To develop and replicate, using data-driven methods, a novel classification system in Takayasu's arteritis based on distribution of arterial lesions. METHODS Patients were included from four international cohorts at major academic centres: India (Christian Medical College Vellore); North America (National Institutes of Health, Vasculitis Clinical Research Consortium and Cleveland Clinic Foundation). All patients underwent whole-body angiography of the aorta and branch vessels, with categorization of arterial damage (stenosis, occlusion or aneurysm) in 13 territories. K-means cluster analysis was performed to identify subgroups of patients based on pattern of angiographic involvement. Cluster groups were identified in the Indian cohort and independently replicated in the North American cohorts. RESULTS A total of 806 patients with Takayasu's arteritis from India (n = 581) and North America (n = 225) were included. Three distinct clusters defined by arterial damage were identified in the Indian cohort and replicated in each of the North American cohorts. Patients in cluster one had significantly more disease in the abdominal aorta, renal and mesenteric arteries (P < 0.01). Patients in cluster two had significantly more bilateral disease in the carotid and subclavian arteries (P < 0.01). Compared with clusters one and two, patients in cluster three had asymmetric disease with fewer involved territories (P < 0.01). Demographics, clinical symptoms and clinical outcomes differed by cluster. CONCLUSION This large study in Takayasu's arteritis identified and replicated three novel subsets of patients based on patterns of arterial damage. Angiographic-based disease classification requires validation by demonstrating potential aetiological or prognostic implications.
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Affiliation(s)
- Ruchika Goel
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - K Bates Gribbons
- Systemic Autoimmunity Branch, NIAMS, National Institutes of Health, Bethesda, MD, USA
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Gary S Hoffman
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - George Joseph
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Nader A Khalidi
- Division of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Sathish Kumar
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Carol Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Carol A McAlear
- Division of Rheumatology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Paul A Monach
- Division of Rheumatology, VA Boston Healthcare System, Boston, MA
| | - Larry W Moreland
- Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA
| | - Aswin Nair
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | | | - Kaitlin A Quinn
- Systemic Autoimmunity Branch, NIAMS, National Institutes of Health, Bethesda, MD, USA.,Division of Rheumatology, Georgetown University, Washington DC, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD
| | - Antoine G Sreih
- Division of Rheumatology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | | | | | - Peter A Merkel
- Division of Rheumatology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Peter C Grayson
- Systemic Autoimmunity Branch, NIAMS, National Institutes of Health, Bethesda, MD, USA
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45
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Quinn KA, Gribbons KB, Carette S, Cuthbertson D, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Pagnoux C, Seo P, Sreih AG, Warrington KJ, Ytterberg SR, Novakovich E, Merkel PA, Grayson PC. Patterns of clinical presentation in Takayasu's arteritis. Semin Arthritis Rheum 2020; 50:576-581. [PMID: 32460147 DOI: 10.1016/j.semarthrit.2020.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Takayasu's arteritis (TAK) is a clinically heterogenous disease. Patterns of clinical presentation in TAK at diagnosis have not been well described, and a "triphasic pattern" of constitutional symptoms evolving into vascular inflammation and fibrosis has been reported but never systematically evaluated. METHODS Patients with TAK were prospectively recruited from the National Institutes of Health (NIH) and the Vasculitis Clinical Research Consortium (VCRC). Based on clinical presentation at diagnosis, patients were divided into five categories: (1) constitutional symptoms alone, (2) carotidynia, (3) other vascular-associated symptoms, (4) major ischemic event, or (5) asymptomatic. Associated clinical characteristics were evaluated in each category. Preceding symptoms were also assessed to determine the presence of a triphasic disease pattern. RESULTS A total of 275 patients with TAK were included (VCRC=208; NIH=67). Similar heterogeneity of clinical presentation was identified in each cohort: constitutional symptoms (8%), carotidynia (13-15%), other vascular symptoms (43-47%), major ischemic event (28-30%), and asymptomatic (2-6%). An increased relative proportion of males was seen in patients who presented with constitutional symptoms or were asymptomatic at diagnosis (p<0.01). Patients who presented with constitutional symptoms and major ischemic events were youngest at diagnosis. Patients in the asymptomatic group were oldest at diagnosis and often were not treated (p<0.01). Relapse was most frequent in patients who presented with carotidynia (p<0.01). A minority of patients (19%) who presented with a major ischemic event reported a triphasic pattern of disease. CONCLUSION There are diverse clinical presentations at diagnosis in TAK. Patients do not necessarily progress sequentially through phases of disease.
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Affiliation(s)
- Kaitlin A Quinn
- Division of Rheumatology, MedStar Georgetown University Hospital, Washington DC, USA; Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA.
| | - K Bates Gribbons
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, CA
| | - David Cuthbertson
- Department of Biostatistics, University of South Florida, Tampa, FL, USA
| | | | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carol A McAlear
- Division of Rheumatology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Monach
- Division of Rheumatology, VA Boston Healthcare System, Boston, MA, USA
| | | | - Christian Pagnoux
- Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, CA
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, MD, USA
| | - Antoine G Sreih
- Division of Rheumatology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Elaine Novakovich
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Peter A Merkel
- Division of Rheumatology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
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46
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Quinn KA, Gelbard A, Sibley C, Sirajuddin A, Ferrada MA, Chen M, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Ytterberg SR, Merkel PA, Grayson PC. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology (Oxford) 2020; 58:2203-2211. [PMID: 31199488 DOI: 10.1093/rheumatology/kez217] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe tracheobronchial disease in patients with granulomatosis with polyangiitis (GPA) and evaluate the utility of dynamic expiratory CT to detect large-airway disease. METHODS Demographic and clinical features associated with the presence of subglottic stenosis (SGS) or endobronchial involvement were assessed in a multicentre, observational cohort of patients with GPA. A subset of patients with GPA from a single-centre cohort underwent dynamic chest CT to evaluate the airways. RESULTS Among 962 patients with GPA, SGS and endobronchial disease were identified in 95 (10%) and 59 (6%) patients, respectively. Patients with SGS were more likely to be female (72% vs 53%, P < 0.01), younger at time of diagnosis (36 vs 49 years, P < 0.01), and have saddle-nose deformities (28% vs 10%, P < 0.01), but were less likely to have renal involvement (39% vs 62%, P < 0.01). Patients with endobronchial disease were more likely to be PR3-ANCA positive (85% vs 66%, P < 0.01), with more ENT involvement (97% vs 77%, P < 0.01) and less renal involvement (42% vs 62%, P < 0.01). Disease activity in patients with large-airway disease was commonly isolated to the subglottis/upper airway (57%) or bronchi (32%). Seven of 23 patients screened by dynamic chest CT had large-airway pathology, including four patients with chronic, unexplained cough, discovered to have tracheobronchomalacia. CONCLUSION SGS and endobronchial disease occur in 10% and 6% of patients with GPA, respectively, and may occur without disease activity in other organs. Dynamic expiratory chest CT is a potential non-invasive screening test for large-airway involvement in GPA.
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Affiliation(s)
- Kaitlin A Quinn
- Division of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA.,Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Alexander Gelbard
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, TN, USA
| | - Cailin Sibley
- Division of Arthritis & Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
| | | | - Marcela A Ferrada
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Marcus Chen
- National Institutes of Health, NHLBI, Bethesda, MD, USA
| | - David Cuthbertson
- Biostatistics and Informatics, University of South Florida, Tampa, FL, USA
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada
| | - Nader A Khalidi
- Division of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Larry W Moreland
- Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, MN, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven R Ytterberg
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
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47
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Moran SM, Monach PA, Zgaga L, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland L, Pagnoux C, Seo P, Specks U, Sreih A, Wyse J, Ytterberg SR, Merkel PA, Little MA. Urinary soluble CD163 and monocyte chemoattractant protein-1 in the identification of subtle renal flare in anti-neutrophil cytoplasmic antibody-associated vasculitis. Nephrol Dial Transplant 2020; 35:283-291. [PMID: 30380100 PMCID: PMC8205505 DOI: 10.1093/ndt/gfy300] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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: 04/12/2018] [Accepted: 08/18/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prior work has shown that urinary soluble CD163 (usCD163) displays excellent biomarker characteristics for detection of active renal vasculitis using samples that included new diagnoses with highly active renal disease. This study focused on the use of usCD163 in the detection of the more clinically relevant state of mild renal flare and compared results of usCD163 testing directly to testing of urinary monocyte chemoattractant protein-1 (uMCP-1). METHODS Patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV, n = 88) were identified within a serially sampled, longitudinal and multicentre cohort. Creatinine-normalized usCD163 and uMCP-1 levels were measured by enzyme-linked immunosorbent assay and, both alone and in combination, were compared between times of active renal AAV and during remission and/or active non-renal AAV. RESULTS Samples from 320 study visits included times of active renal vasculitis (n = 39), remission (n = 233) and active extrarenal vasculitis (n = 48). Median creatinine levels were 0.9 mg/dL [interquartile range (IQR) 0.8-1.2] in remission and 1.4 mg/dL (IQR 1.0-1.8) during renal flare. usCD163 levels were higher in patients with active renal vasculitis compared with patients in remission and those with active extrarenal vasculitis, with median values of 162 ng/mmol (IQR 79-337), 44 (17-104) and 38 (7-76), respectively (P < 0.001). uMCP-1 levels were also higher in patients with active renal vasculitis compared with patients in remission and those with active extrarenal vasculitis, with median values of 10.6 pg/mmol (IQR 4.6-23.5), 4.1 (2.5-8.4) and 4.1 (1.9-6.8), respectively (P < 0.001). The proposed diagnostic cut-points for usCD163 and uMCP-1 were 72.9 ng/mmol and 10.0 pg/mmol, respectively. usCD163 and uMCP-1 levels were marginally correlated (r2 = 0.11, P < 0.001). Combining novel and existing biomarkers using recursive tree partitioning indicated that elevated usCD163 plus either elevated uMCP-1 or new/worse proteinuria improved the positive likelihood ratio (PLR) of active renal vasculitis to 19.2. CONCLUSION A combination of usCD163 and uMCP-1 measurements appears to be useful in identifying the diagnosis of subtle renal vasculitis flare.
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Affiliation(s)
- Sarah M Moran
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Paul A Monach
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, USA
- Rheumatology Section, VA Boston Healthcare System, Boston, MA, USA
| | - Lina Zgaga
- Department of Public Health and General Practice, Trinity College Dublin, Dublin, Ireland
| | - David Cuthbertson
- Department of Biostatistics and Informatics, Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Nader A Khalidi
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | | | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Larry Moreland
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Antoine Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Wyse
- Discipline of Statistics, School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | - Steven R Ytterberg
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Trinity College Dublin, Dublin, Ireland
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48
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Ford JA, Monach PA. Disease heterogeneity in antineutrophil cytoplasmic antibody-associated vasculitis: implications for therapeutic approaches. Lancet Rheumatol 2019; 1:e247-e256. [PMID: 38229381 DOI: 10.1016/s2665-9913(19)30077-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/20/2019] [Accepted: 10/02/2019] [Indexed: 01/18/2024]
Abstract
In recent decades, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis has transformed from an almost uniformly fatal disease to a treatable form of primary systemic vasculitis. Substantial disease heterogeneity exists within ANCA-associated vasculitis and the increasing understanding of this heterogeneity has implications for guiding treatment decisions. Approaches to induction and maintenance therapy vary depending on disease severity, clinical manifestations, and patient-specific factors. In this narrative Review, we examine how disease heterogeneity in ANCA-associated vasculitis, with respect to disease severity, clinical presentations, and ANCA specificity, influences therapeutic decision making. Many questions regarding therapeutic strategies in ANCA-associated vasculitis remain unanswered, and these should guide future research in this complex group of diseases.
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Affiliation(s)
- Julia A Ford
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Paul A Monach
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Veterans Affairs Boston Healthcare System, Boston, MA, USA
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49
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Kronbichler A, Leierer J, Shin JI, Merkel PA, Spiera R, Seo P, Langford CA, Hoffman GS, Kallenberg CGM, St Clair EW, Brunetta P, Fervenza FC, Geetha D, Keogh KA, Monach PA, Ytterberg SR, Mayer G, Specks U, Stone JH. Association of Pulmonary Hemorrhage, Positive Proteinase 3, and Urinary Red Blood Cell Casts With Venous Thromboembolism in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2019; 71:1888-1893. [PMID: 31216123 PMCID: PMC6899947 DOI: 10.1002/art.41017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/13/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the frequency of venous thromboembolism (VTE) events in the Rituximab in Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis (RAVE) trial and identify novel potential risk factors. METHODS VTE events in 197 patients enrolled in the RAVE trial were analyzed. Baseline demographic and clinical characteristics were recorded, and univariate and multivariate analyses were performed to identify factors associated with VTE in ANCA-associated vasculitis (AAV). RESULTS VTE occurred in 16 patients (8.1%) with an overall average time to event of 1.5 months (range 1.0-2.75). In univariate analyses with calculation of hazard ratios (HRs) and 95% confidence intervals (95% CIs), heart involvement (HR 17.408 [95% CI 2.247-134.842]; P = 0.006), positive proteinase 3 (PR3)-ANCA (HR 7.731 [95% CI 1.021-58.545]; P = 0.048), pulmonary hemorrhage (HR 3.889 [95% CI 1.448-10.448]; P = 0.008), and the presence of red blood cell casts (HR 15.617 [95% CI 3.491-69.854]; P < 0.001) were associated with the onset of VTE. In multivariate models adjusted for age and sex, the significant associations between VTE events and heart involvement (HR 21.836 [95% CI 2.566-185.805]; P = 0.005), PR3-ANCA (HR 9.12 [95% CI 1.158-71.839]; P = 0.036), pulmonary hemorrhage (HR 3.91 [95% CI 1.453-10.522]; P = 0.007), and urinary red blood cell casts (HR 16.455 [95% CI 3.607-75.075]; P < 0.001) remained. CONCLUSION Patients diagnosed as having AAV with pulmonary hemorrhage, positive PR3-ANCA, heart involvement, and the presence of red blood cell casts are at an increased risk to develop VTE. Further studies are needed to confirm and expand these findings and to explore the mechanisms of hypercoagulability in these patients with the aim of informing potential targets for therapeutic intervention.
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Affiliation(s)
| | | | - Jae Il Shin
- Yonsei University College of Medicine and Severance Children's Hospital, Seoul, Republic of Korea
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | - Carol A Langford
- Center for Vasculitis Care and Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gary S Hoffman
- Center for Vasculitis Care and Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | | | | | | | | | | | | | - Gert Mayer
- Medical University Innsbruck, Innsbruck, Austria
| | - Ulrich Specks
- Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John H Stone
- Massachusetts General Hospital, Harvard Medical School, Boston
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50
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Rodriguez-Pla A, Warner RL, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Ytterberg SR, Johnson KJ, Merkel PA, Monach PA. Evaluation of Potential Serum Biomarkers of Disease Activity in Diverse Forms of Vasculitis. J Rheumatol 2019; 47:1001-1010. [PMID: 31474593 PMCID: PMC7050393 DOI: 10.3899/jrheum.190093] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE We evaluated potential circulating biomarkers of disease activity in giant cell arteritis (GCA), Takayasu arteritis (TA), polyarteritis nodosa (PAN), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS A panel of 22 serum proteins was tested in patients enrolled in the Vasculitis Clinical Research Consortium Longitudinal Studies of GCA, TA, PAN, or EGPA. Mixed models were used for most analyses. A J48 classification tree method was used to find the most relevant markers to differentiate between active and inactive GCA. RESULTS Tests were done on 418 samples from 152 patients (60 GCA, 29 TA, 26 PAN, 37 EGPA), during both active vasculitis and remission. In GCA, these showed significant (p < 0.05) differences between disease states: B cell-attracting chemokine 1 (BCA)-1/CXC motif ligand 13 (CXCL13), erythrocyte sedimentation rate (ESR), interferon-γ-induced protein 10/CXC motif chemokine 10, soluble interleukin 2 receptor α (sIL-2Rα), and tissue inhibitor of metalloproteinase-1 (TIMP-1). In EGPA, these showed significant increases during active disease: granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage-CSF, interleukin (IL)-6, IL-15, and sIL-2Rα. BCA-1/CXCL13 also showed such increases, but only after adjustment for treatment. In PAN, ESR and matrix metalloprotease (MMP)-3 showed significant differences between disease states. Differences in biomarker levels between diseases were significant for 11 markers and were more striking (all p < 0.01) than differences related to disease activity. A combination of lower values of TIMP-1, IL-6, interferon-γ, and MMP-3 correctly classified 87% of samples with inactive GCA. CONCLUSION We identified novel biomarkers of disease activity in GCA and EGPA. Differences of biomarker levels between diseases, independent of disease activity, were more apparent than differences related to disease activity. Further studies are needed to determine whether these serum proteins have potential for clinical use in distinguishing active disease from remission or in predicting longer-term outcomes.
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Affiliation(s)
- Alicia Rodriguez-Pla
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Roscoe L Warner
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - David Cuthbertson
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Simon Carette
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Nader A Khalidi
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Curry L Koening
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Carol A Langford
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Carol A McAlear
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Larry W Moreland
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Christian Pagnoux
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Philip Seo
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Ulrich Specks
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Antoine G Sreih
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Steven R Ytterberg
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Kent J Johnson
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
| | - Peter A Merkel
- From Boston University, Boston, Massachusetts; University of Arizona, Tucson, Arizona; University of Michigan, Ann Arbor, Michigan; University of South Florida, Tampa, Florida, USA; Mount Sinai Hospital, Toronto; McMaster University, Hamilton, Ontario, Canada; University of Utah, Salt Lake City, Utah; Cleveland Clinic, Cleveland, Ohio; University of Pennsylvania, Philadelphia; University of Pittsburgh, Pittsburgh, Pennsylvania; Johns Hopkins University, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; VA Boston Healthcare System, Boston, Massachusetts, USA.,A. Rodriguez-Pla, MD, PhD, MPH, Boston University, and the University of Arizona; R.L. Warner, PhD, University of Michigan; D. Cuthbertson, MS, University of South Florida; S. Carette, MD, Mount Sinai Hospital; N.A. Khalidi, MD, McMaster University; C.L. Koening, MD, MS, University of Utah; C.A. Langford, MD, MHS, Cleveland Clinic; C.A. McAlear, MD, University of Pennsylvania; L.W. Moreland, MD, University of Pittsburgh; C. Pagnoux, MD, MPH, Mount Sinai Hospital; P. Seo, MD, MHS, Johns Hopkins University; U. Specks, MD, Mayo Clinic; A.G. Sreih, MD, University of Pennsylvania; S.R. Ytterberg, MD, Mayo Clinic; K.J. Johnson, MD, University of Arizona; P.A. Merkel, MD, MPH, University of Pennsylvania; P.A. Monach, MD, PhD, Boston University, and the VA Boston Healthcare System
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