Prognostic factors in pemphigus vulgaris and pemphigus foliaceus.

BACKGROUND: Pemphigus typically has a chronic course, although there is great variability in disease duration (DD) and time taken to disease remission (DR) between individuals with the disease. The reasons for this are unclear. OBJECTIVES: To explore the prognostic influence of epidemiological, clinical, immunological and genetic factors on disease course and remission in pemphigus vulgaris (PV) and pemphigus foliaceus (PF). METHODS: This was a retrospective study of patients with PV and PF, recruited from a single UK centre. Direct and indirect immunofluorescence and enzyme-linked immunosorbent assay studies for antidesmoglein (Dsg) antibodies were used to assess immunological factors. Polymerase chain reaction with sequence specific primers (PCR-SSP) was used to assess the Class II human leukocyte antigen status of patients. Prognostic endpoints investigated were time to initial first DR and total DD. RESULTS: Ninety-five patients were recruited (79 PV and 16 PF). Patients of Indo-Asian origin were significantly associated with longer DD than White-British patients (P = 0.029). In addition, younger age at onset was associated with a worse prognosis in terms of DD: the mean age at presentation of patients with DD of < 5 years was 49 years (SEM = 3.4) compared with 40 years (SEM = 1.9) in those with DD > 5 years (P = 0.039). A higher initial intercellular antibody titre on normal human skin substrate was associated with a greater time to initial DR (P = 0.007) and high anti-Dsg 3 levels at baseline were associated with a longer total DD (P = 0.03). CONCLUSIONS: Ethnic group, age at presentation, initial intercellular antibody titre and initial Dsg 3 antibody levels all had a significant impact on prognosis of pemphigus.

Magnetic resonance studies of lunar samples.

Electron spin resonance searches at 9.5 gigahertz on several fines samples and portions of several rocks have yielded signals whose lineshapes and temperature dependences show that the samples are principally ferromagnetic in nature. Proton magnetic resonance searches at 60 megahertz of these samples have not revealed any signals ascribable to water or any other types of hydrogen in concentrations greater than 0.0001 percent by weight contained in narrow lines (5 oersteds wide or less) and 0.01 percent by weight in wide lines (as wide as 100 oersteds).

Are cytokine gene polymorphisms associated with outcome in patients with idiopathic intermediate uveitis in the United Kingdom?

BACKGROUND/AIM: Competing levels of cytokines, either locally within the eye or systemically, may influence the eventual outcome of ocular inflammation. Polymorphism in the promoter part of the genes controlling cytokine production may result in either higher or lower production of the relevant cytokine to a given stimulus. The authors hypothesised that such polymorphisms may relate to visual outcome in patients with idiopathic intermediate uveitis. METHODS: DNA was obtained from 125 patients with idiopathic intermediate uveitis and analysed for the interleukin 10 IL-10-1082G/Alpha and IL-10-819C/T, and interferon gamma IFNgamma 874T/A gene polymorphisms. Associations with disease were calculated by both allelic frequency and haplotype analysis, and associations between ocular disease outcomes and the presence of polymorphisms were identified. A bad outcome was defined as loss of vision <6/12 Snellen in both eyes at 5 years from presentation when the eyes were quiet. RESULTS: An initial screen showed that the 874T allele of the IFNgamma gene was more prevalent in patients than controls (chi2= 7.9; p = 0.004 OR 1.7; 95% CI 1.2 to 2.6 (Pc = 0.02), whereas the IL-10-1082/-819 AT haplotype of the interleukin 10 (IL-10) gene was not. Analysis of disease outcome showed an association between IL-10-1082 AA homozygosity and bad outcome (chi2= 13; p = 0.0003). Moreover, the two cytokine polymorphisms taken together showed that up to 75% of patients with a poor visual outcome had the combined IFNgamma 874TA or TT genotype together with the IL-10-1082AA genotype (chi2= 13.2 p = 0.0008 OR 6.4; 95% CI 1.85 to 23.6 Pc = 0.1). CONCLUSION: These results show that disease outcome in intermediate uveitis may be partly determined by a complex interplay between cytokine genes and these results may have implications for future treatment with biological agents that target these cytokines.

HLA-DR4 may determine expression of actinic prurigo in British patients.

Human leukocyte antigen (HLA) associations have been reported in Amerindian patients with actinic prurigo. To determine if similar associations are present in the British Caucasoid population with actinic prurigo, 26 patients underwent serological typing for HLC Class I and II antigens. DNA analysis by both sequence-specific priming and group-specific amplification with single-stranded oligonucleotide probe hybridization was used to confirm the DR and DQ typing and to perform DR4 subtyping. All patients were DR4 positive, and 25 of 26 patients were DQ7 positive. DR4 subtyping revealed 12 of 20 patients tested to be DRB1*0407. A nonsignificant association was also found with HLA B55 that is in linkage disequilibrium with DRB1*0407. No HLA associations were found in 25 British Caucasoid patients with polymorphic light eruption. DRB1*0407 is rare in European Caucasoids without actinic prurigo, and HLA-DR4 may have an important role in determining expression of this disease.

HLA-class II alleles in Guillain-Barré syndrome and Miller Fisher syndrome and their association with preceding Campylobacter jejuni infection.

HLA typing for class II alleles was performed on 97 patients with Guillain-Barré syndrome or Miller Fisher syndrome and compared with 100 controls. There was a significant association between HLA-DQB1*03 and preceding Campylobacter jejuni infection (Pc = 0.05).

Immunoglobulin (Gm) allotype frequencies in idiopathic membranous nephropathy and minimal change nephropathy.

40 Caucasoid patients with idiopathic membranous nephropathy (IMN) and 49 Caucasoid patients with minimal change nephropathy (MCN) were immunoglobulin allotyped for the Gm markers G1m (1, 2, 3) and G3m (5, 11, 21). Compared with normal controls the IMN group had a significantly decreased incidence of the G1m (3); G3m (5, 11) phenotype (P = less than 0.005). This decrease was accompanied by concommitant increase in both the G1m (1, 3); G3m (5, 11, 21) and the G1m (1, 2, 3); G3m (5, 11, 21) phenotypes. The result was most pronounced in IMN patients with deteriorating renal function. In contrast no significant differences were observed between the Gm phenotype frequencies of the MCN patients and controls.

The clinical importance of variation within the HLA-Bw4 complex.

BACKGROUND: Antibody screening of a patient with a failed renal transplant showed positive reactions with most, but not all HLA-Bw4-associated B-locus antigens. However, the patient's serological HLA class I type suggested the presence of HLA-Bw4. METHODS: Standard molecular techniques were used to re-type the patient and donor. ELISA antibody screening helped determine the patient's antibody specificity. RESULTS: The patient's type was HLA-B*1402,4703;Bw6 and the donor HLA-B*4703,51011;Bw4,6. Analysis of ELISA results identified three amino acids (positions 77,80,81) as the most likely epitope recognised by the patient's serum. These corresponded to HLA-B*51011 amino acid mismatches, explaining the lymphocytotoxic reactivity pattern. This epitope is located on a subgroup of the HLA-Bw4 antigen suggesting anti-Bw4 was not a sufficient description of this antibody. CONCLUSIONS: This report identifies an antibody to a sub-group of the Bw4 public specificity and also confirms the need for sequence-level analysis in the tissue-typing laboratory to determine future unacceptable mismatches.

Major histocompatibility complex class I and class II polymorphism in chronic idiopathic demyelinating polyradiculoneuropathy.

Thirty-one chronic idiopathic demyelinating polyradiculoneuropathy (CIDP) patients have been typed for HLA-A, -B and -C antigens serologically and for HLA-DR, -DQ and -DP class II genes by RFLP analysis. Our results confirm a previously reported slight association with HLA-B8 and identify a stronger association with HLA-Cw7.

IgG donor-specific crossmatches are not associated with graft rejection or poor graft survival after liver transplantation. An assessment by cytotoxicity and flow cytometry.

Early studies in liver transplantation suggested that there was no association between graft outcome or rejection and the presence of alloantibodies before transplantation. More recent reports have suggested lower graft survival rates and a higher incidence of chronic rejection in patients with IgG warm-T crossmatches. In the present study, panel reactive antibody, direct crossmatch testing, and flow cytometry were used to detect preformed antibodies in sera from 158 consecutive adult recipients of first hepatic grafts. The relationship between preformed antidonor antibodies and liver allograft survival and rejection was determined. Twenty-six (17%) patients were panel reactive antibody (PRA)-positive before transplantation, 22 (15%) had positive donor-specific crossmatches, and 14 (9%) were positive by IgG-specific flow cytometry. Cumulative survival distribution and multivariate analysis failed to reveal any significant associations between overall graft survival and antibody status. Graft survival in patients with PRA-positive sera was 81% compared with 77% for those with PRA-negative sera, 68% for those with positive donor-specific crossmatches compared with 80% for those who were donor-specific crossmatch negative, and 79% for those who were antibody positive by flow cytometric analysis compared with 78% for those who were antibody negative. Subgroup analysis also failed to reveal any significant associations. In addition, Cox proportional hazards regression analysis failed to reveal a relationship between acute or chronic graft rejection with the presence or absence of preformed antibodies, irrespective of immunoglobulin class, cell type (T or non-T), specificity, or technique used for antibody detection. In conclusion, there appears to be no association between either donor-specific or "third-party" alloreactive IgG or IgM antibodies and liver transplant survival or rejection. These data do not indicate a need for prospective crossmatching of liver transplant recipients.

Detection of HLA-specific IGG antibodies using single recombinant HLA alleles: the MonoLISA assay.

BACKGROUND: Because of the presence of confounding antigens, the assignment of HLA antibody specificity is difficult in highly sensitized patients, and the definition of an acceptable HLA mismatch requires a significant workload per patient. We describe a new ELISA method, monoLISA, for detection of immunoglobulin (Ig)G HLA antibody using single recombinant HLA class I monomers bound to microtiter plates. METHODS: HLA-A2 and -B8 monomers were synthesized and used as screening targets for 85 sera from renal patients. The sera contained various IgG and IgM HLA-specific antibodies, including anti-A2 and anti-B8,defined in a conventional complement-dependent cytotoxicity test (CDC). Investigations were performed to determine possible effects on antibody binding of differential monomer peptide presentation as well as lack of glycosylation. RESULTS: A good correlation was found between CDC-defined specificities and the reactivity observed with HLA monomers. MonoLISA attained means of 100% sensitivity and 92.5% specificity compared with CDC. Neither the presence of different peptides, nor the absence of glycosylation of the monomer affected the ability of monoLISA to detect antibody. CONCLUSION: This study demonstrates that the mono-LISA method for HLA antibody detection is valid. Because this has the potential to reduce the work involved in screening sensitized patients awaiting transplantation for HLA antibodies, resources aimed at increasing the number of constructed monomers would be well targeted.

Plasma tumor necrosis factor alpha levels and the -238*A promoter polymorphism in patients with antiphospholipid syndrome.

OBJECTIVES: To explore the possible involvement of the proinflammatory and prothrombotic cytokine TNFalpha in APS by determining the plasma levels in patients and to test for association of TNFA promoter polymorphisms and HLA class II genotypes with both plasma TNFalpha and disease. PATIENTS AND METHOD: We studied 83 Caucasoid patients with APS and two groups of healthy controls. TNFalpha levels were determined in plasma from 35 patients' and 21 controls using a highly sensitive sandwich ELISA. The full patient group was genotyped together with 95 ethnically matched healthy controls. -308 and -238 TNFA promoter polymorphisms were assessed by ARMS-PCR. HLA-DQB1, DQA1 and DRB1 genotypes were determined by PCR using sequence specific primers. RESULTS: TNFalpha levels were significantly higher in patients with APS than healthy controls (median 2.95 pg/ml [range 0.51-10.75] vs. 0.95 pg/ml [0.51-1.6], respectively; p = 0.0001). Frequencies of TNFA-308*2 genotype did not differ between patients and controls. In contrast, TNFA-238*A positive genotype was more frequent in APS patients with arterial thrombosis and pregnancy loss than in controls (OR 3.7 [95% CI 1.37-10.1], p = 0.007 and OR 3.95 [95% CI 1.3-11.7], p = 0.01; respectively). DQB1*0303-DRB1*0701 haplotype was associated with TNFA-238*A in the control group (OR 96.0 [95% CI 9.6-959], p <0.0001) as well as in APS patient's group (OR 54.2 [95% CI 9.6-306.5], p <0.0001). CONCLUSIONS: Raised plasma TNFalpha levels were found in patients with APS. As a prothrombotic and proinflammatory cytokine, TNFalpha may be involved in the development of clinical features of APS. The lack of correlation between the TNFA-238 polymorphism and plasma levels associated with disease suggests that the TNF genetic marker may only indirectly relate to protein levels by virtue of allelic association with a functional marker which may reside in the HLA class II region.

Immunoglobulin C mu gene restriction fragment length polymorphisms associated with chronic renal failure.

The DNA's of 41 patients with various forms of renal disease and of 52 controls were investigated for restriction fragment length polymorphisms (RFLP), using a probe recognising the immunoglobulin Cmu heavy chain gene. With the restriction endonuclease Sst 1, 50 of the controls and 12 of the patients had the expected single 4.3 kilobase (kb) fragment. The remaining 29 patients and 2 controls displayed two patterns of banding, 8 patients and 1 control had a 6.8 kb band in addition to the 4.3 kb, and 21 patients and 1 control had a single band of 5.1 kb. In addition, a significant association between high creatinine levels (greater than 150 mumol/l) and abnormal bands was found (21/25 patients with high levels had abnormal bands compared with only 5/16 patients with normal levels). These results are evidence for an association between the human immunoglobulin heavy chain region and renal disease and they apparently confirm an association already reported at the protein level. However, the new RFLP bands, although reproducible and restricted to renal patients, occur in an area where few polymorphisms would be expected. Further, the association with high creatinine suggests some subtle interaction between the creatinine pathway and this area of the human chromosome.

HLA DQA, DQB, and DRB genotyping by oligonucleotide analysis: distribution of alleles and haplotypes in British caucasoids.

A precise method for comprehensive HLA DQA and DQB genotyping using gene amplification and hybridization with sequence-specific oligonucleotide (SSO) probes is described. Twenty-four SSO probes were used to detect all DQ allotypes defined by nucleotide sequence variation in the second exons of the DQ genes, using a standard set of conditions for all probes at each locus. Five hundred individuals were genotyped for 8 DQA1 and 16 DQB1 alleles by using this method and for 33 alleles of the DRB1, DRB3, DRB4, and DRB5 genes by using previously described SSO probes. The 4-locus DQB1-DQA1-DRB1-DRB3/4/5 haplotypes present were characterized on the basis of known linkage disequilibrium between class II alleles. Fifty-two different haplotypes that have previously been described were further characterized at the nucleotide sequence level and two novel haplotypes were identified. The distributions of these alleles and haplotypes in 177 randomly selected healthy Caucasoid controls from the United Kingdom are reported. These results identify further haplotypic diversity in the HLA class II region, even though strong linkage disequilibrium exists between the DR and DQ gene loci.

A family study confirms that the HLA-DP associations with celiac disease are the result of an extended HLA-DR3 haplotype.

Genotyping for HLA-DR, -DQ, and -DP antigens by restriction fragment length polymorphism (RFLP) analysis along with identification of restriction fragments associated with celiac disease (CD) were undertaken in 13 families in which more than one member had CD. Major histocompatibility complex class II haplotypes for the family members were constructed which included both genotypes and RFLP markers. In 12 of the families all the affected members shared an HLA haplotype which included HLA-DR3a, DQw2 and a BglII 4.0-kb DQA fragment. Eight of these 12 haplotypes also included HLA-DPw1 and both a RsaI 4.0-kb DPB fragment and an XbaI 16.0-kb DPA fragment. In one family, the two affected members shared an HLA-DR7, DQw2 haplotype, although both their second haplotypes included HLA-DR3a and -DQw2. The results suggest that HLA-DP genes do not play an independent predisposing role in the etiology of CD but do mark a disease-associated extended haplotype. This haplotype contains genes coding for specific HLA products which may be necessary for the disease to develop. The findings support the hypothesis that the presence of a specific DQ alpha/DQ beta heterodimer, encoded in a cis arrangement on HLA-DR3a haplotypes, predisposes to celiac disease.

Factor V Leiden mutation is associated with ocular involvement in Behçet disease.

PURPOSE: Behçet disease is a systemic disease of young adults characterized by venous occlusion in both the deep venous and retinal circulations. In severe ocular disease, blindness may occur despite immunosuppressive treatment. The most common inherited risk factor for the development of idiopathic venous thrombosis is the presence of the Factor V (FV Leiden) mutation, which confers resistance to activated protein C. The association of FV Leiden with Behçet disease has been reported, but its influence on ocular disease is not known. We therefore investigated the prevalence of this mutation in patients with Behçet disease to determine its contribution to the presence and severity of ocular disease. METHODS: One hundred and six Middle Eastern patients satisfying international criteria, and 120 healthy control subjects without a history of venous thrombosis were included in the study, and patients underwent standard examination by two ophthalmologists with an interest in Behçet disease. Genomic DNA was extracted from peripheral blood leukocytes and screened for the FV Leiden mutation with the polymerase chain reaction method with sequence-specific primers (PCR-SSP). RESULTS: FV Leiden was detected in 19% (23/120) of the control population compared with 27% (29/106) of all patients with Behçet disease (P = .13). However, among patients with Behçet disease who had ocular disease (75/106), the prevalence of FV Leiden was significantly higher (32%) than it was in control subjects (P = .04). Furthermore, ocular patients with Behçet disease in whom retinal occlusive disease was observed (25/75) had the highest expression of FV Leiden (44%). CONCLUSIONS: These data suggest that FV Leiden may be an additional risk factor for the development of ocular disease and, in particular, retinal vaso-occlusion, and it may contribute to the poor visual outcome in these patients.

Behçet's disease: from Hippocrates to the third millennium.

Behçet's disease (BD) is characterised by recurrent episodes of orogenital aphthae, systemic vasculitis, and systemic and retinal venous thrombosis. An association between HLA-B51 and BD was first identified over 20 years ago, but recently identified gene associations implicate regions both within and without the MHC in the immunological events underlying the lesions in BD. These include allelic variants within the tumour necrosis factor gene region and within the MHC class I chain related gene region, the factor V Leiden mutation, which is associated with retinal vascular occlusion, and alleles of the intercellular adhesion molecule gene. No single causative gene for BD has emerged; the evidence indicates that the underlying immune events in BD are triggered by a microbial antigen and subsequently driven by genetic influences which control leucocyte behaviour and the coagulation pathways. Knowledge of these risk factors may permit a more accurate prognosis for a given patient, and identify new pathways for more targeted intervention than is currently available.

Gas chromatographic determination of fentanyl and its analogues in human plasma.

There is currently no published chromatographic assay for the fentanyl family of analgesics. This study reports the development of a sensitive, precise, and accurate gas chromatographic method for the determination of fentanyl and its analogues in human plasma. Sensitivity attained for fentanyl and sufentanil was 0.1 ng/mL plasma with an average coefficient of variation of 4.5%. Calibration curve correlation coefficients of 0.99% or greater were consistently obtained. Average recovery of drug into the final extract exceeded 80% and was independent of fentanyl concentration. The required degree of specificity was obtained by selective extraction, use of the nitrogen/phosphorous detector, and chromatographic resolution. This method appears suitable for clinical studies of fentanyl and its derivatives in man.

Anesthesiologists in North Carolina: a survey reflecting emerging subspecialization.

This North Carolina case study addresses the migration of anesthesiologists into subspecialty, clinical areas of anesthesiology over a 4-year period (1984 to 1987). Three hundred fourteen members of the North Carolina Society of Anesthesiologists (NCSA) were surveyed using a one-page questionnaire. The response rate was 93.6%. The questionnaire elicited data to characterize the magnitude of change in anesthesiologist manpower, to assess emerging subspecialization, to describe the flux of anesthesiologists entering and leaving practice, and to detail evolving modes of practice. Results indicated a net increase in manpower averaging 8.8% per year in academic programs, whereas clinical community practitioners increased physician positions at a rate three times the former (27% increase per year). Of 184 anesthesiologists recruited to North Carolina over 4 years, 75 different residency programs were represented; 48% of new anesthesiologists were from southern educational programs and 44% entered practice with fellowships (i.e., postgraduate year 4 to 5). The principal fellowship was cardiac (33%). Subspecialty areas were represented in all 53 reporting clinical practices. The principal practice mode emerging was hospital-based, same day surgery (85%) followed by pediatric anesthesia (81%), perioperative pain management (68%), obstetric anesthesia (63%), and an anesthesia "clinic" (54%). Respondents expected additional practice options over the next 3 years with anesthesia for ambulatory diagnostic and therapeutic modalities projected to emerge at the fastest rate. In conclusion, anesthesiologists in North Carolina seem to be filling unmet needs in obstetric and cardiac anesthesia, critical care, ambulatory surgery, and pain therapy units. These observations may represent a vignette of the national scene.

Reinventing a medical specialty. Using anesthesiology as a model for change.

In only a decade, anesthesiology has reversed its fortunes from an underrepresented specialty in the 1980 Graduate Medical Education National Advisory Committee report to "a specialty in trouble" featured in The Wall Street Journal. This article focuses on anesthesiology and its work force dilemma as an evolving specialist model for change. What is happening to anesthesiology will not be unique--managed care competition will affect all physicians. Most specialties will have to reshape curricula and redesign education programs and academic delivery systems concentrating on fewer trainees. What are the options for coping with physicians grieving over lost dreams, such as autonomy and solo practice, while redesigning a medical specialty? The authors untangle fact from fear, mission from myth, and offer strategic thinking and solutions.

The new health care civilization: integration of physician land and manageria.

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.