Anti-C1q antibodies in systemic lupus erythematosus.

OBJECTIVE: Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study. METHODS: Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA. RESULTS: Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% (49/389) in controls (OR = 2.7, 95% CI: 1.8-4, p < 0.001). Anti-C1q was associated with proteinuria (OR = 3.0, 95% CI: 1.7-5.1, p < 0.001), red cell casts (OR = 2.6, 95% CI: 1.2-5.4, p = 0.015), anti-dsDNA (OR = 3.4, 95% CI: 1.9-6.1, p < 0.001) and anti-Smith (OR = 2.8, 95% CI: 1.5-5.0, p = 0.01). Anti-C1q was independently associated with renal involvement after adjustment for demographics, ANA, anti-dsDNA and low complement (OR = 2.3, 95% CI: 1.3-4.2, p < 0.01). Simultaneously positive anti-C1q, anti-dsDNA and low complement was strongly associated with renal involvement (OR = 14.9, 95% CI: 5.8-38.4, p < 0.01). CONCLUSIONS: Anti-C1q was more common in patients with SLE and those of Asian race/ethnicity. We confirmed a significant association of anti-C1q with renal involvement, independent of demographics and other serologies. Anti-C1q in combination with anti-dsDNA and low complement was the strongest serological association with renal involvement. These data support the usefulness of anti-C1q in SLE, especially in lupus nephritis.

Current state of evidence on 'off-label' therapeutic options for systemic lupus erythematosus, including biological immunosuppressive agents, in Germany, Austria and Switzerland--a consensus report.

Systemic lupus erythematosus (SLE) can be a severe and potentially life-threatening disease that often represents a therapeutic challenge because of its heterogeneous organ manifestations. Only glucocorticoids, chloroquine and hydroxychloroquine, azathioprine, cyclophosphamide and very recently belimumab have been approved for SLE therapy in Germany, Austria and Switzerland. Dependence on glucocorticoids and resistance to the approved therapeutic agents, as well as substantial toxicity, are frequent. Therefore, treatment considerations will include 'off-label' use of medication approved for other indications. In this consensus approach, an effort has been undertaken to delineate the limits of the current evidence on therapeutic options for SLE organ disease, and to agree on common practice. This has been based on the best available evidence obtained by a rigorous literature review and the authors' own experience with available drugs derived under very similar health care conditions. Preparation of this consensus document included an initial meeting to agree upon the core agenda, a systematic literature review with subsequent formulation of a consensus and determination of the evidence level followed by collecting the level of agreement from the panel members. In addition to overarching principles, the panel have focused on the treatment of major SLE organ manifestations (lupus nephritis, arthritis, lung disease, neuropsychiatric and haematological manifestations, antiphospholipid syndrome and serositis). This consensus report is intended to support clinicians involved in the care of patients with difficult courses of SLE not responding to standard therapies by providing up-to-date information on the best available evidence.

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

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

Platelet-released supernatant induces osteoblastic differentiation of human mesenchymal stem cells: potential role of BMP-2.

Platelet-rich preparations have recently gained popularity in maxillofacial and dental surgery, but their beneficial effect is still under debate. Furthermore, very little is known about the effect of platelet preparations at the cellular level, and the underlying mechanisms. In this study, we tested the effect of platelet-released supernatant (PRS) on human mesenchymal stem cell (MSC) differentiation towards an osteoblastic phenotype in vitro. Cultures of MSC were supplemented with PRS and typical osteoblastic markers were assessed at up to 28 days post-confluence. PRS showed an osteoinductive effect on MSC, as shown by an increased expression of typical osteoblastic marker genes such as collagen Ialpha1, bone sialoprotein II, BMP-2 and MMP-13, as well as by increased 45Ca²+ incorporation. Our results suggest that the effect of PRS on human MSC could be at least partially mediated by BMP-2. Activated autologous PRS could therefore provide an alternative to agents like recombinant bone growth factors by increasing osteoblastic differentiation of bone precursor cells at bone repair sites, although further studies are needed to fully support our observations.

Dissecting charge relaxation pathways in CdSe/CdS nanocrystals using femtosecond two-dimensional electronic spectroscopy.

Exciton relaxation dynamics of CdSe and quasi-type-II CdSe/CdS core/shell nanocrystals were examined using femtosecond two-dimensional electronic spectroscopy (2DES). The use of 2DES allowed for determination of structure-specific and state-resolved carrier dynamics for CdSe nanocrystals formed with five, or fewer, CdS passivation monolayers (ML). For CdSe and CdSe/CdS nanocrystals formed with one through three MLs of CdS, excitation using broad bandwidth femtosecond visible laser pulses generated electron-hole pairs among the |X1〉 = 2.14 eV and |X2〉 = 2.27 eV exciton states. For both excitations, the electron is promoted to the lowest energy excited (1Se) conduction-band state and the hole is in the 1S3/2 (X1) or 2S3/2 (X2) valence-band state. Therefore, the relaxation dynamics of the hot hole were isolated by monitoring the-time-dependent amplitude of 2DES cross peaks. The time constant for hot hole relaxation within the CdSe valence band was 150 ± 45 fs. Upon passivation by CdS, this hole relaxation time constant increased to 170 ± 30 fs (CdSe/CdS-3ML). This small increase was attributed to the formation of a graded, or alloyed, interfacial region that precedes the growth of a uniform CdS capping layer. The small increase in hole relaxation time reflects the larger nanocrystal volume of the CdSe/CdS system with respect to the CdSe nanocrystal core. In contrast, the dynamics of larger core/shell nanocrystals (≥4ML CdS) exhibited a picosecond buildup in 2DES cross-peak amplitude. This time-dependent response was attributed to interfacial hole transfer from CdS to CdSe valence-band states. Importantly, the 2DES data distinguish CdSe exciton relaxation from interfacial carrier transfer dynamics. In combination, isolation of structurally well-defined nanocrystals and state-resolved 2DES can be used to examine directly the influence of nanoscale structural modifications on electronic carrier dynamics, which are critical for developing nanocluster-based photonic devices.

Cardiovascular events prior to or early after diagnosis of systemic lupus erythematosus in the systemic lupus international collaborating clinics cohort.

OBJECTIVE: To describe the frequency of myocardial infarction (MI) prior to the diagnosis of systemic lupus erythematosus (SLE) and within the first 2 years of follow-up. METHODS: The systemic lupus international collaborating clinics (SLICC) atherosclerosis inception cohort enters patients within 15 months of SLE diagnosis. MIs were reported and attributed on a specialised vascular event form. MIs were confirmed by one or more of the following: abnormal ECG, typical or atypical symptoms with ECG abnormalities and elevated enzymes (≥2 times upper limit of normal), or abnormal stress test, echocardiogram, nuclear scan or angiogram. Descriptive statistics were used. RESULTS: 31 of 1848 patients who entered the cohort had an MI. Of those, 23 patients had an MI prior to SLE diagnosis or within the first 2 years of disease. Of the 23 patients studied, 60.9% were female, 78.3% were Caucasian, 8.7% black, 8.7% Hispanic and 4.3% other. The mean age at SLE diagnosis was 52.5±15.0 years. Of the 23 MIs that occurred, 16 MIs occurred at a mean of 6.1±7.0 years prior to diagnosis and 7 occurred within the first 2 years of follow-up. Risk factors associated with early MI in univariate analysis are male sex, Caucasian, older age at diagnosis, hypertension, hypercholesterolaemia, family history of MI and smoking. In multivariate analysis only age (OR=1.06 95% CI 1.03 to 1.09), hypertension (OR=5.01, 95% CI 1.38 to 18.23), hypercholesterolaemia (OR=4.43, 95% CI 1.51 to 12.99) and smoking (OR=7.50, 95% CI 2.38 to 23.57) remained significant risk factors. CONCLUSIONS: In some patients with lupus, MI may develop even before the diagnosis of SLE or shortly thereafter, suggesting that there may be a link between autoimmune inflammation and atherosclerosis.

Cloning and analysis of MART-1/Melan-A human melanoma antigen promoter regions.

The MART-1/Melan-A human melanoma tumor antigen can be recognized by T lymphocytes and appears to be involved in tumor regression. To study the transcriptional regulation of this important gene, the 5' untranslated (UT) region of the MART-1/Melan-A gene was cloned and sequenced. Human melanoma cell lines were screened for MART-1/Melan-A mRNA expression. Primer extension and northern analysis were performed to confirm the mRNA size and start site. Several overlapping fragments of 5'UT were isolated from genomic DNA by polymerase chain reaction (PCR) from the previously described sequence for an additional 700 bp upstream. The fragments isolated (ranging from 838 bp to 160 bp in length) were used to drive luciferase reporter gene expression in melanoma and non-melanoma cell lines. Tissue-specific promoter activity was found in a 233-bp fragment of 5' UT with an average index of induction of 35 fold. The 233-bp MART-1/Melan-A promoter does not appear to have cytokine (IL-2, IL-4, IL-7, GM-CSF, TNF-alpha or IFN-gamma) responsive elements when studied in transient transfection assays.

Systematic improvement of a chemically-defined protein-free medium for hybridoma growth and monoclonal antibody production.

A chemically-defined protein-free medium (FMX-Turbodoma) has been improved for the production of monoclonal IgA antibodies by hybridoma cells, using a systematic method. Cell growth rate, IgA production, activity and molecular weight pattern have been used as optimization criteria. Of potentially important supplements, glucose, glutamine, Pluronic acid F-68 as well as several amino acids had significant beneficial effects. A determination of amino acids profiles via HPLC analysis allowed the formulation of a balanced medium. Unbalanced supplementations of amino acids were found undesirable because of the toxicity of some amino acids at high concentration. Compared with the basal medium, the maximum viable cell and final IgA concentrations in the final version of the protein-free medium were increased by 130% and 700%, respectively, whereas the IgA molecular weight pattern and in vitro activity were not affected. The IgA production was even higher than in a serum-containing medium (RPMI 1640 + 10% FCS) and the price of the protein-free medium is about 20% of this serum-containing medium. This makes such a protein-free medium very convenient for laboratory and large-scale production.

Development of an on-line control system for the cultivation of animal cells in a hollow-fiber reactor using flowing injection analysis and a visual programming language.

A system for the independent control of ammonia and glutamine in a hollow-fiber reactor has been developed. On-line analysis of the two chemical species was performed using FIA. A custom-made program has been written to fully automate the FIA, to perform measurements, calibrations and data acquisition, and to activate two peristaltic feed pumps. Diagnostic tests were also automatically performed in order to identify, and in some cases eliminate, erroneous measurements and calibrations due to instrument failures. For this purpose, a visual programming language (LabVIEW) has been chosen. Ammonia concentration was controlled by varying the medium supply rate to the hollow-fiber reactor which was shown to behave like an ideal-stirred tank reactor. The glutamine concentration was controlled through the intermittent activation of a pump delivering a concentrated solution of this species to the reactor. This control system was tested with a culture of hybridoma cells at three different ammonia and one glutamine set-points. The hollow-fiber reactor was successfully operated automatically for more than 1200 h with ammonia and glutamine concentrations accurately controlled at non-limiting levels. The visual programming environment was found to be reliable and highly suitable for the development of custom programs for bioprocess control.

Construct validation of the ACR 1991 revised criteria for global functional status in rheumatoid arthritis.

In order to assess the construct and discriminatory validity of the 1991 ACR functional status criteria for rheumatoid arthritis (RA), a cross-sectional analysis of 62 consecutive patients with RA (according to the American Rheumatism Association 1987 revised criteria) who were attending the outpatient clinic of rheumatology, University Hospital Zürich, was carried out. A moderate-to-strong association of the ACR criteria with pain (r = 0.54), the tender (r = 0.54) and swollen joint count (r = 0.31), grip strength (r = -0.49), C-reactive protein (r = 0.35), the HAQ disability index (r = 0.76), self-perceived global health (r = 0.58), and the Larsen radiological score (r = 0.32) was found. The mean scores of most disease parameters and all 8 domains of the health assessment questionnaire were significantly different between, and increased regularly across, the 4 classes. We conclude that the ACR 1991 functional status criteria for RA are a valid measure of the consequences of impairment and discriminate well the physical functional status.

The influence of mechanical stimulus on the pattern of tissue differentiation in a long bone fracture--an FEM study.

2D, coronal plane, finite elements models (FEMs) were developed from orthogonal radiographs of a diaphyseal tibial fracture and its reparative tissue at four different time points during healing. Each callus was separated into regions of common tissue histology by computerised radiographic analysis. Starting point values of tissue material properties from the literature were refined by the model to simulate exactly the mechanical behaviour of the subject's callus and bone during loading. This was achieved by matching measured inter-fragmentary displacements with calculated inter-fragmentary forces. Stress and strain distributions in the callus and bone were calculated from peak inter-fragmentary displacements measured during natural walking activity, and were correlated with the subsequently observed pattern of tissue differentiation and maturation of the callus. The growth and stiffening of the external callus progressively reduced the inter-fragmentary gap strain. Partial maturation of the gap tissue was apparent only one week before fixator removal. Principal stresses in the callus were compared with 'yield stresses' in corresponding tissue from the literature. This indicated the presence of stress concentrations medial and lateral to the fracture gap, which probably caused tissue damage during normal activity levels. Tissue damage may also have precipitated partial structural failure of the callus, both of which were believed to have delayed healing during the middle third of the fixation period. Had the fixation device provided greater inter-fragmentary support during early healing, this may have prevented callus failure and the consequent delay in healing. A further benefit of this would have been the reduction of the initially high intra-gap tissue strains to a magnitude more conducive to earlier maturation of the bridging tissue that united the bone.

Treatment of the missed Monteggia fracture in the child.

Eight children with missed Monteggia fracture-dislocations are described. Seven had reconstructive surgery which included resection of scar tissue from the radiohumeral joint, proximal ulnar osteotomy, reduction of the radial head and reconstruction of the annular ligament. One had excision of the radial head. Excellent results were obtained in patients under ten years of age, up to four years after the initial injury.

Maximal isometric muscle strength: normative values and gender-specific relation to age.

To date, there have been very few studies on the age dependence of maximal isometric muscle strength (MIMS) in healthy subjects aged 20-80 years, based upon measurements of a large number of functional muscle groups (FMGs). Using a hand-held pull gauge it is possible to measure MIMS of nearly every FMG. The objectives of this study were to obtain normative values for MIMS, to evaluate differences in MIMS in relation to gender and body side and to compare the age dependence of muscle strength between women and men. In a convenience sample of 290 healthy women (aged 20-82 years) and 253 men (aged 21-79 years), MIMS of 51 FMGs was measured. For each FMG the age dependence of MIMS was depicted, side and gender specific, as percentile curves and was analysed using linear quantile regression analysis. MIMS was found to be significantly higher in men than in women and higher on the right than on the left side. A biphasic model with linear equations for strength medians was derived for each gender. The age at transition from phase 1 to phase 2 was 55 years (SD 8) for women and 49 years (SD 13) for men. During phase 1, MIMS did not decrease significantly. During phase 2, MIMS decreased in all FMGs in both genders with a steeper slope in women (-0.92) than in men (-0.63). The age dependence of MIMS differed significantly between women and men. The present study gives gender-specific equations which enable one to calculate normative values for MIMS, as measured with a pull gauge, based upon age. These normative values will allow an objective assessment of patients with diminished muscle strength as, for example, in myositis, rheumatoid arthritis and nerve root compression syndromes or in the elderly.

Infection of a total knee joint prosthesis by peptostreptococcus micros and propionibacterium acnes in an elderly RA patient: implant salvage with longterm antibiotics and needle aspiration/irrigation.

We describe the favourable long-term outcome after late total knee joint prosthesis infection in an elderly RA patient. Peptostreptococcus micros and Propionibacterium acnes were cultured from the synovial fluid, and the finding of a coexistent abscess at the root of a wisdom tooth suggested a dental origin to the joint infection. Long-term antibiotics in conjunction with aspiration/irrigation resulted in salvage of the implant and an excellent functional outcome.

Relation of femoral to tibial torsion in children measured by ultrasound.

To study the relation between femoral and tibial torsion, we measured their values by ultrasound (US) in 97 normal children in two groups (aged 6 and 15 years). Anteversion was measured between the anterior aspect of the femoral neck and the axis of the femoral condyles, and tibial torsion as the difference of the proximal to the distal posterior tibial planes. The mean value of anteversion was 37 degrees in the younger group and 24 degrees in the older group. The mean value of tibial torsion was 18 degrees in both groups. We found neither side- nor sex-dependent differences in both age groups. There was no relation between both values.

Cross-section measurements of the nuclear reactions natZn(d,x)64Cu, 66Zn(d,alpha)64Cu and 68Zn(p,alphan)64Cu for production of 64Cu and technical developments for small-scale production of 67Cu via the 70Zn(p,alpha)67Cu process.

The radionuclides 64Cu (T1/2=12.7h) and 67Cu (T1/2=61.9h) are useful in internal therapy. In connection with production of 64Cu, excitation functions of the reactions natZn(d,x)64Cu, 66Zn(d,alpha)64Cu and 68Zn(p,alphan)64Cu were measured radiochemically using the stacked-foil technique. From the measured data, the thick target yields of 64Cu were calculated and compared with experimental data available in the literature. The three investigated processes are discussed in comparison to the commonly used 64Ni(p,n)64Cu reaction for the production of 64Cu. As regards 67Cu production, the technical feasibility of the 70Zn(p,alpha)67Cu process was investigated. An electroplated isotopically enriched 70Zn target was developed which can withstand slanting beams of 20MeV protons of currents up to 20 microA. Methods for chemical separation of 67Cu and efficient recovery of the enriched target material were worked out. The method is suitable only for small-scale production of 67Cu.

[Physiotherapy in lumbar disc herniation ]. / Physiotherapie bei lumbaler Diskushernie.

Physiotherapy is the treatment of choice in patients with symptoms caused by a lumbar disc herniation. In clinical practice a broad range of physiotherapeutic modalities has been revealed to be helpful. During the acute stage the efficacy of the McKenzie-concept, mobilisation therapies and traction has been demonstrated in randomized controlled trials with a blind assessor. In addition, pain reducing physical therapies such as cold or electrotherapy and non-steroidal anti-inflammatory drugs, analgesics and/or muscle relaxants are sensible initial accompanying treatments. The effectiveness of active physiotherapies such as training of local strength endurance of back and abdominal muscles has been proven in patients during the chronic stage. The indications for a in-patient rehabilitation programme, for surgery and the danger of developing chronic low back pain are discussed.

Changes in quality of life in the first 5 years of disease in a multicenter cohort of patients with systemic lupus erythematosus.

OBJECTIVE: The Medical Outcomes Study Short Form 36 (SF-36) is recommended to assess quality of life (QOL) in systemic lupus erythematosus (SLE). The aim of the current study was to assess QOL over time in the first 5 years of a multicenter inception cohort of patients with SLE. METHODS: An inception SLE cohort was assembled according to a standardized protocol between 2000 and 2012. In addition to clinical and laboratory assessments, patients completed the SF-36 at yearly intervals. Only patients who had ≥5 completed QOL questionnaires were included in these analyses. Generalized estimating equation models were run separately for each of the 8 subscales and for the physical and mental component summary scores, adjusting for repeated measures by patients. RESULTS: A total of 495 patients were included. The mean ± SD disease duration at the first visit was 5.3 ± 4.1 months. The mean ± SD age at enrollment was 35.8 ± 13.2 years. All 8 subscales and the 2 summary scores showed improvement in the first 2 years from enrollment. Between years 2 and 5, none of the subscales or summary scores showed any change. Minimum clinically important improvement was achieved by 35-56% of the patients and was influenced by demographic and disease factors. CONCLUSION: Unlike late-stage lupus, where QOL is stable over time, in patients with early disease, all subscales improve in early followup up to 2 years. Therefore, the SF-36 may be a sensitive outcome measure in early disease in patients with SLE.

Evolution of disease burden over five years in a multicenter inception systemic lupus erythematosus cohort.

OBJECTIVE: We describe disease activity, damage, and the accrual of key autoantibodies in an inception systemic lupus erythematosus (SLE) cohort. METHODS: The Systemic Lupus International Collaborating Clinics (SLICC) International Research Network, comprising 27 centers from 11 countries, has followed an inception cohort of SLE patients yearly according to a standardized protocol. Of these patients, 298 were followed for a minimum of 5 years and constitute the study population. Disease activity was assessed using the SLE Disease Activity Index 2000 (SLEDAI-2K) and damage was assessed using the SLICC/American College of Rheumatology Damage Index (SDI). Antinuclear antibody (ANA), anti-DNA, and anticardiolipin antibody (aCL) levels and lupus anticoagulant were assessed yearly. Descriptive statistics were generated and repeated-measures general linear models were used to evaluate SLEDAI-2K and SDI over time between whites and nonwhites. RESULTS: Of the 298 patients, 87% were women, 55% were white, 12% were African American, 14% were Asian, 16% were Hispanic, and 2% were categorized as "other." At enrollment, the mean age was 35.3 years, the mean SLEDAI-2K score was 5.9, and the mean disease duration was 5.5 months. Mean SLEDAI-2K scores decreased in the first year and then remained low. SLEDAI-2K scores were significantly lower at each year in whites compared to nonwhites. Mean SDI scores increased progressively over 5 years; there was no significant difference between whites and nonwhites. As expected, ANA positivity was high and anti-DNA positivity was relatively low at enrollment, and both increased over 5 years. Although lupus anticoagulant increased slightly over 5 years, aCL positivity did not. CONCLUSION: Disease activity in newly diagnosed patients decreases over their first 5 years, while damage increases. Antibody positivity ran variable courses over this period.