A case of aggressive atypical anti-GBM disease complicated by CMV pneumonitis.

BACKGROUND: Anti-glomerular basement membrane (anti-GBM) disease is characterized by circulating IgG glomerular basement membrane antibodies and is clinically expressed as a rapidly progressive crescentic glomerulonephritis (GN), with 30-60% of patients also developing pulmonary hemorrhage. Classically, the renal biopsy shows glomerular crescent formation, bright linear staining of glomerular basement membranes (GBM) for IgG on direct immunofluorescence (IF), and the serologic presence of circulating anti-GBM antibodies. Recently, patients with linear IgG IF staining, undetectable circulating anti-GBM antibodies and glomerular changes atypical for anti-GBM disease have been described as "atypical anti-GBM disease", with a distinctly more benign clinical course than typical anti-GBM disease. We present a case report of a patient with negative anti-GBM serology but positive linear IgG staining by IF, severe diffuse crescentic and endocapillary proliferative glomerulonephritis, and renal failure, complicated by severe pulmonary hemorrhage after immunosuppression, likely due to cytomegalovirus (CMV) pneumonitis. CASE PRESENTATION: A 24-year-old man was admitted to hospital with hemoptysis and renal failure. Investigations for anti-GBM serology by addressable laser bead immunoassay (ALBIA) was negative for anti-GBM antibodies. Renal biopsy showed diffuse endocapillary proliferative glomerulonephritis with membranoproliferative features and diffuse circumferential crescents. Direct IF showed strong linear staining for IgG along GBMs. The patient's hemoptysis improved with immunosuppression, but 1 month later he was readmitted with gross hemoptysis, which was refractory to further cyclophosphamide, plasma exchange and rituximab. Bronchoalveolar lavage (BAL) and blood work confirmed CMV pneumonitis, and the patient's hemoptysis resolved with ganciclovir, though he became dialysis dependent. CONCLUSIONS: This case demonstrates an atypical presentation of anti-GBM disease with both crescents and endocapillary hypercellularity and negative serology. The patient is dialysis dependent, unlike most previously described patients with atypical anti-GBM disease. The course was complicated by CMV pneumonitis, which contributed to the severity of the pulmonary manifestations and added diagnostic difficulty.

Systematic modulation of a bichromic cyclometalated ruthenium(II) scaffold bearing a redox-active triphenylamine constituent.

The syntheses and physicochemical properties of nine bis-tridentate ruthenium(II) complexes containing one cyclometalating ligand furnished with terminal triphenylamine (TPA) substituents are reported. The structure of each complex conforms to a molecular scaffold formulated as [Ru(II)(TPA-2,5-thiophene-pbpy)(Me(3)tctpy)] (pbpy = 6-phenyl-2,2'-bipyridine; Me(3)tctpy = trimethyl-4,4',4''-tricarboxylate-2,2':6',2''-terpyridine), where various electron-donating groups (EDGs) and electron-withdrawing groups (EWGs) are installed about the TPA unit and the anionic ring of the pbpy ligand. It is found that the redox chemistry of the Ru center and the TPA unit can be independently modulated by (i) placing EWGs (e.g., -CF(3)) or EDGs (e.g., -OMe) on the anionic ring of the pbpy ligand (substituted sites denoted as R(2) or R(3)) and/or (ii) installing electron-donating substituents (e.g., -H, -Me, -OMe) para to the amine of the TPA group (i.e., R(1)). The first oxidation potential is localized to the TPA unit when, for example, EDGs are placed at R(1) with EWGs at R(2) (e.g., the TPA(•+)/TPA(0) and Ru(III)/Ru(II) redox couples appear at +0.98 and +1.27 V vs NHE, respectively, when R(1) = -OMe and R(2) = -CF(3)). This situation is reversed when R(3) = EDG and R(1) = -H: TPA-based and metal-centered oxidation waves occur at +1.20 and +1.11 V vs NHE, respectively. The UV-vis spectrum for each complex is broad (e.g., absorption bands are extended from the UV region to beyond 800 nm in all cases) and intense (e.g., ε ∼ 10(4) M(-1)·cm(-1)) because of the overlapping intraligand charge-transfer and metal-to-ligand charge-transfer transitions. The information derived from this study offers guiding principles for modulating the physicochemical properties of bichromic cyclometalated ruthenium(II) complexes.

Design and development of functionalized cyclometalated ruthenium chromophores for light-harvesting applications.

The syntheses and the electrochemical spectroscopic properties of a suite of asymmetrical bistridentate cyclometalated Ru(II) complexes bearing terminal triphenylamine (TPA) substituents are reported. These complexes, which contain structural design elements common to both inorganic and organic dyes that exhibit superior power conversion efficiencies in the dye-sensitized solar cell (DSSC), are broadly formulated as [Ru(II)(L-2,5'-thiophene-TPA-R(1))(L-R(2))](+) [L = tridentate chelating ligand (e.g., 2,2':6',2''-terpyridine (tpy); deprotonated forms of 1,3-di(pyridin-2-yl)benzene (Hdpb) or 6-phenyl-2,2'-bipyridine (Hpbpy)); R(1) = -H, -Me, -OMe; R(2) = -H, -CO(2)Me, -CO(2)H]. The following structural attributes were systematically modified for the series: (i) electron-donating character of the terminal substituents (e.g., R(1) = -H, -Me, -OMe) placed para to the amine of the "L-2,5'-thiophene-TPA-R(1)" ligand framework; (ii) electron-withdrawing character of the tridentate chelate distal to the TPA-substituted ligand (e.g., R(2) = -H, -CO(2)Me, -CO(2)H); and (iii) position of the organometallic bond about the Ru(II) center. UV-vis spectra reveal intense and broad absorption bands arising from a collection of metal-to-ligand charge-transfer (MLCT) and TPA-based intraligand charge-transfer (ILCT) transitions that, in certain cases, extend beyond 800 nm. Electrochemical data indicate that the oxidative behavior of the TPA and metal chelate units can be independently modulated except in cases where the anionic phenyl ring is in direct conjugation with the TPA unit. In most cases, the anionic character of the cyclometalating ligands renders a metal-based oxidation event prior to the oxidation of the TPA unit. This situation can, however, be reversed with an appropriately positioned Ru-C bond and electron-rich R(1) group. This finding is important in that this arrangement confines the highest occupied molecular orbital (HOMO) to the TPA unit rather than the metal, which is optimal for sensitizing TiO(2); indeed, a remarkably high power conversion efficiency (η) in the DSSC (i.e., 8.02%) is measured for the TPA-substituted pbpy(-) chelate where R(1) = -OMe. These results provide a comprehensive strategy for improving the performance of bistridentate Ru sensitizers devoid of NCS(-) groups for the DSSC.

Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease.

Importance: A population-based study using validated algorithms to estimate the costs of treating people with chronic disease with and without mental health disorders is needed. Objective: To determine the association of mental health disorders with health care costs among people with chronic diseases. Design, Setting, and Participants: This population-based cohort study in the Canadian province of Alberta collected data from April 1, 2012, to March 31, 2015, among 991 445 adults 18 years and older with a chronic disease (ie, asthma, congestive heart failure, myocardial infarction, diabetes, epilepsy, hypertension, chronic pulmonary disease, or chronic kidney disease). Data analysis was conducted from October 2017 to August 2018. Exposures: Mental health disorder (ie, depression, schizophrenia, alcohol use disorder, or drug use disorder). Main Outcomes and Measures: Resource use, mean total unadjusted and adjusted 3-year health care costs, and mean total unadjusted 3-year costs for hospitalization and emergency department visits for ambulatory care-sensitive conditions. Results: Among 991 445 participants, 156 296 (15.8%) had a mental health disorder. Those with no mental health disorder were older (mean [SD] age, 58.1 [17.6] years vs 55.4 [17.0] years; P < .001) and less likely to be women (50.4% [95% CI, 50.3%-50.5%] vs 57.7% [95% CI, 57.4%-58.0%]; P < .001) than those with mental health disorders. For those with a mental health disorder, mean total 3-year adjusted costs were $38 250 (95% CI, $36 476-$39 935), and for those without a mental health disorder, mean total 3-year adjusted costs were $22 280 (95% CI, $21 780-$22 760). Having a mental health disorder was associated with significantly higher resource use, including hospitalization and emergency department visit rates, length of stay, and hospitalization for ambulatory care-sensitive conditions. Higher resource use by patients with mental health disorders was not associated with health care presentations owing to chronic diseases compared with patients without a mental health disorder (chronic disease hospitalization rate per 1000 patient days, 0.11 [95% CI, 0.11-0.12] vs 0.06 [95% CI, 0.06-0.06]; P < .001; overall hospitalization rate per 1000 patient days, 0.88 [95% CI, 0.87-0.88] vs 0.43 [95% CI, 0.43-0.43]; P < .001). Conclusions and Relevance: This study suggests that mental health disorders are associated with substantially higher resource utilization and health care costs among patients with chronic diseases. These findings have clinical and health policy implications.