MHC associations with clinical and autoantibody manifestations in European SLE.

Systemic lupus erythematosus (SLE) is a clinically heterogeneous disease affecting multiple organ systems and characterized by autoantibody formation to nuclear components. Although genetic variation within the major histocompatibility complex (MHC) is associated with SLE, its role in the development of clinical manifestations and autoantibody production is not well defined. We conducted a meta-analysis of four independent European SLE case collections for associations between SLE sub-phenotypes and MHC single-nucleotide polymorphism genotypes, human leukocyte antigen (HLA) alleles and variant HLA amino acids. Of the 11 American College of Rheumatology criteria and 7 autoantibody sub-phenotypes examined, anti-Ro/SSA and anti-La/SSB antibody subsets exhibited the highest number and most statistically significant associations. HLA-DRB1*03:01 was significantly associated with both sub-phenotypes. We found evidence of associations independent of MHC class II variants in the anti-Ro subset alone. Conditional analyses showed that anti-Ro and anti-La subsets are independently associated with HLA-DRB1*0301, and that the HLA-DRB1*03:01 association with SLE is largely but not completely driven by the association of this allele with these sub-phenotypes. Our results provide strong evidence for a multilevel risk model for HLA-DRB1*03:01 in SLE, where the association with anti-Ro and anti-La antibody-positive SLE is much stronger than SLE without these autoantibodies.

A targeted association study in systemic lupus erythematosus identifies multiple susceptibility alleles.

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease. Multiple genetic and environmental factors contribute to the pathogenesis of this disease. Recent genome-wide association studies have added substantially to the number of genes associated with SLE. To replicate some of these susceptibility loci, single-nucleotide polymorphisms reported to be associated to SLE were evaluated in a cohort of 245 well-phenotyped Canadian SLE trios. Our results replicate previously reported associations to alleles of interferon regulatory factor 5 (IRF5), major histocompatibility complex (MHC), tumor necrosis factor (ligand) superfamily member 4 (TNFSF4), Kell blood group complex subunit-related family member 6 (XKR6), B-cell scaffold protein with ankyrin repeats 1 (BANK1), protein tyrosine phosphatase non-receptor type 22 (PTPN22), ubiquitin-conjugating enzyme E2L 3 (UBE2L3) and islet cell autoantigen 1 (ICA1). We also identify putative associations to cytotoxic T-lymphocyte-associated protein 4 (CTLA4), a gene associated with several autoimmune disorders, and ERBB3, a locus on 12q13 that was previously reported to be associated with type 1 diabetes. This study confirms the existence of multiple genetic risk factors for SLE, and supports the notion that some risk factors for SLE are shared with other inflammatory disorders.

Variation in the upstream region of P-Selectin (SELP) is a risk factor for SLE.

Systemic lupus erythematosus (SLE) is a complex autoimmune disease. Genome-wide linkage studies implicated a region containing the adhesion molecule P-Selectin. This family-based study revealed two regions of association within P-Selectin. The strongest signal, from a 21.4-kb risk haplotype, stretched from the promoter into the first two consensus repeat (CR) regions (P=8 x 10(-4)), with a second association from a 14.6-kb protective haplotype covering CR 2-9 (P=0.0198). The risk haplotype is tagged by the rare C allele of rs3753306, which disrupts the binding site of the trans-activating transcription factor HNF-1. One other variant (rs3917687) on the risk haplotype was significant after permutation (P(10000)<1 x 10(-5)), replicated in independent pseudo case-control analysis and was significant by meta-analysis (P=4.37 x 10(-6)). A third associated variant on the risk haplotype (rs3917657) replicated in 306 US SLE families and was significant in a joint UK-SLE data set after permutation. The protective haplotype is tagged by rs6133 (a non-synonymous variant in CR8 (P=9.00 x 10(-4)), which also shows association in the pseudo case-control analysis (P=1.09 x 10(-3)) and may contribute to another signal in P-Selectin. We propose that polymorphism in the upstream region may reduce expression of P-Selectin, the mechanism by which this promotes autoimmunity is unknown, although it may reduce the production of regulatory T cells.

Review of recent genome-wide association scans in lupus.

We review the systemic lupus erythematosus (SLE) human genetics literature, including the first wave of genome-wide associations scans (GWAS), to identify confirmed and candidate risk variants that meet stringent statistical criteria. The understanding of the genetic basis of SLE in humans has expanded dramatically over the past year, offering an early glimpse into the primary genetic factors and major dysregulated pathways. A meta-analysis of published candidate variants was performed incorporating data from a 1310 case and 7859 control GWAS. Our review of the literature and meta-analysis identifies a total of 17 well-validated common SLE risk variants, including four candidate variants that achieve our definition of a confirmed SLE risk locus. These variants account for a fraction of the total genetic contribution to SLE risk, with many risk loci remaining to be identified, but may provide insight into the pathways involved in SLE. Initial pathway analyses of the 17 confirmed SLE risk alleles indicate an important role for B-cell signalling and development, signaling through toll-like receptors 7 and 9, and neutrophil function.

The Ro60 autoantigen binds endogenous retroelements and regulates inflammatory gene expression.

Autoantibodies target the RNA binding protein Ro60 in systemic lupus erythematosus (SLE) and Sjögren's syndrome. However, it is unclear whether Ro60 and its associated RNAs contribute to disease pathogenesis. We catalogued the Ro60-associated RNAs in human cell lines and found that among other RNAs, Ro60 bound an RNA motif derived from endogenous Alu retroelements. Alu transcripts were induced by type I interferon and stimulated proinflammatory cytokine secretion by human peripheral blood cells. Ro60 deletion resulted in enhanced expression of Alu RNAs and interferon-regulated genes. Anti-Ro60-positive SLE immune complexes contained Alu RNAs, and Alu transcripts were up-regulated in SLE whole blood samples relative to controls. These findings establish a link among the lupus autoantigen Ro60, Alu retroelements, and type I interferon.

Genetic subtypes of HIV type 1 viruses circulating in the Czech Republic.

We analyzed the genetic diversity of HIV-1 strains circulating in the Czech Republic. Phylogenetic analysis of the env and gag gene sequence fragments from 39 isolates revealed that the majority of these strains (32 of 39, 82%) were of subtype B; other genetic subtypes identified were A, C, F, and recombinant circulating form CRF01_AE. The isolates that did not cluster with subtype B originated almost exclusively from a heterosexual route of transmission. The molecular epidemiological data are suggestive of multiple entry of HIV-1 infection into the Czech Republic and show that the genetic pattern of the HIV-1 strains circulating in this country corresponds to that found in other European countries.

How far have state Medicaid agencies advanced in performance measurement for children?

BACKGROUND: While children represent the largest population group enrolled in Medicaid managed care, little is known about the pediatric performance measures used by state Medicaid agencies. OBJECTIVE: To identify Medicaid managed care requirements for using Health Plan Employer Data and Information Set and other performance measures for children (defined as those aged 0-21 years in this study). DESIGN: A structured telephone survey of pediatric performance measures. PARTICIPANTS: Survey respondents were state Medicaid officials responsible for managed care quality oversight in 39 states. MAIN OUTCOME MEASURES: Percentage of states in 1998 with effectiveness-of-care measures on health promotion and disease prevention, early detection and screening, and acute and chronic illness; with use measures on preventive care, ambulatory care, pharmacy, inpatient hospital care, and mental health and chemical dependency services; and with access measures on primary care, low-birth-weight neonates delivered at appropriate facilities, and dental care. RESULTS: In 1998, state Medicaid agencies placed most of their emphasis on monitoring preventive care for children, with immunization rates being the primary focus. Far less attention was directed at assessing the treatment of acute illness. Although more than half of states monitored the treatment of chronic childhood conditions, they focused exclusively on asthma and selected mental health diagnoses. CONCLUSIONS: States are still in the initial phases of designing and implementing quality oversight systems for Medicaid-insured children. Additional quality reporting requirements are clearly needed to assess the treatment of acute and chronic illness among children along with more age-specific reporting requirements.

The first reported outbreak of dengue hemorrhagic fever in Irian Jaya, Indonesia.

During the months of September 1993 through February 1994, an outbreak of hemorrhagic fever occurred in the city of Jayapura, the provincial capital of Irian Jaya, Indonesia. Seventy-two patients (age range = 1-41 years) with suspected dengue hemorrhagic fever (DHF) were enrolled into the outbreak investigation conducted during October-November 1993. The pediatric patient population consisted of 36 individuals ages 1-12 years of age with a similar male to female ratio. From clinical histories obtained from the children diagnosed with DHF (n = 23), the predominant complaints were fever (100%), headache (96.7%), vomiting (47.8%), abdominal pain (39.1%), back/bone pain (39.1%), cough (39.1%), sore throat (21.7%), convulsions (17.4%), and eye pain (13.0%). Clinical findings of the same pediatric patients included a positive tourniquet test result (100%), thrombocytopenia (100%), hemoconcentration (100%), skin petechiae (43.5%), epistaxis (39.1%), and maculopapular rash (26%). All four of the children diagnosed with DHF grade IV had hepatomegaly, pleural effusion, ascites, cold perspiration, and confusion. Serologic data demonstrated that a majority (46 of 70, 68.7%) of the individuals assessed did not have significant levels of IgM specific for dengue viruses at the time of their admission. However, the nine successful dengue virus isolations were only from these serononreactive cases (19.6%). From the other patients assessed, 11.4% had a primary (or first exposure) serologic response to dengue virus antigen (predominantly IgM); 17.1% had a secondary (or subsequent exposure) serologic response to the same dengue antigens (predominantly IgG response) and 5.7% (four adults) had indeterminate serologic data that could not differentiate between reactivity to dengue or Japanese encephalitis virus antigen preparations. Virus culture of blood samples produced nine dengue virus isolates: DEN- 1 (2), DEN-2 (1), and DEN-3 (6). Japanese encephalitis and influenza viruses were not isolated from blood and pharyngeal specimens, respectively, from any of the patients. Thus, this first reported outbreak of DHF in Irian Jaya, Indonesia was found to be attributed to dengue viruses types 1, 2, and 3.

A prospective seroepidemiologic study on dengue in children four to nine years of age in Yogyakarta, Indonesia I. studies in 1995-1996.

A prospective study on dengue (DEN) viruses was initiated in October 1995 in Gondokusuman kecamatan, Yogyakarta, Indonesia. This report presents data from the first year of the study. The studied cohort included all children 4-9 years of age living in the kecamatan. Blood samples for serology were collected from 1,837 children in October 1995 and again in October 1996. Blood samples for virus isolation and serology were collected from cohort children who were seen in municipal health clinics with febrile syndromes or admitted to hospitals with a provisional diagnosis of dengue hemorrhagic fever. Dengue serotype antibody prevalence and 1995-1996 infection rates were calculated using a single dilution (1:60) 70% plaque reduction endpoint neutralization test. Prevalence of dengue antibody at the beginning of the study was DEN 1 = 12%, DEN 2 = 16%, DEN 3 = 2%, DEN 4 = 4%, and two or more dengue infections = 22%. Total dengue antibody prevalence increased from 38% in 4-year-old children to 69% in 9-year-old children. During the observation period, primary dengue infection rates were DEN 1 = 4.8%, DEN 2 = 7.7%, DEN 3 = 4.2%, and DEN 4 = 3.4%, while two or more dengue infections occurred in 6.7% of the study population. The secondary dengue infection rate was 19.0%. From febrile cases, all four dengue viruses were isolated with DEN 3 predominating. Seven children were hospitalized, including one fatal case with a hospital diagnosis of dengue shock syndrome. Based upon presence of antibody in the initial cohort bleeding and the serologic response both weeks and several months following illness, all had secondary dengue infections. Neutralizing antibody patterns in the initial cohort bleeding and in late convalescent serum samples permitted recognition of dengue infection sequence in five patients: DEN 2-DEN 1 (3), DEN 2-DEN 4 (1), DEN 1-DEN 3 (1), and none in the sequence DEN 1-DEN 2. In the total cohort 6.5% of the observed secondary infections were of the sequence DEN 2-DEN 1, while 4.9% were DEN 1-DEN 2, a highly pathogenic sequence in previous studies. Reduced pathogenic expression of secondary DEN 2 with enhanced pathogenic expression of secondary DEN 1 infections was an unexpected finding. Further studies will be required to understand the respective contributions to pathogenicity of antibody from initial dengue infections versus the biological attributes of the second infecting dengue viruses.

Prevalence of hantavirus antibody in patients with chronic renal disease in Egypt.

In Egypt, the etiology of chronic renal failure (CRF) is not well defined. A hospital-based case-control study was initiated in February 1998, to determine whether hantavirus infection is involved in chronic renal disease (CRD) in Egypt. The study enrolled 350 study patients with a history of CRF and 695 matched controls with CRD due to renal calculus or renal cancer, but with normal renal functions. Sera from cases and controls were tested for anti-hantavirus IgG using ELISA with a cell-lysate antigen from Hantaan virus prototype strain 76-118. A demographic questionnaire was completed for each study participant. Five of the 350 cases (1.4%), and seven of the 695 controls (1.0%) were antibody-positive to hantavirus, with a titer > or =1:400. The difference in antibody prevalence between the study cases and the control cases was not statistically significant (P = 0.48). All antibody-positive study cases and controls had been exposed to rodents. Data indicated that in Egypt, hantavirus seroprevalence in CRD patients is low, and hantavirus infections do not appear to be a significant cause of CRF.

Pathologic correlation in mammographically directed breast biopsies.

In a series of 1137 diagnostic breast biopsy specimens in a 2-year period, nearly half (n = 534) underwent specimen mammography. Calcifications were found in 48% of the specimen mammograms. In a quarter of the cases, calcification was a marker either for carcinoma or a significant precursor lesion. Moreover, in the majority of these malignancies, calcifications were markers of preinvasive carcinoma. In another quarter of cases, some form of proliferative ductal hyperplasia accounted for calcifications, and in the remainder, cysts and miscellaneous other conditions accounted for calcifications. The yield of malignancy was much lower in noncalcified specimens (12%). A nodular or asymmetric density proved to be a fibroadenoma in 30% of cases. However, the majority of cases had less well-defined changes, probably representing some form of lobular fibrosis. We found submission of a duplicate specimen mammogram with the breast biopsy specimen to pathology to be a significant adjunct to correlation. The abnormal area is marked on the mammogram by the radiologist for the pathologist. This is particularly helpful for localizing noncalcified stromal abnormalities. Calcifications are most easily and reliably isolated by serial slicing and performing another radiograph of the slices.

AGUS in cervical endometriosis.

OBJECTIVE: To evaluate cervical endometriosis as a source of abnormal glandular cells in cervicovaginal smears. STUDY DESIGN: Histologically documented cases of cervical endometriosis with concurrent cervicovaginal smears were reviewed. The cytologic specimens were evaluated for the presence of glandular abnormalities. RESULTS: There were eight cases of superficial endometriosis (five of which had concurrent tuboendometrioid glandular metaplasia) and two cases of deep endometriosis in this series. Five of the eight cases of superficial endometriosis had abnormal glandular cells in the smears; neither of two cases of deep endometriosis had glandular abnormalities. Four of the eight cases of superficial endometriosis had previously undergone conization for cervical intraepithelial neoplasia (CIN) (squamous intraepithelial lesion [SIL]) and were being monitored for recurrence. Of the five cases of atypical glandular cells of unknown significance (AGUS), one case had concurrent high grade CIN (SIL). Another case was originally misinterpreted as recurrent glandular dysplasia. CONCLUSION: Physicians monitoring patients after treatment for CIN need to be aware that endometriosis and tuboendometrioid metaplasia may be the source of atypical glandular cells and on occasion may be subject to misinterpretation.

Seroprevalence of hepatitis A virus and varicella zoster antibodies in a Javanese community (Yogyakarta, Indonesia).

Hepatitis A virus (HAV) cause an acute inflammation of the liver. Varicella-zoster virus (VZV) cause chickenpox (varicella) and herpes zoster. Effective vaccines against hepatitis A and varicella are available for children, adolescents and adults. In order to implement an appropriate vaccination policy, a baseline to assess the potential benefits and sections of the population who would benefit most are required. We investigated seroprevalence of hepatitis A virus and varicella zoster antibodies in a Javanese community. A total of 1,103 subjects were studied. The 600 subjects aged 4 to 9 years were sampled between 23 October and 2 November, 1995. The other subjects were sampled between 12 October and 1 November, 1996. The overall prevalence of anti-HAV in cohort was 28.7%. Anti-HAV seroprevalence rates were below 30% until the age of 15 and below 40% until the age of 25. The anti-varicella seroprevalence showed only in two thirds of seropositive population at the age of 15. The results of the study have implications for vaccination strategies for both hepatitis A and varicella zoster.

Microsatellite typing for DRB1 alleles: application to the analysis of HLA associations with rheumatoid arthritis.

The current methods for molecular typing of HLA-DR alleles incur a substantial financial burden when performing large population studies. In the current study, we aimed to provide much less expensive typing approach with high predictability for DRB1 genotype. We have used a panel of three microsatellite markers in the class II region (D6S2666, D6S2665 and D6S2446) for genotyping and haplotype reconstruction in a total of 1687 Caucasian (1313 RA patients and 374 controls) and 1364 Korean individuals (744 RA patients and 620 controls), all of whom were previously genotyped for DRB1. We found that a total of 88.4 and 87.4% of all observed three-marker haplotypes could determine the DR type with a positive predictive value >0.8 with high sensitivity and specificity. There was a high degree of haplotype conservation when comparing Caucasian and Asian populations. Interestingly, we found that the majority of DRB1*09 and DRB1*10 alleles share a common three-marker haplotype in both Caucasian and Asian populations. This is unexpected, since these two alleles are found on very different haplotype families. In addition, these two alleles are both associated with rheumatoid arthritis, making the elucidation of these haplotype relationships potentially important for understanding disease susceptibility.

Fine mapping chromosome 16q12 in a collection of 231 systemic lupus erythematosus sibpair and multiplex families.

Systemic lupus erythematosus (SLE) is a chronic, autoimmune disorder influenced by multiple genetic and environmental factors. Linkage of SLE to chromosome 16q12-13 (LOD score=3.85) was first identified in pedigrees collected at the University of Minnesota, and has been replicated in several independent SLE collections. We performed fine mapping using microsatellites to further refine the susceptibility region(s), and the best evidence for linkage was identified at marker D16S3396 (LOD=2.28, P=0.0006). Evidence of association was suggested in the analysis of all families (D16S3094, P=0.0516) and improved to the level of significance (P=0.0106) when only the Caucasian families were analyzed. Subsets of pedigrees were then selected on the basis of clinical manifestations, and these subsets showed evidence for association with several markers: GATA143D05 (renal, P=0.0064), D16S3035 (renal, P=0.0418), D16S3117 (renal, P=0.0366), D16S3071 (malar rash, P=0.03638; neuropsychiatric, P=0.0349; oral ulcers, P=0.0459), D16S3094 (hematologic, P=0.0226), and D16S3089 (arthritis, P=0.0141). Together, these data provide further evidence that an important susceptibility gene(s) for SLE is located at 16q12.

The Schirmer tear test in rhesus monkeys (Macaca mulatta).

A clinical case of keratoconjunctivitis sicca prompted a study to determine normal values for the Schirmer tear test in rhesus monkeys. Normal values for rhesus monkeys were calculated to be 6 to 24 mm wetting/minute (mean = 15.1) and it was determined that neither sex nor ketamine had a statistically significant effect on these values.

Sweat gland carcinoma of the hand: two cases of malignant eccrine spiradenoma.

Two cases of malignant eccrine spiradenoma of the hand are reported. This malignancy is potentially fatal and is believed to arise from preexisting, long-standing benign spiradenomas. These rare tumors should be considered in the hand surgeon's evaluation and management of any long-standing undiagnosed tumor of the hand. Benign spiradenomas should be excised completely and the patient followed carefully. Location and grade of established malignant tumors should dictate therapy.

Delineating the genetic basis of systemic lupus erythematosus.

Genetic predisposition plays a crucial role in susceptibility to systemic lupus erythematosus (SLE) in both human patients and animal models. Recent progress in experimental systems and human linkage analysis is providing key insights into the genetic basis for susceptibility and elucidating the manner in which genetic interactions mediate severe disease pathogenesis. Genes in multiple pathways appear to participate in specific elements of the disease, and epistatic interactions among these genes play an important role in both aggravating and suppressing disease development.

Experimental infection of the New World owl monkey (Aotus trivirgatus) with hepatitis A virus.

Epidemiological studies have demonstrated the susceptibility of the owl monkey (Aotus trivirgatus) to hepatitis A virus, but have not shown an association between infection and histopathological or chemical evidence of liver disease. Therefore, 12 seronegative, colony-bred monkeys were inoculated intravenously with a fecal suspension containing either PA33 strain hepatitis A virus (a strain recovered from a naturally infected Aotus sp.) or HM-175 virus (recovered from a human). Viral antigen was detected by radioimmunoassay in the feces of six monkeys 6 to 17 days after inoculation with PA33 virus, and by 9 to 21 days serum aminotransferase activities were significantly elevated in each. Antibody to the virus developed in each monkey by 28 days after inoculation. Similar findings were noted in five of six monkeys inoculated with HM-175 virus, although the incubation period preceding aminotransferase elevations was somewhat longer (25 to 39 days). Liver biopsies obtained from the 11 infected monkeys demonstrated mild to moderate portal inflammation, as well as random areas of focal necrosis and inflammation extending outward from the portal region. These data confirm the susceptibility of Aotus sp. to hepatitis A virus and indicate that the infection of this primate provides a useful animal model of human hepatitis A.

Risk factors associated with antibodies to leptospires in inner-city residents of Baltimore: a protective role for cats.

Leptospiral antibody prevalence was 16% in residents of Baltimore. Seropositivity was associated with age, gender, race, and bird ownership, reduced the antibody risk associated with age and race from odds ratios (95% confidence interval) of 3.3 (2.0, 5.5) and 3.3 (1.1, 9.3), respectively, to the baseline level. These data establish the high prevalence of leptospiral antibody in Baltimore and suggest a protective role for cats in reducing the risk of human infection.