A Multianalyte Assay Panel (MAP) with Algorithm Containing Cell-Bound Complement Activation Products (CB-CAPs) Is Superior to AntidsDNA and Low Serum Complement Levels in Predicting Transition of Probable Lupus to ACR Classified Lupus Within 2 Years [Meeting Abstract]
Background/Purpose: We reported previously (Ramsey-Goldman et al., Arthritis Rheumatol 2020) that score > 0.8 of a multianalyte assay panel (MAP) with algorithm predicts fulfillment of a 4th ACR criterion 9-18 months (median 12) after enrollment in patients with probable systemic lupus erythematosus (pSLE). We continued to follow pSLE to better evaluate transition to classifiable SLE.
Method(s): pSLE, defined as fulfilling 3 ACR criteria, were followed at academic lupus centers. At enrollment, 35 (38%) of the 92 pSLE fulfilled SLICC criteria. CB-CAPs - C4d bound to erythrocytes (EC4d) and B-cells (BC4d) - were measured by quantitative flow cytometry, serum C3 and C4 by turbidimetry, and autoantibodies by ELISA. Anti-dsDNA positivity was confirmed by immunofluorescence (IFA). MAP index consists of an algorithm with CB-CAPs and autoantibodies (Dervieux et al., J Immunol Methods 2017). Initial decision analysis with Youden index showed that MAP > 0.8 and EC4d > 20 mean fluorescence intensity units (MFI) reflected the optimal cutoffs for transition to ACR classifiable SLE; the same cutoffs were used for analysis of all follow-up visits. Time to fulfillment of ACR criteria was evaluated by Kaplan-Meier analysis; associations were analyzed by log-rank test and Cox proportional hazards model and are expressed as hazards ratio (HR).
Result(s): Of the 92 pSLE, 74 had 1 or 2 follow-up visits 9-35 months after enrollment for a total of 128 visits. Overall, 28 pSLE (30.4%) transitioned to ACR classifiable SLE: 16 (57%) in the 1st year and 12 (43%) in the 2nd. The clinical or laboratory features that defined fulfillment of ACR criteria are in Table 1. Use of hydroxychloroquine and immunosuppressants was similar in those who did and did not transition to SLE. Of the 17 subjects who accrued hematological criteria during the study (11 as the sole criterion and 6 as one of the new criteria), a minority were on immunosuppressants: 6 at enrollment, 5 at the 1st visit, and 3 at the 2nd. Neither SLICC criteria nor individual biomarkers were significantly associated with transition to SLE (Table 2). Only MAP > 0.8 had significantly high HR for transition to SLE; EC4d > 20 MFI, low complement, and anti-dsDNA were not significant (Table 2).
Conclusion(s): The majority of pSLE transitioned within a year. MAP > 0.8 predicted disease evolution into classifiable SLE better than other biomarkers or fulfillment of SLICC criteria
Complement activation in probable systemic lupus erythematosus (PSLE) may predict progression to SLE defined by fulfillment of acr classification criteria [Meeting Abstract]
Background/Purpose : We reported (R amsey-Goldman et al., Arthritis Rheumatol 2018: 70 [suppl 10]) that cellbound complement activation products (CB-CAPs) and a multi-analyte assay panel with algorithm (MAP) are positive more frequently than standard immunological markers in patients with probable systemic lupus erythematosus (pSLE) who fulfilled 3 ACR criteria. We followed pSLE prospectively to evaluate whether CB-CAPs and MAP positivity at enrollment predict transition to classifiable SLE by fulfillment of a fourth ACR criterion. Methods : pSLE were followed prospectively at academic lupus centers and clinical and laboratory data were collected. Biomarkers were measured at every visit. CB-CAPs -C4d bound to erythrocytes (EC4d) and B-cells (BC4d) -were measured by quantitative flow cytometry and expressed as mean fluorescent intensity (MFI). Serum C3 and C4 and autoantibodies were measured by turbidimetry and ELISA, respectively. Anti-dsDNA positivity was confirmed by immunofluorescence (IFA) with Crithidia Luciliae . MAP was evaluated as previously described (Dervieux T, et al. J Immunol Methods 2017) and consists of an algorithm which utilizes CB-CAPs and autoantibodies. A MAP score >0.1 is considered positive, the higher the number (to 3.5) the greater the likelihood of SLE. For this study, decision analysis with Youden index showed that MAP >0.8 and EC4d >20 MFI reflected the optimal cutoff. Data were analyzed by Fisher's exact test and Kaplan-Meier with log-rank test and Cox proportional hazards model for time to fulfillment of a fourth ACR criterion, expressed as hazard ratios. Results : Of the 92 pSLE enrolled, 69 had 1 follow up visit 9-18 months after enrollment (average+/-SD = 12.4+/-1.7 months; median = 12 months). The time to acquire the 4th ACR criterion was estimated by the investigators at the follow up visit. Twenty pSLE (29%) fulfilled a fourth ACR criterion during this time. SLICC fulfillment at enrollment did not predict fulfillment of ACR criteria (p =0.27). Eight of the 20 (40%) pSLE who transitioned to classifiable SLE by ACR criteria had MAP >0.8 at enrollment while 8/48 (17%) non-transitioned patients had MAP > 0.8 at enrollment (p =0.06). Patients with MAP >0.8 at enrollment fulfilled ACR criteria with a hazard ratio (HR) =3.11 within 18 months (p < 0.01 by log-rank test). HR of MAP was higher than other individual biomarkers, although anti-dsDNA and EC4d >20 MFI were of borderline significance (Table). Conclusion : Complement activation as detected by MAP >0.8 at enrollment may predict disease evolution of pSLE into classifiable SLE by ACR criteria better than anti-dsDNA and low serum complement. (Table Presented)
Cell-bound complement activation products in combination with low complement C3 or C4 have superior diagnostic performance in systemic lupus erythematosus [Meeting Abstract]
Background/Purpose : Cell-bound complement activation products (CB-CAPs) are stable forms of classical complement activation ex-vivo, with high sensitivity and specificity for systemic lupus erythematosus (SLE). We sought to compare the performance of CB-CAPs to the gold standard low complement C3 or C4 in distinguishing SLE from other rheumatic diseases and healthy individuals. Methods : Multiple academic centers in the United States contributed to the adult ( >= 18 years) cross sectional cohort (n=1200) consisting of SLE (n=450), healthy individuals (n=252), and other rheumatic diseases (n=450; 189 RA, 88 Sjogren ' s, 90 fibromyalgia, and 83 other connective tissue diseases). Abnormal CB-CAPs status (erythrocyte bound C4d [EC4d] and/or B-Lymphocyte bound C4d [BC4d] >99th percentile of normal healthy group) was determined using flow cytometry. Serum low C3 (< 81 mg/dl) and low C4 (< 12.9 mg/dl) levels was determined using immunoturbidimetry. Performance of the markers, either alone or in combination, to distinguish SLE from other rheumatic diseases and healthy controls were established using sensitivity, specificity, odds ratio (OR) and area under the curve (AUC) of the receiver operating characteristic curve (ROC). Youden Index (Sensitivity+Specificity-100) and Akaike information criteria (AIC) were also calculated. The combination of 4 complement marker abnormalities was also evaluated using logistic regression and composite score cumulating the presence of these abnormalities was calculated. Results : Abnormal CB-CAPs status yielded 62% sensitivity with 88% specificity in distinguishing SLE from the group with other diseases (Table). Youden index was 0.492+/-0.027. Low C3/C4 status yielded 38% sensitivity and 93% specificity in distinguishing SLE from the group with other diseases. Youden index for low C3/C4 (0.313+/-0.025) was signifi-cantly lower than the index associated with abnormal CB-CAPs status (p< 0.01). Specificity of low C3/C4 and abnormal CB-CAPs in distinguishing SLE from healthy individuals was 93% and 99%, respectively. AUC was significantly higher with BC4d (0.718) than with EC4d (0.675; p< 0.01), low C3 (0.620; p< 0.01), low C4 (0.618; p< 0.01) and low C3 and/or C4 status (0.656; p< 0.01). Average (SEM) composite score cumulating all 4 abnormalities (range 0-4) was higher in SLE (1.47+/-0.06) than disease control group (0.21+/-0.02) (p< 0.01) and healthy individuals (0.01+/-0.02) (p< 0.01). The cumulative complement scoring system yielded higher AUC (0.812), higher OR (36.0 CI95%: 18.8-69.0), lower AIC (1037) than low C3/C4 or abnormal CB-CAPS; score greater than 1 abnormality yielded 45% sensitivity and 98% specificity. Conclusion : Our data suggest that the combination of CB-CAPs with low complement have superior diagnostic performance in SLE than either abnormality alone
Stress biomarker research among lesbian, gay, bisexual, and transgender people [Meeting Abstract]
In 2011, the Institute of Medicine published a timely report on the health inequalities of lesbian, gay, bisexual, and transgender (LGBT) individuals that effectively galvanized research on stress-disease processes. Across the board, LGBT individuals are more vulnerable to various physical and mental health problems due to stigma. And yet, the health and well-being of LGBT populations has rarely been investigated using psychobiological methods commonly applied in Psychosomatic Medicine. In this presentation, we provide a scoping literature review of the existing literature on stress biomarkers among LGBT individuals. A review was conducted using PubMed, Google Scholar, and Scopus search engines. The majority of studies have focused on diurnal cortisol, with some studies assessing immune, cardiovascular, and metabolic biomarkers that are often used in allostatic load studies. This is a small but growing literature of relevance to members of the American Psychosomatic Society. To summarize, emerging research assessing LGBT-related stigma has fallen into two camps: (1) between group analyses whereby LGBT profiles are assumed to differ from heterosexuals because of sexual/gender minority stress that is not actually measured or (2) within-group analyses only among sexual minorities who differ in their self-reports of sexual/gender minority stress. Between-groups analyses of young adults from Canada and the United States have found no disparities in diurnal cortisol profiles when contrasting sexual minorities to heterosexual individuals. In contrast, within-groups analyses of internalized stigma have consistently been associated with hypersecretion of diurnal cortisol among LGBT individuals with one exception. In conclusion, measuring LGBT-specific stigma may be a prerequisite to detecting variability in diurnal cortisol profiles and perhaps also other stress-related biomarkers
Cell bound complement activation products in combination with low complement C3 or C4 have high diagnostic yield in systemic lupus erythematosus [Meeting Abstract]
Background Cell Bound Complement Activation Products (CBCAPs), are stable form of classical complement activation, exvivo, and sensitive and specific marker of SLE. In the present study, we sought to compare the performances of CB-CAPs to gold standard low complement C3 or C4. Methods All subjects (n=1200) were adults (18 years) and enrolled from multiple academic Centers in the United States. All SLE fulfilled the 1997 ACR criteria for SLE (n=498). Patients with Other Rheumatic Diseases (n=450) consisted of 189 rheumatoid arthritis, 88 Sjogrens, 90 Fibromyalgia and 83 patients with other connective tissues diseases. A group of healthy normal individuals was also enrolled (n=252). Abnormal CB-CAPs status (EC4d or BC4d>99 th percentile of normal) were determined using flow-cytometry. Complement C3 and C4 levels were determined using immunoturbidimetry (Binding Site, San Diego, CA) assay kits. Performances of the markers, either alone or in combination to distinguish SLE from other rheumatic diseases and controls were established using Sensitivity, Specificity, Odds Ratio and Area under the Curve (AUC) of the Receiver Operating Characteristic curve (ROC). Youden Index (Sensitivity +Specificity - 100) was also calculated. The combination of 4 complement marker abnormalities were also evaluated using logistic regression and unweighted composite score cumulating the presence of these abnormalities was calculated. Results Abnormal CB-CAPs status yielded 62% sensitivity with 88% specificity in distinguishing SLE from the group of patients with other diseases (table 1). Youden Index was 0.492 +/-0.027. Low C3/C4 status yielded 38% sensitivity and 93% specificity in distinguishing SLE from the group of patients with other diseases. Youden Index was 0.313+/-0.025 for Low C3 or C4 and significantly lower than Youden score associated with abnormal CB-CAPs (p<0.01). Specificity of Low C3/C4 and abnormal CB-CAPs in distinguishing SLE from normal healthy individuals was 93% and 99%, respectively. AUC was also significantly higher with BC4d (0.718) than with low C3 (0.620; p<0.01), low C4 (0.618; p<0.01) and Low C3 or C4 status (0.656; p<0.01). A composite score (unweighted) cumulating all 4 abnormalities, was higher in SLE (1.47+/-0.06) than disease control group (0.21+/-0.02) (p<0.01) and normal healthy individuals (0.01+/-0.02) (p<0.01). The complement scoring system yielded higher AUC (0.812), higher OR (36.0 CI95%: 18.8-69.0), lower AIC (1037) and greater R2 (0.403) than any other combinations Conclusions Our data suggests that CB-CAPs have greater diagnostic yield than low complement C3/C4. The combination of these complement abnormalities in composite complement score has high yield in distinguishing SLE from other rheumatic diseases and normal healthy individuals. (Figure Presented)
Multi-center validation of platelet bound C4D, a biomarker for systemic lupus erythematosus [Meeting Abstract]
Background/Purpose: Previous studies have established the value of measuring complement activation products (C4d) bound to platelets (PC4d) for the diagnosis and monitoring of Systemic Lupus Erythematosus (SLE). Separately, Antiphospholipid (APL) antibodies have been associated with complement activation and PC4d expression. In this study, we sought to validate the performance characteristics of PC4d, stratified by the presence or absence of APL antibodies. Methods: This multi-centered validation cross sectional study (16 sites in the US) enrolled 402 SLE subjects fulfilling the 1982 American College of Rheumatology Criteria revised in 1997 (mean age 41 years; 91% female), 411 subjects with rheumatic and autoimmune diseases other than SLE (mean age 55, 86% female consisting of 181 rheumatoid arthritis, 90 primary fibromyalgia, 92 other rheumatic diseases, and 48 autoimmune thyroiditis or hepatitis) and 198 healthy volunteers (mean age 41 years; 66% female). PC4d densities were determined using flow cytometry (expressed as mean fluorescence intensity [MFI]). Positive PC4d consisted of PC4d levels greater than 20 net MFI. Anticardiolipin IgG, anti-Beta-2-glycoprotein 1 IgG, or anti-Phosphatidylserine/Prothrombin (PSPT) complex IgG antibodies were determined using ELISA (INOVA diagnostics, San Diego, CA). Presence of APL antibodies consisted of any of these antibodies above manufacturer cutoff. SLE Disease activity was assessed using the non-serological SLE Disease Activity Index SELENA modification (ns-SELENA-SLEDAI, without the complement and anti-dsDNA). Performance characteristics were established using sensitivity, specificity, and ROC Curve Area Under the Curve (AUC). Statistical evaluation was by t-test (for disease activity), by chi-squared test for equality of proportions (for sensitivities and specificities) and by the method of DeLong (for ROC Curve AUC). Results: PC4d was highly specific in distinguishing SLE from other rheumatic diseases (Table) and normals. Among SLE subjects, 47% (n=187) presented with at least one APL antibody as compared to 21% (n=86) of subjects with other diseases and 15% of normals. PC4d sensitivity for SLE was higher among APL positive subjects by comparison to APL negative subjects (p=0.003). Specificity was not significantly different between APL positive and negative subjects (p>0.372). ROC AUC was significantly higher among the APL positive compared to negative subjects (p=0.002). The incidence of APL antibodies among all PC4d positive subjects was 60% compared to 27% among PC4d negative subjects (p<0.001). SLE subjects presenting with positive PC4d had higher disease activity (4.1+/-0.5) than those presenting with negative PC4d (3.0+/-0.2) (p=0.03). Conclusion: We confirm that PC4d is highly specific for SLE, and is associated with disease activity. (Table Presented)
Percutaneous gene therapy heals cranial defects
Nonhealing bone defects are difficult to treat. As the bone morphogenic protein and transforming growth factor beta pathways have been implicated in bone healing, we hypothesized that percutaneous Smad7 silencing would enhance signaling through both pathways and improve bone formation. Critical sized parietal trephine defects were created and animals received percutaneous injection of: agarose alone or agarose containing nonsense or Smad7 small interfering RNA (siRNA). At 12 weeks, SMADs1, 2, 3, 5, 7 and 8 levels were assessed. Smad1/5/8 osteogenic target, Dlx5, and SMAD2/3 angiogenic target, plasminogen activator inhibitor-1 (Pai1), transcription levels were measured. Noncanonical signaling through TGFbeta activated kinase-1 (Tak1) and target, runt-related transcription factor 2 (Runx2) and collagen1alpha1 (Col1alpha1), transcription were also measured. Micro-computed tomography and Gomori trichome staining were used to assess healing. Percutaneous injection of Smad7 siRNA significantly knocked down Smad7 mRNA (86.3+/-2.5%) and protein levels (46.3+/-3.1%). The SMAD7 knockdown resulted in a significant increase in receptor-regulated SMADs (R-SMAD) (Smad 1/5/8 and Smad2/3) nuclear translocation. R-SMAD nuclear translocation increased Dlx5 and Pai1 transcription. Additionally, noncanonical signaling through Tak1 increased Runx2 and Col1alpha1 target transcription. Compared with animals treated with agarose alone (33.9+/-2.8% healing) and nonsense siRNA (31.5+/-11.8% healing), animals treated Smad7 siRNA had significantly great (91.2+/-3.8%) healing. Percutaneous Smad7 silencing increases signal transduction through canonical and noncanonical pathways resulting in significant bone formation. Minimally invasive gene therapies may prove effective in the treatment of nonhealing bone defects.
The leukotriene antagonist zafirlukast as a therapeutic agent for atopic dermatitis [Case Report]
Tinea capitis caused by Trichophyton rubrum in a 67-year-old woman with systemic lupus erythematosus [Case Report]