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Khayata M, Wang TKM, Chan N, Alkharabsheh S, Verma BR, Oliveira GH, Klein AL, Littlejohn E, Xu B. Multimodality Cardiac Imaging in Patients with Systemic Lupus Erythematosus. Curr Probl Cardiol 2023; 48:101048. [PMID: 34774920 DOI: 10.1016/j.cpcardiol.2021.101048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 02/01/2023]
Abstract
Systemic lupus erythematous (SLE) is an autoimmune disease with a wide range of cardiovascular complications. The main manifestations include diseases of the coronary arteries, valves, pericardium, and myocardium. Multimodality cardiovascular imaging techniques are critical for evaluating the extent of cardiac manifestations in SLE patients, which can provide valuable prognostic information. However, their utility has previously not been well defined. This review provides a state-of-the-art update on the cardiovascular manifestations of lupus, as well as the role of multimodality cardiac imaging in guiding management of patients with SLE.
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Affiliation(s)
- Mohamed Khayata
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Tom Kai Ming Wang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas Chan
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Saqer Alkharabsheh
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beni R Verma
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme H Oliveira
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Allan L Klein
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, Ohio, USA
| | - Bo Xu
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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Jones JM, Smith F, Littlejohn E, Jorgensen TN. Lack of Association Between Sex Hormones, MDSCs, LDGs and pDCs in Males and Females With Systemic Lupus Erythematosus. Front Immunol 2022; 13:888501. [PMID: 35833144 PMCID: PMC9271771 DOI: 10.3389/fimmu.2022.888501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Plasmacytoid dendritic cells (pDCs) and low-density granulocytes (LDGs) are interferon-alpha producing cells that create a pro-inflammatory response in Systemic Lupus Erythematosus (SLE) leading to auto antibody production and organ damage. Both pDCs and LDGs have been shown to be dysfunctional in patients with active SLE. Myeloid-derived suppressor cells (MDSCs) have the capacity to control T and B cell activation and differentiation, and have recently been identified as cells of interest in SLE as well. While not fully understood, previous studies have suggested that pDCs are regulated in part by both X chromosome inactivation and estradiol. Whether sex chromosomes or sex hormones regulate MDSCs and LDGs remain to be determined. We aimed to explore the relative role of sex and sex hormones on pDC, MDSC and LDG frequency and function in SLE patients. We recruited patients with SLE as defined by ACR or SLICC classification criteria and healthy controls in conjunction with the Cleveland Clinic Lupus Cohort and Clinical Research Unit. We analyzed serum sex hormone levels by ELISA, and frequencies of pDCs, MDSCs, and LDGs among PBMCs and serum cytokine levels by flow cytometry. PBMCs were further analyzed for expression of genes involved in or induced by toll-like receptor (TLR)7 or TLR9 stimulation. In all SLE patients, the serum estradiol/testosterone ratio and levels of granulocytic MDSCs and LDGs were increased, while levels of pDCs were decreased. Furthermore, pDCs from active SLE patients expressed lower levels of TLR7 and TLR9 and showed diminished production of TLR9-induced IFNα and TNFα as compared to healthy controls. LDGs from healthy controls and SLE patients expressed very low levels of TLR7 and TLR9 and largely failed to respond to TLR9 stimulation. Thus, regardless of sex and sex-hormone levels, frequencies of pDCs, MDSCs and LDGs, TLR7 and TLR9 expression, and TLR9-driven cytokine production were similarly altered in male and female SLE patients.
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Affiliation(s)
- Jessica M. Jones
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Frances Smith
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Orthopaedic and Rheumatologic Institute, Lupus Clinic, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Trine N. Jorgensen
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, OH, United States
- *Correspondence: Trine N. Jorgensen,
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Frydenberg A, Oborne N, Polley C, Littlejohn E, Gray A. Paediatric asthma education: Implementation of video-based education for families. J Paediatr Child Health 2022; 58:868-872. [PMID: 35037728 DOI: 10.1111/jpc.15862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 10/03/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
AIM To understand the impact of an asthma education video resource introduced to the short stay unit (SSU) of a tertiary paediatric hospital on: (i) parental understanding of and confidence in managing their child's asthma; (ii) the impact of this resource on nurse-led education practices; and (iii) readmission rates. METHODS A mixed methods study was conducted in the SSU over an 18-month period using quantitative survey data from parents and nursing staff and qualitative data from nursing staff focus groups. RESULTS Of 117 parents surveyed, 94% reported an increase in their understanding of asthma. Following the introduction of the resource, there were fewer nurse-led education sessions delivered (1.91 vs. 1.54, P = 0.04) and a trend towards reduction in time spent delivering this education (27.24 vs. 24.98 min, P = 0.47). Nursing staff confidence in the family's understanding of asthma education was similar pre- and post-implementation (4.22 vs. 4.30, P = 0.97). Readmission rates dropped by 25% (readmissions within 1 month) and by 33.3% (readmission within a week) in the post-intervention cohort. CONCLUSIONS Our asthma education video resource was demonstrated to be an acceptable and effective way of delivering asthma education to families. It created efficiency and consistency for nursing education and practice in our SSU. This resource was viewed by nursing staff as a useful adjunct to their education, enabling consistent messaging and helping structure education delivery. It has been incorporated into hospital systems and national resources which we hope will translate to a reduction in burden of asthma across the community.
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Affiliation(s)
- Alexis Frydenberg
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Naomi Oborne
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Clare Polley
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Emily Littlejohn
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amy Gray
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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Ming Wang TK, Chan N, Khayata M, Flanagan P, Grimm RA, Griffin BP, Husni ME, Littlejohn E, Xu B. Cardiovascular Manifestations, Imaging, and Outcomes in Systemic Lupus Erythematosus: An Eight-Year Single Center Experience in the United States. Angiology 2022; 73:877-886. [PMID: 35238664 DOI: 10.1177/00033197221078056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Systemic lupus erythematosus (SLE) is a challenging autoimmune and multi-system condition. With advances in cardiovascular screening and therapies for SLE patients, we evaluated the cardiovascular characteristics, multi-modality imaging, and outcomes of SLE at our tertiary referral center over an 8 year period. Consecutive patients from our SLE registry from April 2012 to March 2020 were retrospectively analyzed. Data pertaining to cardiovascular manifestations, investigations, management, and outcomes were assessed. We studied 258 SLE patients (mean age 42.2 ± 14.7 years); 233 (90.3%) were female. The main cardiac manifestations at index SLE clinic were pericardial disease in 33.3%, valve disease in 18%, cardiomyopathy in 9.6%, and stroke in 7.4%. During a mean follow-up of 3.0 ± 2.2 years after index SLE clinic, there were 5 (1.9%) deaths, 24 (9.3%) cardiovascular events, and 44 (17.1%) SLE-related hospitalizations. A history of stroke and hypertension were independently associated with cardiovascular events, hazard ratio (HR) (95% confidence intervals (CI)) of 5.38 (1.41-20.6) and 3.31 (1.02-10.7), respectively, while younger age and lower albumin predicted SLE-related hospitalizations. Cardiovascular manifestations are prevalent in SLE, especially for pericardial, valvular, and atherosclerotic diseases. With contemporary SLE and cardiovascular management, subsequent adverse cardiovascular events were infrequent in this study.
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Affiliation(s)
- Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas Chan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed Khayata
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Cardiovascular Sciences, 33697University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Patrick Flanagan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Richard A Grimm
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - M Elaine Husni
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Littlejohn
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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Abstract
Hydroxychloroquine (HCQ) has multiple potential antiviral mechanisms of action that differ according to the pathogen studied (eg, Chikungunya, Dengue virus, human immunodeficiency virus, poliovirus, Zika virus). Data on HCQ for treatment of COVID-19 are rapidly evolving. To date, there is no evidence from randomized controlled trials that HCQ, or any single therapy, improves outcomes in patients infected with COVID-19. There are also no clinical trial data supporting prophylactic HCQ therapy in COVID-19. Use of HCQ in patients with COVID-19 is being investigated for prophylaxis, postexposure prophylaxis, and treatment.
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Affiliation(s)
- Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Orthopaedic & Rheumatologic Institute, Cleveland Clinic
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Abstract
Hydroxychloroquine (HCQ) is in short supply as a result of the coronavirus disease 2019 (COVID-19) pandemic, presenting a challenge to rheumatologists to ensure their patients with systemic lupus erythematosus (SLE) continue to take this essential drug. HCQ is the only SLE treatment shown to increase survival and any change in the HCQ regimen is potentially dangerous. Changes in the HCQ regimen should be made jointly with the patient after a discussion of the available evidence and expert opinion and the patient's preferences. Providers need to make thoughtful, informed decisions in this time of medication shortage.
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Affiliation(s)
- Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic
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Littlejohn E, Marder W, Lewis E, Francis S, Jackish J, McCune WJ, Somers EC. The ratio of erythrocyte sedimentation rate to C-reactive protein is useful in distinguishing infection from flare in systemic lupus erythematosus patients presenting with fever. Lupus 2018; 27:1123-1129. [PMID: 29546774 DOI: 10.1177/0961203318763732] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Both C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be elevated in systemic lupus erythematosus (SLE) flare and infection, and are therefore of limited utility for distinguishing between the two conditions in febrile SLE patients. Methods A medical records review of hospitalizations (1997-2006) of SLE patients in the Michigan Lupus Cohort was performed. Eligible hospitalizations were those in which patients presented with a temperature of >100.3°F or with subjective fevers as a presenting complaint at admission. Detailed demographic, clinical, and laboratory data were collected. Multivariable logistic regression was used to examine the associations between ESR and CRP and the outcome of flare vs infection, adjusted for confounders. Results Among 557 SLE patients screened, there were 53 eligible hospitalizations (28 flares and 25 infections). Each unit increase in the ratio of ESR:CRP was associated with a 17% increase in the odds of fever being attributable to SLE flare compared to infection (OR 1.17, 95% CI 1.04, 1.31; p = 0.009), when adjusted for white blood cell count, SLE duration, sex, race, and age. ESR and CRP were not individually associated with flare vs infection when modeled with their ratio. Conclusions The ratio of ESR:CRP may provide diagnostic value beyond individual ESR and CRP levels in distinguishing flare vs infection in SLE patients presenting with fever.
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Affiliation(s)
- E Littlejohn
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA
| | - W Marder
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,2 Department of Obstetrics & Gynecology, 1259 University of Michigan , Ann Arbor, MI, USA
| | - E Lewis
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA
| | - S Francis
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,3 Orthopedics & Sports Medicine P.C., New Windsor, NY, USA
| | - J Jackish
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,4 25214 Park Nicollet/Health Partners Methodist Hospital , St. Louis Park, MN, USA
| | - W J McCune
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA
| | - E C Somers
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,2 Department of Obstetrics & Gynecology, 1259 University of Michigan , Ann Arbor, MI, USA.,5 Department of Environmental Health Sciences, 1259 University of Michigan , Ann Arbor, MI, USA
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