Leveraging Lymphatic System Targeting in Systemic Lupus Erythematosus for Improved Clinical Outcomes

The role of advanced drug delivery strategies in drug repositioning and minimizing drug attrition rates, when applied early in drug discovery, is poised to increase the translational impact of various therapeutic strategies in disease prevention and treatment. In this context, drug delivery to the lymphatic system is gaining prominence not only to improve the systemic bioavailability of various pharmaceutical drugs but also to target certain specific diseases associated with the lymphatic system. Although the role of the lymphatic system in lupus is known, very little is done to target drugs to yield improved clinical benefits. In this review, we discuss recent advances in drug delivery strategies to treat lupus, the various routes of drug administration leading to improved lymph node bioavailability, and the available technologies applied in other areas that can be adapted to lupus treatment. Moreover, this review also presents some recent findings that demonstrate the promise of lymphatic targeting in a preclinical setting, offering renewed hope for certain pharmaceutical drugs that are limited by efficacy in their conventional dosage forms. These findings underscore the potential and feasibility of such lymphatic drug-targeting approaches to enhance therapeutic efficacy in lupus and minimize off-target effects of the pharmaceutical drugs. SIGNIFICANCE STATEMENT: The World Health Organization estimates that there are currently 5 million humans living with some form of lupus. With limited success in lupus drug discovery, turning to effective delivery strategies with existing drug molecules, as well as those in the early stage of discovery, could lead to better clinical outcomes. After all, effective delivery strategies have been proven to improve treatment outcomes.

Comparison of the Aotearoa New Zealand Early Warning Score and National Early Warning Score to predict adverse inpatient events in a vital sign dataset

Aotearoa New Zealand uses a single early warning score (EWS) across all public and private hospitals to detect adult inpatient physiological deterioration. This combines the aggregate weighted scoring of the UK National Early Warning Score with single parameter activation from Australian medical emergency team systems. We conducted a retrospective analysis of a large vital sign dataset to validate the predictive performance of the New Zealand EWS in discriminating between patients at risk of serious adverse events and compared this with the UK EWS. We also compared predictive performance for patients admitted under medical vs. surgical specialties. A total of 1,738,787 aggregate scores (13,910,296 individual vital signs) were obtained from 102,394 hospital admissions to six hospitals within the Canterbury District Health Board of New Zealand's South Island. Predictive performance of each scoring system was determined using area under the receiver operating characteristic curve. Analysis showed that the New Zealand EWS is equivalent to the UK EWS in predicting patients at risk of serious adverse events (cardiac arrest, death and/or unanticipated ICU admission). Area under the receiver operating characteristic curve for both EWSs for any adverse outcome was 0.874 (95%CI 0.871-0.878) and 0.874 (95%CI 0.870-0.877), respectively. Both EWSs showed superior predictive value for cardiac arrest and/or death in patients admitted under surgical rather than medical specialties. Our study is the first validation of the New Zealand EWS in predicting serious adverse events in a broad dataset and supports previous work showing the UK EWS has superior predictive performance in surgical rather than medical patients.

POS0187 DRUG REPURPOSING FOR TREATING LUPUS NEPHRITIS BASED ON TRANSCRIPTOME PROFILING AND AUTOIMMUNITY-RELATED SEROLOGICAL MARKERS

Background

Lupus nephritis (LN) is one of the most severe organ manifestations of systemic lupus erythematosus (SLE) and constitutes an important cause of morbidity and death among patients with SLE [1]. The associated renal injury, and ultimately damage, is the result of an immune-mediated process which involves leukocytes, immune complexes, complement and cytokines [2].

Objectives

Lupus nephritis (LN) is one of the most severe organ manifestations of systemic lupus erythematosus (SLE) and constitutes an important cause of morbidity and death among patients with SLE [1]. The associated renal injury, and ultimately damage, is the result of an immune-mediated process which involves leukocytes, immune complexes, complement and cytokines [2].

Methods

We analysed differentially expressed genes (DEGs), pathways and their druggability via the Drug Gene Interaction database (DGIdb) [3] in active LN (n=41) versus healthy controls (HC; n=497), and eQTLs in active or past LN (n=87), based on validated (identified in two independent SLE populations) DEGs in SLE (n=350) vs HC (n=497), in whole blood collected within the frame of the European PRECISESADS consortium [4]. Genome-wide RNA-sequencing and genotyping was previously performed by Illumina assays, and serum levels of 17 cytokines and 18 autoantibodies were analysed using a Luminex assay, ELISA, IDS-iSYS and SPAPLUS analyser [4].

Results

A total of 6 869 significant and validated DEGs were identified in active LN patients compared with HC. Of these, 1010 validated DEGs were tagged to 34 KEGG pathways including 24 DEGs with a |fold change (FC)| > 1.5, genes of 18 cis-eQTLs and 3 trans-eQTLs, and 1 gene from cytokines that differed significantly between active LN and HC. Moreover, 2446 validated DEGs were tagged to 216 Reactome pathways included 85 DEGs with a |FC| > 1.5, genes of 21 cis-eQTLs and 5 trans-eQTLs, and 1 gene from cytokines that differed significantly between active LN and HC. These genes could be targeted by 203 different drugs, with the proteasome inhibitor bortezomib interfering with cathepsin B (CTSB) regulation and cyclophosphamide interfering with the regulation of tumour necrosis factor receptor superfamily member 1A (TNFRSF1A) being of particular interest.

Conclusion

Integrated multilevel omics analysis in LN revealed a set of enriched pathways of potential interest for future drug investigation. A prospect for proteasome inhibition was implicated.

References

[1]Croca SC, Rodrigues T, Isenberg DA. Assessment of a lupus nephritis cohort over a 30-year period. Rheumatology (Oxford). 2011 Aug; 50(8):1424-1430.

[2]Anders HJ, Saxena R, Zhao MH, Parodis I, Salmon JE, Mohan C. Lupus nephritis. Nat Rev Dis Primers. 2020 Jan 23; 6(1):7.

[3]Wagner AH, Coffman AC, Ainscough BJ, Spies NC, Skidmore ZL, Campbell KM, et al. DGIdb 2.0: mining clinically relevant drug-gene interactions. Nucleic Acids Res. 2016 Jan 4; 44(D1):D1036-1044.

[4]Barturen G, Babaei S, Català-Moll F, Martínez-Bueno M, Makowska Z, Martorell-Marugán J, et al. Integrative Analysis Reveals a Molecular Stratification of Systemic Autoimmune Diseases. Arthritis Rheumatol. 2021 Jun; 73(6):1073-1085.

[5]Kanehisa M, Furumichi M, Tanabe M, Sato Y, Morishima K. KEGG: new perspectives on genomes, pathways, diseases and drugs. Nucleic Acids Res. 2017 Jan 4; 45(D1):D353-d361.

[6]Jassal B, Matthews L, Viteri G, Gong C, Lorente P, Fabregat A, et al. The reactome pathway knowledgebase. Nucleic Acids Res. 2020 Jan 8; 48(D1):D498-d503.

Acknowledgements

The PRECISESADS Clinical Consortium

Disclosure of Interests

None declared

POS0188 TRANSCRIPTOME PROFILING AND AUTOIMMUNITY-RELATED SEROLOGICAL MARKERS IDENTIFY TP53 and C3aR AS DRUG TARGETS IN NEUROPSYCHIATRIC SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Involvement of the nervous system is a common but poorly understood manifestation of systemic lupus erythematosus (SLE), termed neuropsychiatric SLE (NPSLE). Although studies have reported varying prevalence estimates [1], NPSLE affects at least 20% of patients with SLE within the first years of the disease course [2]. The management of neuropsychiatric SLE (NPSLE) is poorly optimised and specific treatment is lacking.

Objectives

The aim of this study was to investigate expression quantitative trait loci (eQTLs), the transcriptome, and autoimmunity-related cytokines and autoantibodies in patients with central nervous system (CNS) lupus to gain insights into underlying genetics and biologic mechanisms towards identification of novel drug targets.

Methods

We analysed differentially expressed genes (DEGs), pathways and their druggability via the Drug Gene Interaction database (DGIdb) [3] in active CNS lupus (n=26) versus healthy controls (HC; n=497), and eQTLs in active or past CNS lupus (n=53), based on validated (identified in two independent SLE populations) DEGs in SLE (n=350) versus HC (n=497), in whole blood collected within the frame of the European PRECISESADS consortium [4]. CNS lupus was defined according to SLE Disease Activity Index 2000 (SLEDAI-2K) [5] CNS items or by CNS manifestations such as chorea, acute confusional state, transverse myelitis, aseptic meningitis, and optic neuritis in the absence of predisposing conditions unrelated to SLE. Genome-wide RNA-sequencing and genotyping was previously performed by Illumina assays, and serum levels of 17 cytokines were analysed using a Luminex assay and ELISA [4].

Results

Among 5631 significant and validated DEGs in active CNS patients compared with HC, 1922 unique DEGs were tagged to 21 and 176 significant KEGG [6] and Reactome [7] pathways, respectively. Pathways included “Interferon signalling”, “TNF signalling” and “Toll-like Receptor Cascades”. The pathways included 29 of 59 DEGs with a |fold change (FC)| > 1.5, 6 genes from 14 significant cis-eQTLs and 10 genes from 22 trans-eQTLs, and 2 genes from 8 cytokines that differed significantly between active CNS lupus and HC. These genes could be targeted by 496 different drugs, with the Bruton tyrosine kinase (BTK) inhibitor ibrutinib and the anti-CD20 B cell depleting monoclonal rituximab with ability to interfere with tumour protein P53 (TP53) activity, and a complement C3a Receptor (C3aR) antagonist being of particular interest.

Conclusion

Integrated multilevel omics analysis revealed a set of enriched pathways of potential interest for future drug investigation in CNS lupus, including BTK and C3aR inhibition, and B cell depletion.

References

[1]Unterman A, Nolte JE, Boaz M, Abady M, Shoenfeld Y, Zandman-Goddard G. Neuropsychiatric syndromes in systemic lupus erythematosus: a meta-analysis. Semin Arthritis Rheum. 2011 Aug; 41(1):1-11

[2]Hanly JG, Urowitz MB, Su L, Bae SC, Gordon C, Wallace DJ, et al. Prospective analysis of neuropsychiatric events in an international disease inception cohort of patients with systemic lupus erythematosus. Ann Rheum Dis. 2010 Mar; 69(3):529-535

[3]Wagner AH, Coffman AC, Ainscough BJ, Spies NC, Skidmore ZL, Campbell KM, et al. DGIdb 2.0: mining clinically relevant drug-gene interactions. Nucleic Acids Res. 2016 Jan 4; 44(D1):D1036-1044

[4]Barturen G, Babaei S, Català-Moll F, Martínez-Bueno M, Makowska Z, Martorell-Marugán J, et al. Integrative Analysis Reveals a Molecular Stratification of Systemic Autoimmune Diseases. Arthritis Rheumatol. 2021 Jun; 73(6):1073-1085

[5]Gladman DD, Ibanez D, Urowitz MB. Systemic lupus erythematosus disease activity index 2000. J Rheumatol. 2002 Feb; 29(2):288-291

[6]Kanehisa M, Furumichi M, Tanabe M, Sato Y, Morishima K. KEGG: new perspectives on genomes, pathways, diseases and drugs. Nucleic Acids Res. 2017 Jan 4; 45(D1):D353-d361

[7]Jassal B, Matthews L, Viteri G, Gong C, Lorente P, Fabregat A, et al. The reactome pathway knowledgebase. Nucleic Acids Res. 2020 Jan 8; 48(D1):D498-d503

Acknowledgements

The PRECISESADS clinical consortium

Disclosure of Interests

None declared

Imaging of cochlear implants

Aim : To evaluate the role of various imaging modalities in pre and post operative evaluation of cochlear implant candidates. Materials and methods : 30 patients were evaluated by HRCT and 15 of these subsequently underwent MRI temporal bones prior to cochlear implant device insertion. All implanted patients were subjected to post operative radiography to assess position of implant. Results : Both modalities provided critical information on abnormalities of the otic capsule, pneumatisation of the mastoid, middle ear abnormalities, cochlear ducts patency and vascular abnormalities- thus helping to assess the suitability of the ear for implantation, determine the side to be implanted and to find any associated abnormality which could adversely influence the surgery or post op period. HRCT missed two cases of luminal ossification and MRI was more reliable in detecting early luminal obstruction. Conclusion : Based on our findings, we offer a realistic and practical protocol for imaging in cochlear implants in the Indian setting. HRCT is recommended in all patients for pre implant analysis of the temporal bone morphology due to its reliability and easy availability. MRI is recommended in all cases of post meningitic deafness and in others with doubtful CT findings.

SAT0234 SERUM AXL, FERRITIN, IGFBP4 AND STNFR2 AS BIOMARKERS OF PEDIATRIC SLE

Background:

Proteomic screening is an efficient approach for identifying protein biomarkers in various inflammatory diseases. Our preliminary proteomic analysis revealed elevated levels of serum Axl, Ferritin, IGFBP4 and sTNFR2 in adult patients with active lupus nephritis (LN) (1). However, the role of these serum biomarkers in pediatric systemic lupus erythematosus (SLE) patients has not been examined.

Objectives:

To evaluate the performance of 4 serum protein markers for detecting disease activity in pediatric patients with SLE.

Methods:

83 pediatric patients who fulfilled ≥4 ACR criteria for SLE and 25 healthy controls were recruited for serological testing of 4 protein markers identified by antibody-coated microarray screen, namely Axl, ferritin, IGFBP4 and sTNFR2. SLE disease activity was assessed using the SLEDAI-2k score, renal disease activity was assessed by the renal SLEDAI (range 0-16; 0= inactive LN, ≥ 8= active renal). 57 patients had clinically active SLE (SLEDAI score ≥ 4 or having a flare) (28 active renal and 29 active non-renal SLE patients). In active renal patients, concurrent renal biopsy was performed, unless contraindicated. The ISN/RPS criteria were used to assess the histopathologic features of LN. Those Patients were further subcategorized into 2 groups; active proliferative (ISN/RPS classes III/IV) and non-proliferative (classes I/II/V).

Results:

The serum concentrations of Axl and ferritin were significantly higher in patients with active SLE than inactive SLE (3765±235 vs. 2513±130 pg/ml,P= 0.001) and (111±26 vs. 18±4 ng/ml,P =0.0001) respectively. Serum Axl levels were significantly higher in active renal versus active non-renal SLE patients (3765±235.3 vs. 2825±200.7 pg/ml,P= 0.04). In the active renal patients with paired kidney tissue and blood samples, none of the biomarkers tested discriminated classes of LN, although serum Axl, ferritin and IGBPB4 levels were higher in the proliferative subgroup. The levels of Axl, ferritin and IGFBP4 correlated significantly with SLEDAI scores (Axl, r= 0.58,P<0.0001; ferritin, r= 0.53,P<0.0001; IGFBP4, r= 0.229,P= 0.03). However, only serum Axl levels correlated significantly with the renal SLEDAI (r= 0.46,P= 0.01). The levels of Axl, IFGBP4 and sTNFR2 correlated with decreased C3 levels (r= - 0.54,P<0.0001; r= - 0.29,P= 0.007; r= - 0.29,P= 0.007) respectively. Only serum Axl and ferritin correlated with urinary PCR (r= 0.42,P<0.0001; r= 0.22,P=0.04) respectively. These markers were more specific, but less sensitive, in detecting concurrent SLE activity than elevated anti-dsDNA or decreased C3. The specificity values of serum ferritin and IGFBP4 for concurrent active lupus nephritis were higher than anti-dsDNA or C3. Serum ferritin was the best predictor of global SLE activity (AUC 0.81,P<0.0001), followed by C3 (AUC 0.79,P<0.0001) then Axl (AUC 0.71,P= 0.002), while both Axl and C3 were the best predictors of lupus nephritis activity (AUC 0.72, both).

Conclusion:

In pediatric SLE patients, serum ferritin and Axl perform better than traditional yardsticks in identifying disease activity, either global or renal. The performance of these serum markers should be explored further in a longitudinal cohort of pediatric SLE patients.

References:

[1]Wu T, Ding H, Han J, et al. Antibody-Array-Based Proteomic Screening of Serum Markers in Systemic Lupus Erythematosus: A Discovery Study. J Proteome Res. 2016 Jul 1;15 (7): 2102-14.

Disclosure of Interests:

None declared

PKK deficiency in B cells prevents lupus development in Sle lupus mice

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the production of autoantibodies that can result in damage to multiple organs. It is well documented that B cells play a critical role in the development of the disease. We previously showed that protein kinase C associated kinase (PKK) is required for B1 cell development as well as for the survival of recirculating mature B cells and B-lymphoma cells. Here, we investigated the role of PKK in lupus development in a lupus mouse model. We demonstrate that the conditional deletion of PKK in B cells prevents lupus development in Sle1Sle3 mice. The loss of PKK in Sle mice resulted in the amelioration of multiple classical lupus-associated phenotypes and histologic features of lupus nephritis, including marked reduction in the levels of serum autoantibodies, proteinuria, spleen size, peritoneal B-1 cell population and the number of activated CD4 T cells. In addition, the abundance of autoreactive plasma cells normally seen in Sle lupus mice was also significantly decreased in the PKK-deficient Sle mice. Sle B cells deficient in PKK display defective proliferation responses to BCR and LPS stimulation. Consistently, B cell receptor-mediated NF-κB activation, which is required for the survival of activated B cells, was impaired in the PKK-deficient B cells. Taken together, our work uncovers a critical role of PKK in lupus development and suggests that targeting the PKK-mediated pathway may represent a promising therapeutic strategy for lupus treatment.

Serum soluble tumour necrosis factor receptor-2 (sTNFR2) as a biomarker of kidney tissue damage and long-term renal outcome in lupus nephritis

OBJECTIVES

We investigated the performance of soluble tumour necrosis factor receptor-2 (sTNFR2) as a biomarker of renal activity, damage, treatment response, and long-term outcome in lupus nephritis (LN).

METHOD

Serum sTNFR2 levels were assessed in 64 LN patients (52 proliferative, 12 membranous) before and after induction treatment, and in 314 non-lupus controls. In LN patients, renal biopsies were performed at baseline and post-treatment. Patients with ≥ 50% reduced proteinuria, normal or improved estimated glomerular filtration rate (eGFR) by ≥ 25%, and inactive urinary sediment were considered clinical responders (CRs). Patients with ≥ 50% improved renal activity index were considered histopathological responders (HRs). Long-term renal outcome was determined using the chronic kidney disease (CKD) stage after a median follow-up of 11.3 years.

RESULTS

sTNFR2 levels were elevated in LN patients versus controls both at baseline (p < 0.001) and post-treatment (p < 0.001), and decreased following treatment (p < 0.001). Baseline sTNFR2 correlated with Chronicity Index scores in both baseline (r = 0.34, p = 0.006) and post-treatment (r = 0.43, p < 0.001) biopsies. In membranous LN, baseline sTNFR2 levels were higher in CRs (p = 0.048) and HRs (p = 0.03) than in non-responders, and decreased only in CRs (p = 0.03). Both baseline (p = 0.02) and post-treatment (p = 0.03) sTNFR2 levels were associated with decreasing eGFR throughout long-term follow-up, and post-treatment levels were higher in patients with long-term follow-up CKD stage ≥ 3 versus 1-2 (p = 0.008).

CONCLUSIONS

Our data suggest serum sTNFR2 as a marker of kidney tissue damage and a predictor of long-term prognosis in LN, and merit further evaluation of sTNFR2 as a predictor of clinical and histopathological treatment outcomes in membranous LN.

Environment versus genetics in autoimmunity: a geneticist's perspective

Both environmental as well as genetic factors have been documented to contribute to autoimmunity, as is evident from the accompanying articles in this journal. This raises an important question–which of these two elements plays a more important role in the genesis of autoimmunity? This report encapsulates a geneticist's perspective on this interesting question. Though lupus is used as an example in this essay, the proposed model is envisaged to operate in other autoimmune diseases as well.

Arraying Autoantibodies in SLE - Lessons Learned

Systemic lupus erythematosus (SLE) is a chronic autoimmune connective tissue disease characterized by the production of a large number of autoantibodies, but the etiology is complex and poorly understood. A range of different platforms have served as screening methods for the determination of autoantibody specificities over the past few decades. Proteomic microarray is a relatively new high-throughput technology which is playing an increasingly important role in autoantibody diagnostics. In this article, we review different platforms for assaying autoantibodies in SLE, and highlight the use of autoantigen arrays as powerful tools for autoantibody exploration in SLE.

Resistin as a potential marker of renal disease in lupus nephritis

Systemic lupus erythematosus (SLE) and lupus nephritis (LN) have strong concomitance with cardiovascular disease that cannot be explained fully by typical risk factors. We examined the possibility that serum or urine expression of adipokines may act as biomarkers for LN, as these proteins have been associated previously with cardiovascular disease as well as SLE. Antibody arrays were performed on serum and urine from lupus patients and matched controls using a cross-sectional study design. From the initial array-based screening data of 15 adipokines, adiponectin, leptin and resistin were selected for validation by enzyme-linked immunosorbent assay (ELISA). Correlations were determined between adipokine expression levels and measures of disease activity or lupus nephritis. The expression of adiponectin and resistin was increased in both sera and urine from LN patients, while leptin was increased in LN patient sera, compared to matched controls. Serum resistin, but not urine resistin, was correlated with measures of renal dysfunction in LN. Serum resistin expression may be useful as a marker of renal dysfunction in patients with LN, although longitudinal studies are warranted. Further studies are necessary to determine if resistin has functional consequences in LN.

Intra-articular nuclear factor-κB blockade ameliorates collagen-induced arthritis in mice by eliciting regulatory T cells and macrophages

Nuclear factor (NF)-κB is a transcription factor implicated in the pathogenesis of autoimmune disorders such as rheumatoid arthritis (RA). Here we have examined the effect of intra-articular administration of the IKK inhibitor, NEMO-binding domain peptide (NBD), on the severity of collagen-induced arthritis (CIA). NBD peptides were injected intra-articularly into the knee joints of DBA/1J mice after the onset of disease. Collagen-injected mice given a scrambled peptide served as controls. Arthritis severity was determined by visual examination of paws. Intra-articular NBD injection reduced the arthritis score and ameliorated morphological signs of bone destruction compared to the controls. Serum levels of type-II collagen-specific immunoglobulin (Ig)G2a antibodies were lower in NBD-treated mice versus the control mice, whereas the levels of type-II collagen-specific IgG1 antibodies were increased by NBD treatment. NBD treatment diminished the proinflammatory cytokines interleukin (IL)-17 and interferon (IFN)-γ in serum, but increased the regulatory cytokine IL-10. NBD-treated CIA mice exhibited significantly higher percentages and numbers of forkhead box protein 3 (FoxP3(+)) CD4(+) CD25(+) regulatory T cells than controls. Immunofluorescence analysis of NBD-treated mice revealed that FoxP3 and Ym1, a marker of alternatively activated macrophages, were juxtaposed to each other within draining inguinal lymph nodes. Intra-articular administration of NBD peptide is effective as an experimental therapy in a murine model of RA. Nevertheless, the intra-articular treatment modality is still associated with systemic effects on the immune system.

Murine lupus strains differentially model unique facets of human lupus serology

Systemic lupus erythematosus (SLE) is a polygenic autoimmune disease characterized by the production of anti-nuclear autoantibodies that lead to subsequent end organ damage. Previous array-based studies in patients with SLE have shown that high immunoglobulin (Ig)G anti-nuclear autoantibody reactivity was associated with severe renal lupus, whereas IgM polyreactivity was associated with less severe disease. To ascertain how different murine lupus strains recapitulate these different autoantibody profiles seen in patients, serum from New Zealand black (NZB)/NZ white (W) F(1), Murphy Roths large (MRL)/lpr, NZ mixed (M)2410 and BXSB strains were compared using a comprehensive array-based screen. The array results were verified using enzyme-linked immunosorbent assays (ELISAs). Serum from MRL/lpr mice exhibited high levels of IgG anti-nuclear antibodies as well as anti-glomerular antibodies and variable levels of antibodies to myosin, Matrigel and thyroglobulin. Elevated anti-nuclear IgG antibodies were associated with severe nephritis in this strain. In contrast, NZM2410 mice exhibited lower IgG autoantibody levels with less severe nephritis but a significantly higher polyreactive IgM autoantibody profile. ELISA analysis confirmed these results. The NZB/NZW F(1) and BXSB strains exhibited an intermediate serological profile. Hence, just as in patients with SLE, whereas strong IgG reactivity to nuclear antigens is associated with severe renal disease, a polyreactive IgM seroprofile is also less ominous in murine lupus.

Structures and oscillations of rotationally and tidally distorted polytropic models of stars in the presence of the Coriolis force

The problems of equilibrium structures and periods of oscillations of rotationally and/or tidally distorted polytropic models of stars in binary systems have been studied previously. In the studies, only the effects of gravitational and centrifugal forces while obtaining the Roche equipotential of such stars were considered. The Coriolis force were not considered. In the present study, we have included the effects of the Coriolis force also. The objective of this study is to investigate as to how the inclusion of the Coriolis force in the Roche equipotential affects the equilibrium structures and periods of oscillations of rotationally and/or tidally distorted stars. The results of our study show that the Coriolis force has no appreciable effect on the equilibrium structures and periods of small oscillations of polytropic models of stars in binary systems. The present study also confirms the earlier conclusions that uniform rotation decreases the eigenfrequencies of various modes of oscillation.

Magnetic Resonance Urography in Obstructive Uropathy

BACKGROUND

Urinary obstruction is one of the few reversible causes of renal failure. Early diagnosis and treatment can salvage the kidney. Presently intravenous urography, ultrasonography, computed tomography and magnetic resonance imaging are in vogue to detect the cause and demonstrate the site of obstruction.

METHODS

An evaluation of imaging technique in obstructive uropathy was undertaken in a group of 25 patients.

RESULT AND CONCLUSION

Magnetic resonance urography delivered highest accuracy amongst the techniques studied.

Awake Craniotomy for Tumour Excision

BACKGROUND

Craniotomy and excision of tumours can produce neurological deficits if the tumour is located close to eloquent areas of the brain. One technique of overcoming this problem is to keep the patient 'awake' during surgery.

METHODS

Eight patients with intra cranial space occupying lesions (ICSOL) were operated 'awake', using a combination of skull block with sedation and analgesia. A mixture of 0.125% bupivacaine and 0.5% lignocaine was used for various nerve and field blocks. Midazolam, fentanyl and propofol in titrated doses were used to achieve conscious sedation.

RESULT

The procedure was successful in all the patients. They tolerated the procedure well and were able to follow the commands intraoperatively as desired. There were no significant complications.

CONCLUSION

Awake craniotomy with skull blocks with sedation and analgesia is a well established procedure. It requires a good rapport between surgeon, anaesthesiologist and the patient.

Interferon signature gene expression is correlated with autoantibody profiles in patients with incomplete lupus syndromes

Interferon (IFN) signature genes have been shown to be expressed highly in peripheral blood of patients with systemic lupus erythematosus (SLE), especially in the presence of active disease. However, the expression of this gene signature in individuals with incomplete forms of lupus and the pathogenic relationship between IFN signature genes and autoantibody production have not been explored fully. In the present study, we examined the gene expression and autoantibody profiles of patients diagnosed with incomplete lupus erythematosus (ILE) to determine correlations of the gene expression signature with autoantibody production. Gene expression analysis was carried out on the 24K Illumina Human Refseq-8 arrays using blood samples from 84 subjects, including patients with SLE (n = 27) or ILE (n = 24), first-degree relatives (FDR) of these patients (n = 22) and non-autoimmune control (NC) individuals (n = 11). Autoantibody expression was measured using standard immunoassays and autoantigen proteomic arrays. Up-regulation of a set of 63 IFN signature genes was seen in 83% of SLE patients and 50% of ILE patients. High levels of IFN gene expression in ILE and SLE showed significant correlations with the expression of a subset of IgG autoantibodies, including chromatin, dsDNA, dsRNA, U1snRNP, Ro/SSA, La/SSB, topoisomerase I and Scl 70, while low IFN levels were correlated with immunoglobulin (Ig)M autoreactivity. These studies suggest that in patients with ILE the IFN gene expression signature may identify a subset of these individuals who are at risk for disease progression. Furthermore, high levels of alpha IFN may promote autoantibody class-switch from IgM to the more pathogenic IgG class.

The lupus-susceptibility gene kallikrein downmodulates antibody-mediated glomerulonephritis

Sle3 is a NZM2410/NZW-derived lupus-susceptibility interval on murine chromosome 7, which is associated with spontaneous lupus nephritis (SLN), and also anti-GBM-induced glomerulonephritis (GN). The tissue kallikrein gene cluster is located within the Sle3 interval and constitutes potential candidate genes for this locus. We have recently reported that renal kallikrein expression was upregulated by anti-GBM antibody challenge in a strain-specific manner and that it was significantly underexpressed in the anti-GBM-sensitive strains, including B6.Sle3. Further sequencing and functional studies reported earlier provided evidence that kallikreins could constitute disease genes in lupus. In this report, we have used an adenoviral vector to deliver the klk1 gene to B6.Sle3 congenics to directly test if kallikreins might have a protective effect against anti-GBM-induced nephritis. Our data show that klk1 gene delivery ameliorated anti-GBM-induced nephritis in B6.Sle3 congenics. Taken together with earlier studies, these findings indicate that kallikreins play an important protective role in autoantibody-initiated GN and could constitute potential candidate genes for anti-GBM-induced GN and SLN.

Effect of change in symptoms, respiratory status, nutritional profile and quality of life on response to treatment for advanced non-small cell lung cancer

INTRODUCTION

Quality of life (QOL), and pulmonary and nutritional parameters are important outcome measures during treatment of lung cancer; however, the effect of chemotherapy on these factors and their relationship with clinical response is unclear.

METHODS

Patients with non-small cell lung cancer (NSCLC) were evaluated for symptom profile, nutritional status (using anthropometry), pulmonary functions by spirometry and six minute walk distance (6 MWD), and QOL using the WHO-QOL Bref 26 questionnaire, before and after chemotherapy.

RESULTS

Forty-four patients were studied (mean (SD) age, 55 (10) years, 75% males). The majority (98%) had stage III or IV disease and 72% were current / ex-smokers with median pack-years of 27.0 (range, 0.5-90). Some 61% had a Karnofsky Performance Scale (KPS) 70 or 80. The commonest symptoms were coughing, dyspnea, chest pain, anorexia and fever (79%, 72%, 68%, 57% and 40%, respectively). The mean (SD) 6 MWD was 322.5 (132.6) meters. The mean (SD) percentage forced vital capacity (FVC %), and forced expiratory volume in one second (FEV1 %) were 64.7 (18.8) and 57.8 (19.4), respectively. The mean (SD) QOL scores for the physical, psychological, social, and environmental domains were 52.9 (20.5), 56.1 (17.9), 64.5 (21.8), 57.1 (16.6), respectively. Fourteen patients (32%) responded to chemotherapy. Non-responders had significantly higher baseline occurrence of fever, anorexia, and weight loss, higher pack-years of smoking and poorer KPS compared to responders. Overall, chemotherapy caused significant decline in the frequency of coughing, dyspnea, chest pain, fever, anorexia, weight loss, and improvement in hemoglobin and albumin levels. There was no significant improvement in pulmonary functions, nutritional status, or QOL scores after treatment.

CONCLUSIONS

Lung cancer patients have a poor QOL. Although chemotherapy provides significant symptomatic benefit, this does not translate into similar benefit in respiratory and nutritional status or QOL. Patients with constitutional symptoms, higher smoking burden, and poor KPS are less likely to respond to chemotherapy. Management of NSCLC must include strategies to improve various aspects of QOL, nutritional status and pulmonary reserve to achieve comprehensive benefit.

Derivation of a prognostic equation to predict in-hospital mortality and requirement of invasive mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

Predicting in-hospital mortality and formulating a scoring system derived from predictors of mortality may aid prognostication.

METHODS

One hundred and fifty-one consecutive patients admitted with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) were followed to discharge or death in hospital stay. Secondary variables studied were duration of hospital stay, and need for and duration of mechanical ventilation (MV).

RESULTS

Mean (SD) age of patients was 60.5 (11.4) years; 65.6% were mechanically ventilated, and 25.2% died in hospital. Independent predictors of mortality at admission were serum creatinine (odds ratio [OR] 2.1, 95% Confidence intervals [CI] 1.03 to 4.30; p = 0.04), and serum sodium (OR 0.94, 95% CI 0.90 to 0.99; p = 0.03). An equation derived [Score = 8+ (0.74 x creatinine) = (0.015 x sodium)] to predict mortality, had an area under receiver operating characteristic (ROC) curve of 73%, with a cut-off of 6.74 having sensitivity, specificity, positive and negative predictive values for predicting death of 71%, 64%, 40% and 87%, respectively. Glasgow coma scale (GCS), partial pressure of oxygen in arterial blood (PaO2) and partial pressure of carbon dioxide in arterial blood (PaCO2) at admission independently predicted need for invasive ventilation. An equation derived [Score = 2.36+(0.02 x PaO2)+(0.05 x PaCO2)-(0.47 x GCS)] to predict need for MV, had an area under ROC curve of 85%, with a cut-off of 0.54 having sensitivity, specificity, positive and negative predictive values for predicting need for MV of 82%, 81%, 89% and 70%, respectively.

CONCLUSIONS

Serum creatinine and sodium at admission are independent predictors of mortality for patients admitted with AECOPD. The equation derived from these two variables is a simple and useful method for predicting outcome.

Clinicopathological and radiological evaluation of cervical lymph node metastasis in head and neck malignancies

The cervical lymphadenopathy due to metastasis carry poor prognosis. The status of cervical nodes is of critical interest to surgical, radiation and medical oncologists who manage patients with head and neck cancers. We conducted a prospective randomized study to assess the role of palpation, ultrasound and CT in detection of cervical metastasis in 25 patients presented to us with head and neck malignancy irrespective of cervical nodal status. It was observed that clinical examination was least sensitive (73.33%) when compared with computerized tomography (80%) and ultrasound (93.93%). The computerized tomography was found to be most specific (90%) when compared to clinical examination or ultrasonography (70% each).

Quality of life in lung cancer patients: impact of baseline clinical profile and respiratory status

As cure is attainable in very few cases of lung cancer, the imperative issue is to make quality of life (QOL) as good as possible as part of the palliative care package. The aim of this paper was to evaluate the baseline QOL of lung cancer patients and observe its association with various clinical parameters and overall respiratory status. A total of 101 patients were administered the European Organization for Research and Treatment of Cancer core quality of life (EORTC QLQ-C30, version 3) questionnaire. Clinical profile and measures of respiratory status, including spirometry, measures of dyspnoea, and 6-min walk test, were recorded. Higher Karnofsky Performance Status (KPS) significantly correlated with better global health status (P < 0.001) and healthy level of functioning (P < 0.001). The cumulative symptom burden was significantly associated with global QOL (P = 0.01) and physical, role and cognitive function scales (P < 0.05). All dyspnoea measures negatively correlated with global QOL and functioning scales. Spirometric indices showed a positive correlation with all functional scales (P < 0.05) except social. In conclusion, lung cancer patients have unsatisfactory QOL, with the global health status and physical functions being most affected. Number of symptoms, KPS, dyspnoea and spirometry significantly affect QOL.

Cervical neuroblastoma

Cervical neuroblastoma is relatively uncommon. It present, most often as a firm mass in the lateral neck. Primary neuroblastomas of the neck usually arise in the cervical sympathetic ganglia. They are the sixth most common head and neck extracranial neoplasms. Neuroblastoma is the most common malignancy in children under 1 year of age. No known cause of Neuroblastoma has been reported.

Sle3 and Sle5 can independently couple with Sle1 to mediate severe lupus nephritis

Genetic analyses of the lupus-prone NZM2410 mouse have identified multiple susceptibility loci on chromosome 7, termed Sle3 and Sle5. Both of these loci were contained within a large congenic interval, originally termed as Sle3 that strongly impacts a variety of myeloid and T-cell phenotypes and mediates fatal lupus nephritis when combined with Sle1. We have now produced two subcongenic strains, B6.Sle3 and B6.Sle5, carrying the Sle3 and Sle5 intervals separately and characterized their phenotypes as monocongenic strains and individually in combination with Sle1. Neither B6.Sle3 nor B6.Sle5 monocongenic strain develop severe autoimmunity; however, both of these intervals cause the development of severe glomerulonephritis when combined with Sle1. Thus, B6.Sle1Sle3 and B6.Sle1Sle5 exhibit splenomegaly, expansion of activated B and CD4+ T-cell populations and high levels of IgG and IgM autoantibodies targeting multiple nuclear antigens, intact glomeruli and various other autoantigens. In addition, B6.Sle1Sle3 mice also produced higher levels of IgA antinuclear autoantibodies, which were implicated in the development of IgA nephropathy. Our results indicate that Sle3 and Sle5 can independently complement with Sle1, through shared and unique mechanisms, to mediate the development of severe autoimmunity.

Fibrous dysplasia of Sphenoid bone

Fibrous dysplasia represents a disturbance of normal bone development specifically a defect in osteoblastic differentiation and maturation that originates in the mesenchymal precursor of the bone. In fibrous dysplasia, the lesion expands, which leads to a distortion and weakening of bone. Although the lesion is not encapsulated, it tends to remain enclosed within a shell of cortical bone. This shell can be thinned as a result of the pressure exerted on it. As it slowly progresses, fibrous dysplasia can cause skeletal destruction and deformity.

Protein array autoantibody profiles for insights into systemic lupus erythematosus and incomplete lupus syndromes

The objective of this study was to investigate the prevalence and clinical significance of a spectrum of autoantibodies in systemic lupus erythematosus and incomplete lupus syndromes using a proteome microarray bearing 70 autoantigens. Microarrays containing candidate autoantigens or control proteins were printed on 16-section slides. These arrays were used to profile 93 serum samples from patients with systemic lupus erythematosus (SLE (n = 33), incomplete LE (ILE; n = 23), first-degree relatives (FDRs) of SLE patients (n = 20) and non-autoimmune controls (NC; n = 17). Data were analysed using the significance analysis of microarray (SAM) and clustering algorithms. Correlations with disease features were determined. Serum from ILE and SLE patients contained high levels of IgG autoantibodies to 50 autoantigens and IgM autoantibodies to 12 autoantigens. Elevated levels of at least one IgG autoantibody were detected in 26% of SLE and 19% of ILE samples; elevated IgM autoantibodies were present in 13% of SLE and 17% of ILE samples. IgG autoantibodies segregated into seven clusters including two specific for DNA and RNA autoantigens that were correlated with the number of lupus criteria. Three IgG autoantibody clusters specific for collagens, DNA and histones, were correlated with renal involvement. Of the four IgM autoantibody clusters, two were correlated negatively with the number of lupus criteria; none were correlated with renal disease. The IgG : IgM autoantibody ratios generally showed a stepwise increase in the groups following disease burden from NC to SLE. Insights derived from the expanded autoantibody profiling made possible with the antigen array suggest differences in autoreactivity in ILE and SLE. Determining whether the IgM aurotreactivity that predominates in ILE represents an early stage prior to IgG switching or is persistent and relatively protective will require further longitudinal studies.

Quality of life in newly diagnosed patients with lung cancer in a developing country: is it important?

There are no data regarding quality of life (QoL) assessments in lung cancer in developing countries like India. Quality of life was evaluated in 76 newly diagnosed lung cancer patients by using the World Health Organization Quality of Life questionnaire in Hindi (WHOQoL-Bref) (men 87%). The mean age was 55 years (SD = 10). Cough, dyspnoea, chest pain and haemoptysis were present in 83%, 72%, 66% and 43% of patients respectively. The median duration of symptoms was 5.9 months (range 1-13). Eighty-nine per cent had non-small cell lung cancer. The median pack-years smoked was 23 (range 0.5-88). Most patients (53%) had a Karnofsky's Performance Status (KPS) of 70 and 83% had stage III or IV disease. Quality of life did not correlate with age, gender, presence or duration of symptoms, histological type, stage of disease or degree of smoking. The physical and psychological domains of QoL correlated significantly with the KPS (P = 0.001 and P = 0.01 respectively). Patients with a KPS of 80 had better physical (P < 0.001), psychological (P < 0.01) and social (P < 0.05) QoL than those with a KPS of 70. In conclusion, patients with lung cancer in a developing country like India have an unsatisfactory QoL. The Karnofsky's Performance Scale is a simple and reliable surrogate marker for assessing QoL in these patients. Larger multi-centric studies may help in providing a more comprehensive evaluation of the effect of various demographic and clinical variables on QoL in this setting.

Loss of human leucocyte antigen class I and gain of class II expression are early events in carcinogenesis: clues from a study of Barrett's oesophagus

BACKGROUND

Human leucocyte antigen (HLA) expression is altered in oesophageal carcinomas compared with normal tissue. It is unclear, however, whether this phenotype precedes malignant transformation or results as a consequence of it.

AIM

To investigate HLA class I and II expression in Barrett's oesophagus and normal squamous oesophageal tissue.

METHODS

Asian patients with Barrett's oesophagus (n = 64) and a control group (n = 60) with a normal oesophagus but without reflux symptoms were recruited using endoscopic and histopathological criteria. Tissue samples were stained with monoclonal antibodies specific for HLA-ABC, HLA-DR alpha chain or HLA-DP/DQ/DR, and scored semiquantitatively. The results of immunohistochemical staining were correlated with clinical and histopathological characteristics of patients.

RESULTS

Marked expression of HLA-ABC was observed in 50% of Barrett's oesophagus sections as compared with 68.3% of controls (p = 0.038). HLA-DR staining was seen in 51.6% of Barrett's oesophagus samples versus 11.7% of controls (p<0.001). Expression of HLA-DP/DQ/DR was evident in 73.4% of oesophageal intestinal metaplasia tissue as opposed to 18.3% of controls (p<0.001). Importantly, a total loss of HLA-ABC and a concomitant gain of HLA-DP/DQ/DR expression were seen in 37.5% of patients with Barrett's oesophagus but in none of the controls (p<0.001). Interestingly, this phenotype was associated positively with dysplasia (adjusted p, p* = 0.031) but negatively with non-steroidal anti-inflammatory drug use (p* = 0.004).

CONCLUSIONS

HLA class I expression is down regulated and class II expression is up regulated in Barrett's oesophagus. As these changes predate malignant transformation, altered major histocompatibility complex expression may be a key event in disease progression, possibly in facilitating evasion from immune surveillance.

Human leucocyte antigen determinants of susceptibility to Barrett's oesophagus in Asians--a preliminary study

BACKGROUND

Characteristic immune profiles have been demonstrated in gastro-oesophageal reflux disease. However, the genetic basis of gastro-oesophageal reflux disease remains unclear.

AIM

To investigate whether certain human leucocyte antigen genes are associated with Barrett's oesophagus.

METHODS

Asian patients of Malay, Chinese and Indian descent with Barrett's oesophagus (n = 59) and those without reflux symptoms and a normal oesophagus (n =60) were recruited prospectively using endoscopic and histopathological criteria. Human leucocyte antigen class I and II typing was performed using a polymerase chain reaction sequence-specific primers method.

RESULTS

The HLA-B7 allele was present in 17% (10 of 59) of patients with Barrett's oesophagus when compared with 0% (zero of 60) of controls [P = 0.0006, corrected P = 0.0171, OR = 25.67]. Subgroup analysis revealed that the HLA-B7 allele was confined almost exclusively to Indians with Barrett's oesophagus, 43% (nine of 21) vs. 0% (zero of 19) Indian controls (P = 0.0014, corrected P = 0.0406, OR = 29.64). No class II associations, protective human leucocyte antigens or extended haplotypes for disease susceptibility were identified.

CONCLUSIONS

Barrett's oesophagus in Asians, particularly Indians, is strongly positively associated with HLA-B7; reinforcing a genetic component to gastro-oesophageal reflux disease. A larger sample size and different ethnic populations should be genotyped to further confirm this association and identify possible additional risk factors in the human leucocyte antigen locus.

Laser bronchoscopy--current status

The majority of patients with lung cancer have advanced disease with severe endobronchial symptoms such as cough, dyspnea, and hemoptysis for which palliation is required. Laser resection of endobronchial lesions located in the trachea, mainstem or proximal lower lobe bronchi provides significant and rapid improvement in the patient's symptoms. Neodymium:yttrium-aluminium-garnet (Nd:YAG) laser is gaining popularity due to efficient photocoagulation, good penetration and excellent hemostasis. Complications are rare and can be minimized by following standardized techniques and safety guidelines. Laser resection is equally effective with the rigid and flexible bronchoscope. The future may see combinations of laser with other palliative modalities to improve the chances of a symptom-free life for lung cancer patients.

Dominant NZB contributions to lupus in the (SWR x NZB)F1 model

(SWR x NZB)F1 (or SNF1) mice succumb to lupus nephritis. Analysis of NZB x SNF1 backcross mice has recently revealed the existence of four dominant SWR loci (H2 on Chr 17, Swrl-1 on Chr 1, Swrl-2 on Chr 14 and Swrl-3 on Chr 18), and two NZB loci (Nba1 and Lbw2/Sbw2, both on Chr 4) conferring lupus susceptibility. The present study focusing on a panel of 88 SWR x SNF1 backcross mice reveals the existence of five suggestive loci for antinuclear antibody formation, consisting of three dominant NZB contributions (Nba4 on Chr 5, Lbw4 on Chr 6, and Nba5 on Chr 7), and two recessive SWR contributions (Swrl-1 on Chr 1, and Swrl-4 on Chr 10). In addition, this study reveals a dominant NZB locus for GN (Nba3 on Chr 7, peak at 31 cM), and a dominant NZB locus linked to early mortality, on Chr 10 (peak at 4 cM). Collectively, these studies suggest that lupus in the SNF1 strain is the epistatic end-product of four dominant SWR loci and four dominant NZB loci. The immunological functions and molecular identities of these loci await elucidation.

Genetic contributions of nonautoimmune SWR mice toward lupus nephritis

(SWR x New Zealand Black (NZB))F(1) (or SNF(1)) mice succumb to lupus nephritis. Although several NZB lupus susceptibility loci have been identified in other crosses, the potential genetic contributions of SWR to lupus remain unknown. To ascertain this, a panel of 86 NZB x F(1) backcross mice was immunophenotyped and genome scanned. Linkage analysis revealed four dominant SWR susceptibility loci (H2, Swrl-1, Swrl-2, and Swrl-3) and a recessive NZB locus, Nba1. Early mortality was most strongly linked to the H2 locus on chromosome (Chr) 17 (log likelihood of the odds (LOD) = 4.59 - 5.38). Susceptibility to glomerulonephritis was linked to H2 (Chr 17, LOD = 2.37 - 2.70), Swrl-2 (Chr 14, 36 cM, LOD = 2.48 - 2.71), and Nba1 (Chr 4, 75 cM, LOD = 2.15 - 2.23). IgG antinuclear autoantibody development was linked to H2 (Chr 17, LOD = 4.92 - 5.48), Swrl-1 (Chr 1, 86 cM, colocalizing with Sle1 and Nba2, LOD = 2.89 - 2.91), and Swrl-3 (Chr 18, 14 cM, LOD = 2.07 - 2.13). For each phenotype, epistatic interaction of two to three susceptibility loci was required to attain the high penetrance levels seen in the SNF(1) strain. Although the SWR contributions H2, Swrl-1, and Swrl-2 map to loci previously mapped in other strains, often linked to very similar phenotypes, Swrl-3 appears to be a novel locus. In conclusion, lupus in the SNF(1) strain is truly polygenic, with at least four dominant contributions from the SWR strain. The immunological functions and molecular identities of these loci await elucidation.

Murine lupus genetics: lessons learned

Recent reverse genetic studies in murine lupus have taught us the following lessons: (1) Lupus is extremely polygenic; (2) A single locus may be associated with many different phenotypes; (3) What appears to be a single locus may turn out to be a cluster of loci; (4) Different loci facilitate different immunologic steps leading to lupus; (5) Epistatic interactions between loci may engender novel autoimmune phenotypes; (6) Whereas some loci may be pathogenic, others may confer disease resistance; (7) Whereas the expression of some loci is sex-dependent, the expression of others clearly is not; (8) Two or more loci may have an impact on the same phenotype; (9) Lupus susceptibility loci appear to co-cluster with other autoimmunity susceptibility loci; (10) Lupus genes are likely to be polymorphic alleles with subtle impacts, rather than outright mutations with extreme functions. In contrast, forward genetic studies have revealed that molecules that impact apoptosis, the clearance of apoptotic cells, B-cell or T-cell function, and end-organ pathology can all potentially contribute to lupus. Collectively, the loci and genes identified by these two different approaches factorize into a few distinct pathways leading to lupus. Delineating the molecular mediators of these distinct checkpoints is the challenge that lies ahead.